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 B
Explanation
Choice A reason: Positioning the head of the client’s bed in the flat position is not a good way to reduce the risk of ventilator associated pneumonia. This position can increase the risk of aspiration of oral secretions or gastric contents into the lungs, which can cause infection. The nurse should elevate the head of the bed to 30 to 45 degrees to prevent aspiration and promote drainage of secretions.
Choice B reason: Brushing the client’s teeth with a suction toothbrush every 12 hr is an effective way to reduce the risk of ventilator associated pneumonia. Oral hygiene can reduce the number of bacteria in the mouth and prevent the formation of dental plaque, which can harbor pathogens that can cause pneumonia. The nurse should use a suction toothbrush to remove debris and secretions from the mouth and prevent them from entering the lungs.
Choice C reason: Providing humidity by maintaining moisture within the ventilator tubing is not a helpful way to reduce the risk of ventilator associated pneumonia. Humidity can increase the growth of bacteria and fungi in the ventilator circuit, which can contaminate the air delivered to the lungs. The nurse should change the ventilator tubing and filters regularly and use sterile water to fill the humidifier.
Choice D reason: Turning the client every 4 hr is not a sufficient way to reduce the risk of ventilator associated pneumonia. Turning can help prevent pressure ulcers and improve blood circulation, but it does not prevent the accumulation of secretions in the lungs, which can cause infection. The nurse should use chest physiotherapy, suctioning, and coughing techniques to mobilize and clear secretions from the airways.
Correct Answer is C
Explanation
Choice A reason: Budesonide via dry powder inhaler is not a suitable medication for an acute asthma exacerbation. Budesonide is an inhaled corticosteroid that helps to reduce inflammation and prevent asthma attacks. It is taken daily as a maintenance therapy and does not work quickly enough to relieve the symptoms of an acute asthma exacerbation.
Choice B reason: Cromolyn via metered dose inhaler is not an effective medication for an acute asthma exacerbation. Cromolyn is a mast cell stabilizer that helps to prevent the release of inflammatory mediators that cause asthma symptoms. It is taken daily as a preventive therapy and does not work quickly enough to relieve the symptoms of an acute asthma exacerbation.
Choice C reason: Albuterol via jet nebulizer is a recommended medication for an acute asthma exacerbation. Albuterol is a short acting beta 2 agonist that helps to relax the smooth muscles of the airways and improve breathing. It is taken as needed as a rescue therapy and works quickly to relieve the symptoms of an acute asthma exacerbation.
Choice D reason: Montelukast orally is not a preferred medication for an acute asthma exacerbation. Montelukast is a leukotriene modifier that helps to reduce inflammation and prevent asthma attacks and exercise induced bronchoconstriction. It is taken once a day as an adjunctive therapy and does not work quickly enough to relieve the symptoms of an acute asthma exacerbation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.