A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

Massage bony prominences on the client's left side.

Support the client's left arm on a pillow while sitting.

Position the bedside table on the client's left side.

Place the client's cane on their left side while ambulating.

Answer and Explanation

The Correct Answer is B

A is incorrect because massaging bony prominences on the client's left side can increase the risk of skin breakdown and pressure ulcers. The nurse should avoid applying pressure to areas with impaired circulation or sensation.

B is correct because supporting the client's left arm on a pillow while sitting can prevent edema, contractures, and nerve damage. The nurse should also encourage the client to perform active and passive range of motion exercises on their left arm.

C is incorrect because positioning the bedside table on the client's left side can discourage the client from using their right side, which can lead to neglect and learned nonuse. The nurse should position the bedside table on the client's right side and encourage them to reach for items with their right hand.

D is incorrect because placing the client's cane on their left side while ambulating can cause instability and falls. The nurse should place the cane on the client's right side and instruct them to move their left leg and cane together, followed by their right leg.

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Correct Answer is B

Explanation

A is incorrect because diarrhea is not an adverse effect of clonidine, but rather a symptom of other conditions such as infection, inflammation, or food intolerance.

B is correct because dry mouth is a common adverse effect of clonidine, which is an alpha-2 adrenergic agonist that reduces sympathetic nervous system activity.

C is incorrect because photophobia, or sensitivity to light, is not an adverse effect of clonidine, but rather a symptom of other conditions such as migraine, eye injury, or infection.

D is incorrect because bruising, or bleeding under the skin, is not an adverse effect of clonidine, but rather a symptom of other conditions such as coagulation disorders, vitamin deficiency, or trauma.

A. "Your body temperature will drop approximately 1 degree 1 week after ovulation." B. "You should take your body temperature each evening prior to going to sleep." C. "Your body temperature might decrease slightly just prior to ovulation." D. "Your body temperature is at its highest during menstruation."

Correct Answer is C

Explanation

A. This choice is incorrect because the body temperature does not drop 1 degree 1 week after ovulation. The body temperature rises slightly (about 0.4 to 0.8 degrees Fahrenheit) after ovulation and remains elevated until the next menstrual period.

B. This choice is incorrect because the body temperature should be taken each morning before getting out of bed or doing any activity. Taking the temperature in the evening can result in inaccurate readings due to variations in daily activities, meals, stress, exercise, etc.

C. This choice is correct because the body temperature might decrease slightly (about 0.2 degrees Fahrenheit) just prior to ovulation due to a surge in estrogen levels. This dip in temperature can indicate that ovulation is about to occur and that the client should avoid unprotected intercourse if she wants to prevent pregnancy.

D. This choice is incorrect because the body temperature is not at its highest during menstruation. The body temperature drops at the onset of menstruation due to a decline in progesterone levels and marks the beginning of a new cycle.

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A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?

Correct Answer is B

Explanation

A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?

An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?

A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching?

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A nurse is caring for a client whose partner died in a fire that destroyed their home. Which of the following actions should the nurse take first?

A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?

A nurse is teaching a prenatal class about infection prevention at a community centre. Which of the following statements by a client indicates an understanding of the teaching?