A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make?

It must be hard to see your mother so ill and upset.

If you just sit quietly with your mother, I'm sure she will calm down.

I'll talk with your mother and see if I can comfort her.

"Your mother's crying seems to bother you more than it does her."

Answer and Explanation

The Correct Answer is A

A. It must be hard to see your mother so ill and upset is a compassionate and empathetic response that acknowledges the son's distress while validating his feelings. This approach fosters open communication and emotional support, which is important for both the patient and their family.

B. Telling the son to sit quietly with his mother may invalidate his feelings and suggests that the solution is simply to wait for the mother to calm down. It does not acknowledge his emotional distress or provide the necessary support.

C. While offering to comfort the mother is kind, this response does not address the son’s emotional needs. It is important to support the family members as well, not just the patient.

D. "Your mother's crying seems to bother you more than it does her" is dismissive of the son's feelings and could make him feel misunderstood or judged. It does not provide the necessary emotional support for the son.

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Correct Answer is C

Explanation

A. Palpebral angle rigid, right and left angles is not a part of the PERRLA assessment. The term refers to the space between the eyelids, which is not assessed with the PERRLA acronym.

B. Patient's eyes round, regular, lively, active is a description of the general appearance of the eyes but does not correspond to the PERRLA acronym, which specifically addresses the pupils' response to light and accommodation.

C. PERRLA stands for Pupils Equal, Round, and Reactive to Light and Accommodation. This means the pupils should be equal in size, round in shape, react to light (constricting when exposed to light), and accommodate (adjust) when focusing on near or far objects. This is a standard neurological assessment used to evaluate the functioning of the eyes and the nervous system.

D. Pupils equilateral, regular, round, little accommodation does not accurately describe PERRLA. The correct term is "accommodation," which refers to the pupils' ability to adjust when focusing on near or far objects, not "little accommodation."

A. Educating the client on anticonvulsant medications B. Monitor vital signs C. Restraining the client D. Prevention of occlusion of airway or aspiration

Correct Answer is D

Explanation

A. Educating the client on anticonvulsant medications is important, but it is not the priority during an active seizure. Education should be provided after the seizure has ended.

B. Monitoring vital signs is important but should not be the immediate priority during a seizure. The nurse should focus on airway management first.

C. Restraining the client is contraindicated during a seizure. Restraining can cause injury to both the client and the nurse. The focus should be on protecting the client from harm.

D. The prevention of occlusion of the airway or aspiration is the priority. During a tonic-clonic seizure, there is a risk of the client choking, biting their tongue, or having difficulty breathing. The nurse should ensure the airway is open, prevent aspiration, and protect the client from injury during the seizure.

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A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?

Correct Answer is C

Explanation

A nurse is caring for a client experiencing a tonic-clonic seizure. What is the nursing priority in caring for this client?

Correct Answer is D

Explanation

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

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