Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client who recently suffered a stroke suffers from leftsided homonymous hemianopsia.What action does the nurse take when caring for the client during meal time?
A. Place food trays on the on the left side of the client
Place food trays on the on the left side of the client. This is an incorrect choice. Leftsided homonymous hemianopsia means that the client has lost vision in the left half of both eyes due to damage to the right side of the brain from a stroke. Placing food trays on the left side of theclient would make it difficult for them to see or reach their food.
B. Place food trays on the right side of the client
Place food trays on the right side of the client. This is an incorrect choice. Although this would allow the client to see their food better, it would not help them develop awareness of their left visual field or compensate for their visual loss.
C. Sit with the client at each meal and explain where to find the food.
Sit with the client at each meal and explain where to find the food. This is a correct choice.This would help the client orient themselves to their surroundings and locate their food using verbal cues and guidance from the nurse.
D. Place food directly in front of the client.
Place food directly in front of the client. This is an incorrect choice. This would not address the client's visual impairment or help them adapt to their condition. It would also increase the risk of choking or aspiration if the client does not see the food properly or does not chew or swallow well.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Similar Questions
A nurse collects health history from a 65 year old client. Which of the following risk factors in the client's history put the client at the highest risk for embolic stroke?
A. Diabetes
Diabetes is a risk factor for ischemic stroke, but not embolic stroke. Diabetes can damage the blood vessels and cause atherosclerosis, which can lead to blockage of blood flow to the brain. Embolic stroke occurs when a blood clot or other debris travels from another part of the body and lodges in an artery supplying the brain.
B. Anemia
Anemia is not a direct risk factor for embolic stroke, but it can cause hypoxia and increase the viscosity of blood, which can contribute to ischemic stroke. Anemia can also affect the heart function and cause cardiac arrhythmias, which can increase the risk of embolism.
C. Hypertension
Hypertension is a major risk factor for both ischemic and hemorrhagic stroke, but notspecifically for embolic stroke. Hypertension can weaken the blood vessel walls and cause them to rupture or leak blood into the brain tissue. Hypertension can also accelerate the development of atherosclerosis and increase the risk of thrombosis.
D. Mitral valve replacement
Mitral valve replacement is the highest risk factor for embolic stroke among the choicesgiven. Mitral valve replacement involves replacing a damaged or diseased mitral valve with an artificial one, which can create turbulence in the blood flow and cause clots to form on or around the valve. These clots can break off and travel to the brain, causing an embolic stroke.
A nurse is in a client's room when the client begins having a tonicclonic seizure. Which of the following actions should the nurse take first?
A. Document the time the seizure began.
Documenting the time the seizure began is important, but not the first priority. The nurse should document the onset, duration, type, and characteristics of the seizure after ensuring the client's safety and airway patency.
B. Turn the client's head to the side.
Turning the client's head to the side is the first action that the nurse should take to prevent aspiration of saliva or vomitus and maintain a patent airway during a seizure. The nurse should also protect the client from injury by removing any objects that could harm them and placing a soft pad under their head.
C. Check the client's motor strength.
Checking the client's motor strength is not relevant during a seizure, as the client will have involuntary muscle contractions and loss of consciousness. The nurse should assess the client's neurological status after the seizure has ended and they have regained consciousness.
D. Loosen the clothing around the client's waist.
Loosening the clothing around the client's waist is a helpful measure, but not as urgent as turning their head to the side. Loosening clothing can prevent restriction of breathing andcirculation during a seizure, but it does not address airway patency or aspiration risk.
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?
A. Perform a Romberg's test.
Correct. A Romberg's test is used to assess balance and coordination, which are impaired in clients with ataxia. The nurse should ask the client to stand with feet together and arms at the sides, first with eyes open and then with eyes closed. The nurse should observe for swaying or loss of balance.
B. Observe for the presence of Kernig's sign.
Incorrect. Kernig's sign is a sign of meningeal irritation, not ataxia. It is elicited by flexing the client's hip and knee to 90 degrees and then attempting to extend the leg. A positive sign is pain and resistance to leg extension.
C. Inspect for the presence of clubbing.
Incorrect. Clubbing is a sign of chronic hypoxia, not ataxia. It is characterized by an increased angle between the nail and the nail bed, and a spongy feeling of the nail base.
D. Check the function of cranial nerve V.
Incorrect. Cranial nerve V is the trigeminal nerve, which innervates the muscles ofmastication and provides sensory input from the face, scalp, and oral cavity. It is not related to ataxia or ambulation.