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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: Sweet potatoes are not a food that the client should avoid after passing a calcium oxalate renal stone, because they are low in oxalate, which is a substance that can combine with calcium in the urine and form stones. The client should limit foods that are high in oxalate, such as spinach, rhubarb, beets, nuts, chocolate, tea, and wheat bran. Therefore, this choice is incorrect.

Choice B reason: Spinach salad is a food that the client should avoid after passing a calcium oxalate renal stone, because it is high in oxalate, which can increase the risk of stone formation. The client should consume foods that are low in oxalate, such as rice, corn, apples, grapes, peaches, and cheese. Therefore, this choice is correct.

Choice C reason: Bananas are not a food that the client should avoid after passing a calcium oxalate renal stone, because they are low in oxalate and high in potassium, which can help prevent stone formation. The client should increase the intake of fluids, calcium, and citrate, which can reduce the concentration of oxalate and calcium in the urine and inhibit stone formation. Therefore, this choice is incorrect.

Choice D reason: Fish is not a food that the client should avoid after passing a calcium oxalate renal stone, because it is low in oxalate and high in protein, which can help maintain muscle mass and prevent weight loss. The client should moderate the intake of animal protein, such as meat, poultry, eggs, and dairy products, which can increase the acidity of the urine and promote stone formation. Therefore, this choice is incorrect.

A. Applies prescribed lotions to the radiation site. B. Washes the radiation site with antibacterial soap and water. C. Wears clothing to cover the radiation site. D. Dries the area with patting motions after taking a shower.

Correct Answer is B

Explanation

Choice A reason: Applying prescribed lotions to the radiation site is a good action for a client with cancer receiving external beam radiation, because it can help moisturize and protect the skin from irritation and breakdown. The client should follow the instructions of the health care provider regarding the type and frequency of lotion application. Therefore, this choice does not indicate a need for further teaching.

Choice B reason: Washing the radiation site with antibacterial soap and water is a bad action for a client with cancer receiving external beam radiation, because it can cause dryness, inflammation, and infection of the skin. The client should use mild soap and water or saline solution to gently cleanse the area without rubbing or scrubbing. Therefore, this choice indicates a need for further teaching.

Choice C reason: Wearing clothing to cover the radiation site is a good action for a client with cancer receiving external beam radiation, because it can help shield the skin from sun exposure and friction. The client should wear loose-fitting, soft, cotton clothing that does not irritate or constrict the area. Therefore, this choice does not indicate a need for further teaching.

Choice D reason: Drying the area with patting motions after taking a shower is a good action for a client with cancer receiving external beam radiation, because it can help prevent trauma and infection of the skin. The client should avoid rubbing or scratching the area or using hair dryers or heating pads on it. Therefore, this choice does not indicate a need for further teaching.

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A patient is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

Correct Answer is B

Explanation

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

Correct Answer is B

Explanation

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