While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

Teach the client to rotate the meal plate to visualize all the food on the plate.

Instruct the client to lift the left extremities with the right hand when transferring.

Implement precautions when the client is judging distances during transfers.

Encourage the client to touch, wash, look at, and dress the affected side first.

Answer and Explanation

The Correct Answer is C

A. Teach the client to rotate the meal plate to visualize all the food on the plate: While this intervention may be helpful for other reasons, it does not directly address the client’s difficulty walking in a straight line.

B. Instruct the client to lift the left extremities with the right hand when transferring: This intervention helps with weight-bearing and balance during transfers. It compensates for the left hemiplegia and promotes stability.

C. Implement precautions when the client is judging distances during transfers: This is crucial. Clients with hemiplegia may have impaired spatial awareness and difficulty judging distances. Strategies like using a gait belt, providing cues, or ensuring a clear path can help prevent falls. Implementing precautions during transfers helps prevent falls.

D. Encourage the client to touch, wash, look at, and dress the affected side first: While this approach promotes independence, it does not directly address the client’s gait instability.

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Correct Answer is D

Explanation

A. Notify the healthcare provider. While notifying the healthcare provider is important if the issue persists, the nurse should first attempt to confirm the absence of pulses using other methods to ensure it is not a technical error or due to poor technique.

B. Apply warm blankets to both feet. Warming the feet might help if the pulses are weak due to vasoconstriction from cold, but this is not the most immediate or effective action to determine the presence of pulses.

C. Palpate pulse points with legs dependent. Having the legs in a dependent position might increase blood flow to the lower extremities, potentially making pulses easier to palpate. However, this is not as reliable as using more advanced technology.

D. Use a doppler ultrasonic stethoscope. Using a Doppler device is the best next step if pulses are not palpable. Dopplers can detect blood flow that is not palpable, providing more accurate assessment of circulation in the extremities before notifying the healthcare provider.

A. Auscultate the lymph node for the presence of a bruit. B. Ask the client about any localized tenderness at the site. C. Cover the inflamed area and notify the healthcare provider. D. Record this normal finding in the assessment record.

Correct Answer is B

Explanation

A. Auscultate the lymph node for the presence of a bruit.

Auscultating for a bruit over a lymph node may not be the most immediate or relevant action in this situation. While it could provide additional information about blood flow, it may not necessarily explain the cause of the enlarged lymph node.

B. Ask the client about any localized tenderness at the site.

This is an appropriate action. Localized tenderness at the site of an enlarged lymph node could indicate inflammation or infection. Gathering information about tenderness can help in understanding the possible cause of the lymphadenopathy.

C. Cover the inflamed area and notify the healthcare provider.

This is a reasonable action. Covering the inflamed area can help protect it from further irritation or infection. Notifying the healthcare provider is important because they can assess the lymph node, gather additional history, and determine if further evaluation or treatment is necessary.

D. Record this normal finding in the assessment record.

This option is incorrect. An enlarged, visible lymph node is not considered a normal finding. It could indicate underlying infection, inflammation, or another health issue. Recording it as a normal finding could lead to overlooking potential health concerns.

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While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

Correct Answer is D

Explanation

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

Correct Answer is B

Explanation

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