A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client’s partner should indicate to the nurse that the teaching was effective?

Choice A reason: Difficulty moving the upper extremities is not a complication of immobility, but a result of the stroke. A stroke can damage the part of the brain that controls movement, sensation, or coordination of the limbs, causing hemiparesis (weakness) or hemiplegia (paralysis) on one side of the body. The nurse should assist the client with passive or active range of motion exercises to prevent muscle atrophy and contractures.

Choice B reason: Stiffness in the lower extremities is not a complication of immobility, but a result of the stroke. A stroke can affect the muscle tone of the limbs, causing spasticity (increased muscle tension) or flaccidity (decreased muscle tone) on one side of the body. The nurse should apply splints or braces to prevent deformities and provide massage or stretching to relieve stiffness.

Choice C reason: A reddened area over the sacrum is a complication of immobility, and a sign of a pressure injury. A pressure injury is a localized damage to the skin and underlying tissue caused by prolonged pressure, friction, or shear. The sacrum is a common site for pressure injuries, as it is a bony prominence that bears the weight of the body when lying down. The nurse should reposition the client every 12 hours, provide skin care, and use pressure relieving devices to prevent pressure injuries.

Choice D reason: Difficulty hearing some types of sounds is not a complication of immobility, but a result of aging or other factors. Hearing loss can occur due to various causes, such as exposure to loud noise, ear infections, earwax buildup, or ototoxic medications. The nurse should assess the client's hearing and use communication strategies, such as speaking clearly, facing the client, and reducing background noise.

Choice A reason: A stroke involving the right cerebral hemisphere can affect the cognitive and emotional functions of the brain, such as judgment, impulse control, and emotional regulation³. This can lead to risky or inappropriate behaviors, such as acting impulsively or disregarding social norms. Therefore, the nurse should monitor the client for poor impulse control and provide appropriate interventions, such as education, cueing, feedback, and environmental modifications.
Choice B reason: A stroke involving the right cerebral hemisphere can affect the visual functions of the brain, such as depth perception, spatial orientation, and visual recognition³. However, the deficits are usually in the left visual field, not the right, because the right side of the brain controls the left side of the body and the environment. Therefore, the nurse should monitor the client for deficits in the left visual field, not the right.
Choice C reason: A stroke involving the right cerebral hemisphere can affect the abstract reasoning functions of the brain, such as understanding metaphors, humor, or sarcasm. However, the ability to discriminate words and letters is more related to the language functions of the brain, which are mainly controlled by the left cerebral hemisphere. Therefore, the nurse should monitor the client for language deficits, such as aphasia or dysarthria, if the stroke involves the left cerebral hemisphere, not the right.
Choice D reason: A stroke involving the right cerebral hemisphere can affect the motor functions of the brain, such as movement, coordination, and balance³. However, the motor retardation, which is a slowing down of physical and mental activity, is more related to the mood functions of the brain, which are mainly controlled by the frontal lobe of the brain. Therefore, the nurse should monitor the client for motor retardation if the stroke involves the frontal lobe, not the right cerebral hemisphere.