A patient is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?
Pupillary changes to ipsilateral dilation.
Left-sided facial drooping and dysphagia.
Orientation to person and place only.
Unequal bilateral hand grip strengths.
The Correct Answer is A
Choice A reason: Pupillary changes to ipsilateral dilation indicate increased intracranial pressure, which is a life-threatening complication of stroke. The nurse should notify the physician and prepare for emergency measures.
Choice B reason: Left-sided facial drooping and dysphagia are common signs of right hemisphere stroke, but they do not require immediate intervention by the nurse. The nurse should monitor the patient's swallowing ability and provide oral care.
Choice C reason: Orientation to person and place only is a sign of impaired cognition, which is also common in right hemisphere stroke. The nurse should assess the patient's memory, judgment, and attention span.
Choice D reason: Unequal bilateral hand grip strengths are a sign of hemiparesis, which is a weakness on one side of the body. The nurse should assist the patient with mobility and prevent contractures.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Restriction of caloric intake is not a good change for a client with diabetes mellitus and an upper respiratory infection, because it can lead to hypoglycemia and malnutrition. The client needs adequate calories to maintain blood glucose levels and support immune function. Therefore, this choice is incorrect.
Choice B reason: Fewer fingerstick glucose checks are not a good change for a client with diabetes mellitus and an upper respiratory infection, because they can lead to poor blood glucose control and complications. The client needs frequent monitoring of blood glucose levels to adjust insulin doses and prevent hyperglycemia or hypoglycemia. Therefore, this choice is incorrect.
Choice C reason: Higher doses of insulin are a good change for a client with diabetes mellitus and an upper respiratory infection, because they can help lower blood glucose levels and prevent ketoacidosis. The client needs more insulin to overcome the increased insulin resistance caused by the infection and the stress hormones. Therefore, this choice is correct.
Choice D reason: Increased oral fluid intake is a good change for a client with diabetes mellitus and an upper respiratory infection, but it is not directly related to blood glucose management. The client needs more fluids to prevent dehydration and clear mucus from the respiratory tract. Therefore, this choice is not the best answer.
Correct Answer is B
Explanation
Choice A reason: This is incorrect because teaching the client to wear a mask, hand wash, and social distance is not the most important action for the nurse to take. These are preventive measures that should be followed by everyone, regardless of their COVID-19 status.
Choice B reason: This is correct because isolating the client from other clients, family, and healthcare workers not wearing proper PPE is the most important action for the nurse to take. This is to prevent transmission of COVID-19 to others who may be at risk of severe complications or death.
Choice C reason: This is incorrect because reporting the COVID-19 result to the local health department according to CDC guidelines is not the most important action for the nurse to take. This is a legal and ethical obligation that should be done after confirming the diagnosis, but it does not have an immediate impact on the client's health or safety.
Choice D reason: This is incorrect because explaining to the client to inform others that they may have been potentially exposed in the last 14 days is not the most important action for the nurse to take. This is a moral and social responsibility that should be done as soon as possible, but it does not address the urgent need of isolating the client from potential sources of infection.
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