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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Sit in a straight-backed chair. After a total hiparthroplasty, the client should avoid sitting in chairs that are too low or too soft, as they can be difficult to rise from and can risk dislocating the new hip. The clientshould apply ice to the incision site, not moist heat, in the first few dayspostoperatively. The client should avoid adducting the hip as this can also riskdislocation of the new hip joint. Hydrogen peroxide should not be used to cleanthe surgical incision, as it can delay wound healing.
Choice A: The client shouldapply ice to the incision site, not moist heat, in the first few days postoperatively.
Choice C: The client should avoid adducting the hip as this can risk dislocation ofthe new hip joint.
Correct Answer is A
Explanation
The correct answer is choice A. The nurse should check the conjunctiva to determine the presence of pallor in a client who is African-American. Choices B, C, and D are incorrect because pallor is not expected in these areas. Choice B is not correct because pallor is not expected in the pinna of the ear. Choice C is not correct because pallor is not expected in the abdomen. Choice D is not correct because pallor is not expected in the antecubital space.
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