A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
Poor impulse control
Deficits in the right visual field
Unable to discriminate words and letters
Motor retardation
The Correct Answer is A
Choice A reason: A stroke involving the right cerebral hemisphere can affect the cognitive and emotional functions of the brain, such as judgment, impulse control, and emotional regulation³. This can lead to risky or inappropriate behaviors, such as acting impulsively or disregarding social norms. Therefore, the nurse should monitor the client for poor impulse control and provide appropriate interventions, such as education, cueing, feedback, and environmental modifications.
Choice B reason: A stroke involving the right cerebral hemisphere can affect the visual functions of the brain, such as depth perception, spatial orientation, and visual recognition³. However, the deficits are usually in the left visual field, not the right, because the right side of the brain controls the left side of the body and the environment. Therefore, the nurse should monitor the client for deficits in the left visual field, not the right.
Choice C reason: A stroke involving the right cerebral hemisphere can affect the abstract reasoning functions of the brain, such as understanding metaphors, humor, or sarcasm. However, the ability to discriminate words and letters is more related to the language functions of the brain, which are mainly controlled by the left cerebral hemisphere. Therefore, the nurse should monitor the client for language deficits, such as aphasia or dysarthria, if the stroke involves the left cerebral hemisphere, not the right.
Choice D reason: A stroke involving the right cerebral hemisphere can affect the motor functions of the brain, such as movement, coordination, and balance³. However, the motor retardation, which is a slowing down of physical and mental activity, is more related to the mood functions of the brain, which are mainly controlled by the frontal lobe of the brain. Therefore, the nurse should monitor the client for motor retardation if the stroke involves the frontal lobe, not the right cerebral hemisphere.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "Use simple, childlike statements when speaking." This response is not appropriate because it can be demeaning and disrespectful to the client. The client is an adult who knows what they want to say, but they have difficulty saying it. Using simple statements is helpful, but they should not be childlike or patronizing.
Choice B reason: "Use a higher pitched tone of voice when speaking." This response is not appropriate because it can be irritating and confusing to the client. The client may have normal hearing, or they may have hearing loss due to age or stroke. Using a higher pitched tone of voice can make the speech harder to understand and may imply that the client is not intelligent.
Choice C reason: "Incorporate nonverbal cues in the conversation." This response is appropriate because nonverbal cues, such as gestures, facial expressions, and drawings, can help the client understand and express themselves better. Nonverbal cues can also reduce frustration and anxiety for both the client and the family member.
Choice D reason: "Ask multiple choice questions as part of the conversation." This response is not appropriate because it can be overwhelming and stressful for the client. Multiple choice questions can be hard to process and remember for someone with aphasia. It is better to ask yes or no questions, or to provide options with visual cues.
Correct Answer is D
Explanation
Choice A reason: Droplet precautions are not appropriate for a client who has tuberculosis and a productive cough. Droplet precautions are used to prevent the transmission of infectious agents that are spread by large respiratory droplets, such as influenza, pertussis, or meningitis. Droplet precautions require the use of a surgical mask, eye protection, and gloves when in close contact with the client.
Choice B reason: Protective precautions are not applicable for a client who has tuberculosis and a productive cough. Protective precautions are used to protect immunocompromised clients from exposure to pathogens, such as those undergoing chemotherapy, organ transplantation, or stem cell transplantation. Protective precautions require the use of a HEPA filter, a positive pressure room, and a mask for the client when leaving the room.
Choice C reason: Contact precautions are not sufficient for a client who has tuberculosis and a productive cough. Contact precautions are used to prevent the transmission of infectious agents that are spread by direct or indirect contact with the client or the client's environment, such as Clostridioides difficile, MRSA, or VRE. Contact precautions require the use of gloves and gowns when entering the room and the dedicated use of noncritical patientcare equipment.
Choice D reason: Airborne precautions are the correct type of isolation precautions for a client who has tuberculosis and a productive cough. Airborne precautions are used to prevent the transmission of infectious agents that are spread by small respiratory droplets that can remain suspended in the air, such as tuberculosis, measles, or chickenpox. Airborne precautions require the use of a respirator, such as an N95 mask, a negative pressure room, and a mask for the client when leaving the room.
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