A patient is hospitalized poststroke. The nurse approaches the patient from the patient's left side to provide morning care. The patient is staring straight ahead and does not respond to the nurse's presence or voice. Which action should the nurse take first?

Walk to the other side of the bed and try again.

Wave a hand in front of the patient's face.

Speak more loudly and clearly.

Use a picture board to explain to the patient what the nurse is going to do.

Answer and Explanation

The Correct Answer is A

A. Walk to the other side of the bed and try again: The patient may have right-sided neglect due to the stroke, meaning they are not aware of stimuli on the left side. Approaching from the other side where the patient has better perception might help them respond better.
B. Wave a hand in front of the patient's face: This might not be effective and can startle the patient. It does not address the underlying issue of spatial neglect.
C. Speak more loudly and clearly: There is no indication that the patient has hearing loss or language comprehension issues. Speaking louder may not be effective if the patient is experiencing spatial neglect.
D. Use a picture board to explain to the patient what the nurse is going to do: This is a good strategy for communication but does not address the immediate need to reposition to a more effective approach to gain the patient’s attention first.

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Correct Answer is C

Explanation

A. Obtain an electrocardiogram (ECG) exam: While an ECG is important to assess cardiac status, it is not the immediate priority compared to addressing the low oxygen saturation.
B. Obtain intravenous access: IV access is important for administering medications and fluids but does not take precedence over addressing hypoxia.
C. Administer 2 L of oxygen per nasal cannula: This is correct. The priority is to improve oxygenation since hypoxia can exacerbate neurological damage in a stroke patient. An SpO2 of 88% is low and requires immediate correction to prevent further complications.
D. Obtain a rectal temperature: Temperature assessment is not as urgent as addressing the immediate need for oxygen to improve SpO2 levels.

A. Diabetes mellitus B. Calcium deficiency C. Peripheral vascular problems in both legs D. An acute obstruction in the vessels of the legs

Correct Answer is C

Explanation

A. Diabetes mellitus: While diabetes can cause peripheral vascular disease, it alone does not specifically cause intermittent claudication (pain on exertion relieved by rest).
B. Calcium deficiency: Calcium deficiency is not typically associated with intermittent claudication or peripheral vascular symptoms.
C. Peripheral vascular problems in both legs: This is correct. The symptoms described are classic for intermittent claudication, which is commonly due to peripheral arterial disease (PAD). PAD causes pain due to reduced blood flow to the muscles during exertion, which is relieved by rest.
D. An acute obstruction in the vessels of the legs: Acute obstruction would likely cause more severe and persistent symptoms, such as acute pain and loss of pulses, not just pain with walking.

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A patient is hospitalized poststroke. The nurse approaches the patient from the patient's left side to provide morning care. The patient is staring straight ahead and does not respond to the nurse's presence or voice. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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