An adult client is admitted to the nursing unit with a medical diagnosis of Acute Stroke. The client does not respond to verbal stimuli. In this situation, what is the best action by the nurse to provoke a client response?

Apply pressure to the temporomandibular joint (TM)

Squeeze the trapezius muscle

Press hard on the client's sternum

Gently shake the client's shoulders

Answer and Explanation

The Correct Answer is C

A.   While pressure on the TM joint could stimulate a response, it is not the most appropriate method for provocation of a response in an unconscious or semiconscious client.
B.   This action can be used to assess for painful stimuli, but pressing on the sternum is a more effective method for provoking a response in non-responding clients.
C.   Applying firm pressure to the sternum, or sternal rub, is an effective technique to stimulate a response from clients who are non-responsive to verbal stimuli.
D.   While shaking might be used for awakening a client, it is not as reliable or effective as a sternal rub when assessing neurological response in acute stroke patients.

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Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

A. Poor dental health can be linked to hypothyroidism, as it may cause a decrease in oral health.
B. Skin should be dry and cool in hypothyroidism, making this finding abnormal.
C. Client states, "I can't seem to get warm lately." Cold intolerance is a hallmark symptom of hypothyroidism due to slowed metabolism.
D. Weight gain of five pounds in two months. Mild weight gain can occur in hypothyroidism but may not be significant enough to consider abnormal without other symptoms.
E. Periorbital non-pitting edema. This finding is common in hypothyroidism and indicates water retention around the eyes.

A. Lack of a bowel movement in 2 days B. Difficulty sleeping at night C. +3 edema in the ankles. D. Blanching erythema in the sacral area

Correct Answer is D

Explanation

A. While this can be uncomfortable and may require attention, it is not typically considered an emergency unless accompanied by severe pain, vomiting, or other concerning symptoms.
B. Insomnia or difficulty sleeping can significantly impact a person's quality of life, but it is not usually an immediate threat to health.
C. While it is important to assess and manage the underlying cause, it is not usually an immediate emergency unless it is accompanied by other severe symptoms like shortness of breath or chest pain.
D. This finding suggests the early stages of pressure ulcer development, which can rapidly progress if not addressed promptly. Immediate intervention is crucial to prevent further tissue damage and complications.

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An adult client is admitted to the nursing unit with a medical diagnosis of Acute Stroke. The client does not respond to verbal stimuli. In this situation, what is the best action by the nurse to provoke a client response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding(s) for a client with hypothyroidism should the nurse document as abnormal? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment?

Correct Answer is D

Explanation

​​​​​​​The nurse is performing a physical assessment on a newly admitted patient. Select subjective or objective for the findings below.

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A nurse is obtaining a history from a 30-year-old female client. Which of the following questions would you ask to assess health promotion act?

During a cardiovascular assessment of an 80-year-old adult, a nurse should consider which of the following as expected findings?

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The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group?

While assessing the client's gait during, which of the following would indicate a need for further evaluation?