The nurse is assigned to care for a client with complete right-sided hemiparesis. The nurse plans care knowing that this condition:

Correct Answer: B

Rationale: The correct answer is B because right-sided hemiparesis involves weakness on the right side of the body, including the face and tongue. This condition is not characterized by complete bilateral paralysis (A), the ability to walk independently (C, D), or the loss of movement in just the right arm (C, D). In right-sided hemiparesis, the weakness affects more than just the arm and may impact various parts of the body on the right side.

Correct Answer: B

Rationale: The correct answer is B because asking the patient what they had for breakfast this morning evaluates their recent memory. This question assesses the patient's ability to recall a specific event from the same day, testing their short-term memory. Choices A, C, and D do not focus on recent memory. Choice A tests long-term memory, choice C assesses immediate memory, and choice D evaluates remote memory. Therefore, B is the best question to evaluate recent memory.

Correct Answer: A

Rationale: The Romberg test is primarily performed to evaluate balance and coordination by assessing the proprioceptive function of the lower extremities. This test helps identify sensory ataxia, a condition where there is a loss of proprioception leading to impaired balance. Testing cranial nerve function (Choice B) involves different assessments, such as cranial nerve examination. Muscle strength (Choice C) is evaluated through manual muscle testing, not the Romberg test. Reflexes (Choice D) are typically assessed using tests like deep tendon reflexes, not the Romberg test. Thus, the correct answer is A as it aligns with the purpose and methodology of the Romberg test.

Correct Answer: D

Rationale: The correct answer is D because a positive Babinski sign in an adult indicates an abnormal response suggesting potential neurological dysfunction, specifically upper motor neuron pathology. This finding is concerning as it can indicate underlying issues such as spinal cord injury, brain tumor, or multiple sclerosis. In contrast, choices A and B are normal findings, indicating proper pupil response and equal strength, respectively. Choice C also indicates normal mental status. So, a positive Babinski sign is the most concerning because it suggests potential serious neurological issues, while the other choices are within normal parameters.

Correct Answer: A

Rationale: The correct answer is A: Joint mobilization. Joint mobilization involves skilled passive movement techniques applied to a joint to restore motion. In adhesive capsulitis, there is restricted motion due to adhesions within the joint capsule. Joint mobilization helps break down these adhesions, improving range of motion. Electrical stimulation (B) and ultrasound therapy (C) may help with pain management but do not directly address the joint restriction. Postural training (D) may be beneficial for overall shoulder function but is not the most direct intervention for improving range of motion in adhesive capsulitis.