Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing the medical record of a client who had a left-sided stroke.
Which of the following findings should the nurse expect?
A. Blood pressure
Option A, "Blood pressure," is incorrect because it may be affected by the stroke, but it is not specific to a left-sided stroke.
B. Temperature
Option B, "Temperature," is incorrect because it may be affected by the stroke, but it is not specific to a left-sided stroke.
C. Neurologic status
Clients with a left-sided stroke will have neurological deficits on the right side of the body, including paralysis or weakness. Impaired speech, language, and cognition are also possible. Blood pressure, temperature, and laboratory results may be affected by the stroke, but they are not specific to a left-sided stroke.
D. Laboratory results
Option D, "Laboratory results," is incorrect because they may be affected by the stroke, but they are not specific to a left-sided stroke.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
Clients with a left-sided stroke will have neurological deficits on the right side of the body, including paralysis or weakness. Impaired speech, language, and cognition are also possible. Blood pressure, temperature, and laboratory results may be affected by the stroke, but they are not specific to a left-sided stroke.
Option A, "Blood pressure," is incorrect because it may be affected by the stroke, but it is not specific to a left-sided stroke.
Option B, "Temperature," is incorrect because it may be affected by the stroke, but it is not specific to a left-sided stroke.
Option D, "Laboratory results," is incorrect because they may be affected by the stroke, but they are not specific to a left-sided stroke.
Similar Questions
A nurse is reinforcing discharge teaching with a client who had an abdominal hysterectomy 2 days ago. Which of the following instructions should the nurse include in the teaching?
A. "Take a shower rather than a tub bath."
B. "Avoid climbing stairs for 8 weeks."
incorrect because clients are encouraged to walk around after surgery to prevent blood clots
C. "Douche with warm water to remove vaginal discharge."
incorrect because douching after surgery can increase the risk of infection
D. "Expect bright red vaginal bleeding for 1 week following surgery."
is incorrect because bright red vaginal bleeding after surgery warrants a follow-up with a healthcare provider
Full Explanation
The correct answer is choice A, "Take a shower rather than a tub bath." This is a safety precaution to prevent infection . Choice B is incorrect because clients are encouraged to walk around after surgery to prevent blood clots. Choice C is incorrect because douching after surgery can increase the risk of infection. Choice D is incorrect because bright red vaginal bleeding after surgery warrants a followup with a healthcare provider. Choice B is not correct because clients are encouraged to walk around after surgery to prevent blood clots. Choice C is not correct because douching after surgery can increase the risk of infection. Choice D is not correct because bright red vaginal bleeding after surgery warrants a followup.
A nurse is preparing a client for a sigmoidoscopy. In which of the following positions should the nurse place the client?
A. Orthopneic
Orthopneic position is upright sitting with arms and elbows resting on a table or on a pillow, which helps clients who have difficulty breathing; it is not suitable for sigmoidoscopy.
B. Trendelenburg
Trendelenburg's positionis supine with the head lower than the feet, which can cause blood flow to the head and increased intracranial pressure; it is not suitable for sigmoidoscopy.
C. Prone
The prone position is lying face down, which is not suitable for sigmoidoscopy.
D. Knee-chest
During sigmoidoscopy, the client should lie on their left side with their right knee flexed slightly. The nurse should then position the client in the knee-chest (Sims) position, where the client leans forward with bent knees and support the chest and forearms on the table or a pillow. This allows better visualization and access to the rectal area for the sigmoidoscopy procedure.
Full Explanation
knee-chest. During sigmoidoscopy, the client should lie on their left side with their right knee flexed slightly. The nurse should then position the client in the knee-chest (Sims) position, where the client leans forward with bent knees and support the chest and forearms on the table or a pillow. This allows better visualization and access to the rectal area for the sigmoidoscopy procedure.
An explanation for incorrect choices:
A. Orthopneic position is upright sitting with arms and elbows resting on a table or on a pillow, which helps clients who have difficulty breathing; it is not suitable for sigmoidoscopy.
B. Trendelenburg position
is supine with the head lower than the feet, which can cause blood flow to the head and increased intracranial pressure; it is not suitable for sigmoidoscopy.
C. Prone position is lying face down, which is not suitable for sigmoidoscopy.
A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take?
A. Cover the pad prior to use.
This is a necessary precaution to prevent burns
B. Fill the pad with sterile water.
incorrect because filling the pad with sterile water is not necessary
C. Apply the pad for 45 min at a time.
incorrect because aquathermia pads should only be applied for 20-30 minutes at a time
D. Use safety pins to secure the pad in place.
incorrect because using safety pins to secure the pad in place can puncture the pad and cause burns.
Full Explanation
The correct answer is choice A, "Cover the pad prior to use." This is a necessary precaution to prevent burns. Choice B is incorrect because filling the pad with sterile water is not necessary. Choice C is incorrect because aquathermia pads should only be applied for 20-30 minutes at a time. Choice D is incorrect because using safety pins to secure the pad in place can puncture the pad and cause burns. Choice B is not correct because filling the pad with sterile water is not necessary. Choice C is not correct because aquathermia pads should only be applied for 20-30 minutes at a time. Choice D is not correct because using safety pins to secure the pad in place can puncture the pad and cause burns.