The practical nurse (PN) and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. Which action should the PN implement?

Instruct the UAP to protect the client's left side when transferring to a chair.

Demonstrate to the UAP how to approach the client from the client's left side.

Carefully observe the interaction between the client and family members.

Ask the UAP to leave the room and assess the client's body for bruising.

Answer and Explanation

The Correct Answer is B

A. Protecting the client's left side during transfers is not directly related to addressing neglect syndrome. Clients with right hemisphere strokes may neglect the left side, but the UAP should be guided to approach from the left to help manage the neglect.
B. Demonstrating to the UAP how to approach the client from the left side helps manage the effects of neglect syndrome. Clients with right hemisphere strokes may not be aware of or may ignore the left side, so approaching from this side can improve the client’s awareness and safety.
C. Observing interactions between the client and family members might provide insights into the client’s condition but is not a direct intervention for managing neglect syndrome. The focus should be on practical strategies to help the client with neglect.
D. Asking the UAP to leave the room and assessing the client for bruising does not address the immediate needs of managing neglect syndrome. The priority is to ensure the client is safely engaged and managed, rather than performing a solitary assessment.

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Correct Answer is []

Explanation

The child’s symptoms—drowsiness, thick yellow secretions, low respiratory rate, and fever—along with the chest x-ray showing consolidation consistent with pneumonia, indicate that he is experiencing respiratory insufficiency. Respiratory insufficiency occurs when the respiratory system fails to meet the body's oxygen needs or remove carbon dioxide effectively.

Actions to Take:

1. Perform oropharyngeal suctioning
Suctioning is necessary to clear the thick yellow secretions that can obstruct the airway and contribute to respiratory insufficiency. It helps maintain a patent airway and improves the child's ability to breathe.

2. Provide humidified supplemental oxygen
Humidified oxygen helps to maintain airway moisture and improve oxygenation, which is critical for managing respiratory insufficiency. It can also help loosen secretions and alleviate symptoms related to pneumonia.

Parameters to Monitor:

1. Oxygen Saturation
Monitoring oxygen saturation is essential to assess the effectiveness of supplemental oxygen and interventions for respiratory insufficiency. Low oxygen saturation indicates that the respiratory system is not meeting the oxygen demands of the body.

2. Temperature
Temperature monitoring is important to assess the effectiveness of fever management and to monitor for potential worsening of the infection. Elevated temperature can exacerbate respiratory insufficiency and indicate ongoing infection.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

Respiratory acidosis
The laboratory results show a pH of 7.31, which is below the normal range of 7.35-7.45, indicating acidosis. Additionally, the PaCO2 is elevated at 51 mmHg, which is above the normal range of 35-45 mmHg, pointing towards a respiratory cause of the acidosis.

Carbon dioxide retention
During the submersion, the child likely experienced impaired ventilation, leading to hypoventilation and subsequent retention of carbon dioxide. This retention of CO2 contributes to respiratory acidosis.

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The practical nurse (PN) and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. Which action should the PN implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the practical nurse (PN) should take to address that condition, and two parameters the PN should monitor to assess the client's progress.

Correct Answer is []

Explanation

Exhibits Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. When the laboratory results are available, the practical nurse (PN) would expect the child to have dropdown related to dropdown during the submersion.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

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