Nokea
A stroke victim regains consciousness three days after admission. She has right-sided hemiparesis and hemiplegia and also has expressive aphasia. She becomes upset when she is unable to say simple words. The best approach for the nurse is to do which of the following?
- A. Stay with her and give her time and encouragement in attempting to speak.
- B. Say, 'I'm sure you want a glass of water. I'll get it for you.'
- C. Say, 'Don't get upset. You rest now and I'll come back later and try to talk to you then.'
- D. Encourage her attempts and say, 'Don't worry, it will get easier every day.'
Correct Answer: A
Rationale: Staying with the client and offering encouragement supports her attempts to speak, fostering communication and emotional support.
You may also like to solve these questions
The nurse is examining the client's ear using an otoscope and sees the image illustrated. Which documentation by the nurse is best?
- A. Tympanic membrane ruptured, no excessive cerumen
- B. External ear canal showing no lesions or drainage
- C. Tympanic membrane cone of light reflex distorted
- D. Bony landmarks prominent on tympanic membrane
Correct Answer: C
Rationale: The tympanic membrane shown is reddened, and the cone of light is distorted, indicating increased pressure behind the tympanic membrane. The membrane is intact, the external canal is not shown, and bony landmarks are not prominent.
The client comes to the clinic and is diagnosed with otitis media. Which intervention should the clinic nurse include in the discharge teaching?
- A. Instruct the client not to take any over-the-counter pain medication.
- B. Encourage the client to apply cold packs to the affected ear.
- C. Tell the client to call the HCP if an abrupt relief of ear pain occurs.
- D. Wear a protective ear plug in the affected ear.
Correct Answer: C
Rationale: Abrupt pain relief in otitis media may indicate tympanic membrane rupture, requiring HCP notification. OTC pain meds are safe, cold packs are less effective, and ear plugs are unnecessary.
The client recovering at home following a stapedectomy for otosclerosis reports having dizziness. To decrease symptoms, which interventions should the nurse recommend? Select all that apply.
- A. Refrain from sudden movements.
- B. Avoid chewing on the affected side.
- C. Avoid lifting objects that are heavy.
- D. Minimize bending over at the waist.
- E. Restrict the intake of oral fluids.
Correct Answer: A,C,D
Rationale: Refraining from sudden movements, avoiding heavy lifting, and minimizing bending decrease dizziness by reducing fluid shifts in the inner ear. Chewing and fluid restriction do not affect dizziness.
A 17-year-old client had one generalized convulsion several hours prior to admission to the medical unit for a neurological workup. Physician's orders include Dilantin (phenytoin) 100 mg orally (PO) tid and phenobarbital 100 mg PO daily. He tells the nurse, 'I can't believe I really had a seizure. My mom says she was in the room when it happened, but I don't even remember it.' What is the best interpretation of his comments?
- A. They indicate an initial denial mechanism, but he will begin to remember the seizure later.
- B. Anoxia suffered during the seizure has damaged part of his cerebral cortex.
- C. Inability to remember the seizure is a normal response of a person who has had a seizure.
- D. They are an indication that he would rather not talk about his seizure at this time.
Correct Answer: C
Rationale: Amnesia for the seizure event is a normal response due to altered consciousness during a generalized seizure.
The nurse is assessing the client's cranial nerves. Which assessment data indicate cranial nerve I is intact?
- A. The client can identify cold and hot on the face.
- B. The client does not have any tongue tremor.
- C. The client has no ptosis of the eyelids.
- D. The client is able to identify a peppermint smell.
Correct Answer: D
Rationale: Cranial nerve I (olfactory) is assessed by identifying smells like peppermint. Temperature sensation (trigeminal), tongue movement (hypoglossal), and ptosis (oculomotor) involve other nerves.