A nurse is collecting data from a client who had a left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately?

A change in pupil size

Difficulty speaking

Inability to follow direction

Right-sided weakness

Answer and Explanation

The Correct Answer is A

A change in pupil size can indicate an increase in intracranial pressure, which can lead to a life-threatening situation. The nurse should immediately report this finding to the provider.

Choice B is incorrect because difficulty speaking is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Choice C is incorrect because inability to follow direction is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Choice D is incorrect because right-sided weakness is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Reasons why the other choices are not answers:

Choice B: Difficulty speaking is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Choice C: Inability to follow direction is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Choice D: Right-sided weakness is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

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Correct Answer is B

Explanation

"Sitting quietly near the bedside can provide comfort and support." The nurse's response should provide appropriate comfort and support to the dying client's family, and sitting quietly near the bedside can provide just that.

Options A, C, and D are incorrect because medicating the client to wake them up or to minimize drowsiness is not appropriate as it interferes

A. Review the signs of anaphylaxis with the client. B. Instruct the client to store the injector at room temperature. C. Inform the client to seek medical attention following administration of the injection. D. Have the client perform a return demonstration of the equipment.

Correct Answer is C

Explanation

The correct answer is c. Inform the client to seek medical attention following administration of the injection.

Choice A reason: Reviewing the signs of anaphylaxis with the client is important, but it’s not the priority. The client must first know what to do in case of an emergency.

Choice B reason: Instructing the client to store the injector at room temperature is a part of the storage instructions, but it’s not the immediate action to take during an anaphylactic reaction.

Choice C reason: This is the priority because anaphylaxis is a potentially life-threatening condition and even after administering epinephrine, it’s crucial to seek immediate medical attention.

Choice D reason: Having the client perform a return demonstration of the equipment is a good teaching method, but it’s not the immediate action to take when an anaphylactic reaction occurs.

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A nurse is collecting data from a client who had a left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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