A nurse approaches a hospitalized poststroke patient from the patient’s left side to do an assessment. The patient is staring straight ahead, and does not respond to the nurse’s presence or voice. Which action should the nurse take first?

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Question 1 of 5

A nurse approaches a hospitalized poststroke patient from the patient’s left side to do an assessment. The patient is staring straight ahead, and does not respond to the nurse’s presence or voice. Which action should the nurse take first?

Correct Answer: A

Rationale: Rationale: 1. By approaching the patient from the other side, the nurse can assess if the patient has a visual field deficit. 2. This step helps determine if the lack of response is due to a sensory issue. 3. It allows the nurse to rule out unilateral neglect or hemianopsia. 4. Walking to the other side is a basic assessment technique to evaluate visual and sensory deficits in poststroke patients. Other Choices: B. Speaking more loudly and clearly may not address the potential sensory issues the patient is experiencing. C. Waving fingers in front of the patient's face does not provide a comprehensive assessment of visual field deficits. D. Using a picture may be helpful, but addressing the potential visual field deficit should be prioritized first.

Question 2 of 5

A client on hemodialysis is complaining of muscle weakness and numbness in his legs. His lab results are: Na 136 mEq/L, K 5.9 mEq/L, Cl 100 mEq/L, ca 8.5 mg/dl. Which electrolyte imbalance is the client suffering from?

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In hemodialysis, potassium levels can be elevated due to impaired renal excretion. High potassium can lead to muscle weakness and numbness. The client's K level of 5.9 mEq/L is above the normal range (3.5-5.0 mEq/L), confirming hyperkalemia. Na, Cl, and Ca levels are within normal limits, ruling out hypernatremia, hypochloremia, and hypocalcemia as the client's primary electrolyte imbalance. Monitoring and managing hyperkalemia are crucial to prevent life-threatening complications like cardiac arrhythmias.

Question 3 of 5

Clinical manifestations of Huntington’s disease include:

Correct Answer: D

Rationale: The correct answer is D because Huntington's disease is a neurodegenerative disorder that presents with a triad of symptoms: abnormal involuntary movements (chorea), intellectual decline, and emotional disturbances. Abnormal involuntary movements are a hallmark feature, while cognitive decline and emotional disturbances are also commonly observed. Therefore, all three manifestations are typically present in individuals with Huntington's disease. Choices A, B, and C are incorrect because each of these symptoms alone does not encompass the full spectrum of clinical manifestations seen in Huntington's disease.

Question 4 of 5

The nurse recognizes that the major early problem for Mr. Gabatan will be:

Correct Answer: A

Rationale: The correct answer is A: Bladder control. This is the major early problem for Mr. Gabatan because urinary retention is a common complication post-surgery, especially for older males like him. Bladder control is essential for preventing urinary tract infections and maintaining overall health. Quadriceps setting (B) and client education (C) are important but not as critical early on. Use of aids for ambulation (D) is important but not the major early problem compared to bladder control in this case.

Question 5 of 5

What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?

Correct Answer: A

Rationale: The correct answer is A: Expressive aphasia and paralysis on the right side of the body. In a right-handed person, the left side of the brain controls language and right-sided motor function. A stroke affecting the left side of the cortex would lead to expressive aphasia due to damage to Broca's area, causing difficulty in speaking and forming words. Paralysis on the right side of the body would result from damage to the motor cortex in the left hemisphere. Choices B, C, and D are incorrect because they do not align with the typical deficits seen in a person with a stroke affecting the left side of the cortex in a right-handed individual.

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