Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse caring for a client who had a rightsided stroke and is exhibiting homonymous hemlanopsia when eating. Which of the following actions should the nurse take?
A. Encourage the use of the wide grip utensils.
Encouraging the use of wide grip utensils may be helpful for clients with impaired fine motor skills or hand weakness, but it does not address the issue of homonymous hemianopsia, which is a loss of vision in half of the visual field on the same side in both eyes. This choice is incorrect.
B. Remind the client to look for food on the left side of the tray
Reminding the client to look for food on the left side of the tray can help compensate for the loss of vision on the right side due to homonymous hemianopsia. The nurse should also place food and utensils on the left side and orient the client to their location before eating. This choice is correct.
C. Provide a nonskid mat to alleviate plate movement
Providing a nonskid mat to alleviate plate movement may prevent spills and accidents, but it does not help the client with homonymous hemianopsia to see the food on the right side of the tray. This choice is incorrect.
D. Encourage the client to use his right hand when feeding himself
Encouraging the client to use his right hand when feeding himself may be appropriate for clients with leftsided weakness or paralysis due to stroke, but it does not address the visualimpairment caused by homonymous hemianopsia. This choice is incorrect.
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 is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?
A. Nuchal rigidity
Nuchal rigidity is a sign of meningitis, not concussion.
B. A lingering headache that comes and goes
A lingering headache that comes and goes is a common manifestation of concussion, as the brain tissue is bruised and inflamed.
C. Glasgow Coma Scale score of 11
Glasgow Coma Scale score of 11 indicates moderate brain injury, while concussion is usually mild and does not affect the level of consciousness significantly.
D. Loss of consciousness lasting 30 to 60 min
Loss of consciousness lasting 30 to 60 min is a sign of severe brain injury, not concussion.
A client arrived by EMS after a bar fight. He is disoriented with a Glasgow coma scale of 10.
What additional finding indicates that he has suffered a basilar skull fracture?
A. bruising over the cheek
Bruising over the cheek is a sign of facial trauma, not basilar skull fracture.
B. missing teeth
Missing teeth is a sign of dental injury, not basilar skull fracture.
C. discoloration behind the left ear
Discoloration behind the left ear, also known as Battle's sign, is a sign of basilar skull fracture, as blood accumulates in the mastoid process due to a fracture in the temporal bone.
D. Bleeding from the nose
Bleeding from the nose is a sign of nasal trauma, not basilar skull fracture.
Full Explanation
Bruising over the cheek is a sign of facial trauma, not basilar skull fracture.
Missing teeth is a sign of dental injury, not basilar skull fracture.
Discoloration behind the left ear, also known as Battle's sign, is a sign of basilar skull fracture, as blood accumulates in the mastoid process due to a fracture in the temporal bone.
Bleeding from the nose is a sign of nasal trauma, not basilar skull fracture.
A client who suffered a stroke now has functional musculoskeletal deficits and is unable to perform ADLS independently. Which of the following Interventions are appropriate for this client?
A. monitor vital signs
Monitor vital signs. This is not an appropriate intervention for this client because it does not address the functional musculoskeletal deficits or the inability to perform ADLS independently. Monitoring vital signs is a general nursing responsibility that should be done for all clients, but it is not specific to this client's needs.
B. monitor for changes in consciousness
Monitor for changes in consciousness. This is not an appropriate intervention for this client because it does not address the functional musculoskeletal deficits or the inability to perform ADLS independently. Monitoring for changes in consciousness is important for clients who have had a stroke, but it is not the main focus of rehabilitation.
C. assist with range of motion exercises
Assist with range of motion exercises. This is an appropriate intervention for this client because it helps to prevent contractures, maintain joint mobility, and improve muscle strength and coordination. Assisting with range of motion exercises can also promote independence in ADLS by enhancing the client's functional abilities.
D. identify aspiration risks
Identify aspiration risks. This is not an appropriate intervention for this client because it does not address the functional musculoskeletal deficits or the inability to perform ADLSindependently. Identifying aspiration risks is important for clients who have had a stroke,especially if they have dysphagia or facial weakness, but it is not the main focus of rehabilitation.