The nurse is caring for a client who experienced a stroke in the right hemisphere of the brain. What should the nurse do to ensure the safety of the patient?
Support the right arm with a sling or pillow to prevent shoulder dislocation.
Anticipate the client will exhibit some degree of expressive or receptive aphasia.
Place the wheelchair on the client’s left side when transferring him into a wheelchair.
Provide close supervision because of the client’s impulsiveness and poor judgment.
The Correct Answer is D
Choice A rationale
Supporting the right arm with a sling or pillow can help prevent shoulder dislocation, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice B rationale
While it is true that a patient who has experienced a stroke in the right hemisphere of the brain may exhibit some degree of expressive or receptive aphasia, anticipating this does not directly ensure the patient’s safety.
Choice C rationale
Placing the wheelchair on the client’s left side when transferring him into a wheelchair is a good practice, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice D rationale
Patients who have experienced a stroke in the right hemisphere of the brain often exhibit impulsiveness and poor judgment. Therefore, providing close supervision can help ensure the patient’s safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While participation in multiple-step activities can provide mental stimulation, it may be challenging for a patient with Alzheimer’s disease. These activities often require a level of cognitive functioning that may be impaired in Alzheimer’s patients. As a result, these activities could lead to frustration and agitation rather than fostering socialization.
Choice B rationale
Hobbies involving fine motor skills can be beneficial for maintaining dexterity and coordination. However, as Alzheimer’s disease progresses, these skills often decline. Therefore, while these hobbies may be enjoyable, they may not necessarily foster socialization.
Choice C rationale
Limiting visitors to one or two at a time can help to prevent overstimulation, which can be distressing for a person with Alzheimer’s disease. Smaller, more intimate gatherings can also foster more meaningful social interactions. Therefore, this approach can be beneficial for promoting socialization.
Choice D rationale
While social interaction is important for people with Alzheimer’s disease, frequent lengthy visits from friends may be overwhelming and lead to fatigue. It’s important to balance socialization with rest and relaxation. Therefore, promoting frequent lengthy visits may not be the best approach to foster socialization.
Correct Answer is C
Explanation
Choice A rationale
The Rinne test is a hearing test used to evaluate the difference between sound transmission through air conduction versus bone conduction. It is not typically used following a Romberg test, which evaluates balance.
Choice B rationale
While ensuring the patient’s safety is always important, repositioning the client supine is not the typical response to slight swaying during a Romberg test.
Choice C rationale
Slight swaying during a Romberg test is considered normal. Therefore, documenting successful completion of the assessment would be the appropriate action.
Choice D rationale
A referral to a neurologist is not typically necessary for slight swaying during a Romberg test, as this is considered within normal limits.
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