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. Incorrect. Measuring the group's work against the assigned objectives is a task role that belongs to the evaluator, who assesses the quality and effectiveness of the group's performance.

B. Correct. Noting the progress of the group toward assigned goals is a task role that belongs to the orienteer, who keeps track of where the group is heading and summarizes what has been accomplished.

C. Incorrect. Sharing experiences as an authority figure is a task role that belongs to the information giver, who provides factual data or personal knowledge to the group.

D. Incorrect. Offering new and fresh ideas on an issue is a task role that belongs to the initiator, who proposes new solutions or approaches to problems.

A. A B. B C. C

Correct Answer is C

Explanation

A. Incorrect. HD does not affect the eyes.

B. Incorrect. HD does not affect the respiratory system or cause chest manifestations.

C. Correct. Hirschsprung disease (HD) is a congenital disorder that affects the nerve cells in the colon, causing a lack of peristalsis and bowel obstruction. Infants with HD may have a distended abdomen due to fecal accumulation and gas.

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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 assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?

Correct Answer is B

Explanation

A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is C

Explanation

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