Nokea
A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patients plan of care?
- A. Adult failure to thrive
- B. Post-trauma syndrome
- C. Hyperthermia
- D. Disturbed sensory perception
Correct Answer: D
Rationale: Disturbed sensory perception is a common stroke-related diagnosis due to sensory deficits. Other options are less directly associated.
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A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurses care of this patient?
- A. The patient should be approached on the side where visual perception is intact.
- B. Attention to the affected side should be minimized to decrease anxiety.
- C. The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation.
- D. The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.
Correct Answer: A
Rationale: Approaching on the intact visual side ensures the patient notices the nurse, reducing confusion. Encouraging head turning to the affected side compensates for deficits.
A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities?
- A. Place the patient in the prone position for 30 minutes/day.
- B. Assist the patient in acutely flexing the thigh to promote movement.
- C. Place a pillow in the axilla when there is limited external rotation.
- D. Place patients hand in pronation.
Correct Answer: C
Rationale: A pillow in the axilla prevents shoulder adduction, reducing deformity risk. Prone positioning aids hip extension, not daily for 30 minutes. Acute thigh flexion may cause edema, and hand pronation is less functional than supination.
A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?
- A. Sit with the patient for a few minutes.
- B. Administer an analgesic.
- C. Inform the nurse-manager.
- D. Call the physician immediately.
Correct Answer: D
Rationale: A severe headache may indicate aneurysm leakage, requiring immediate physician notification. Analgesics or sitting with the patient delays critical intervention.
A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patients safety during mobilization, the nurse should perform what action?
- A. Support the patients full body weight with a waist belt during ambulation.
- B. Have a colleague follow the patient closely with a wheelchair.
- C. Avoid mobilizing the patient in the early morning or late evening.
- D. Ensure that the patients family members do not participate in mobilization.
Correct Answer: B
Rationale: A wheelchair nearby ensures safety if the patient becomes fatigued or dizzy. Family participation is encouraged, and timing is not restricted.
What should be included in the patients care plan when establishing an exercise program for a patient affected by a stroke?
- A. Schedule passive range of motion every other day.
- B. Keep activity limited, as the patient may be over stimulated.
- C. Have the patient perform active range-of-motion (ROM) exercises once a day.
- D. Exercise the affected extremities passively four or five times a day.
Correct Answer: D
Rationale: Passive ROM four to five times daily prevents contractures and maintains mobility. Active ROM should be more frequent, and limited activity is not ideal.