Nokea
An adult is admitted to the long-term care facility. She had a cerebrovascular accident and no longer needs acute care. The client has left side hemiplegia. Because of the type of deficit the client has, the nurse knows that this woman is at increased risk for which of the following?
- A. Speech and language deficits
- B. Slow and cautious behavior
- C. Difficulty with visual-spatial relationships
- D. Hearing deficits
Correct Answer: C
Rationale: Left hemiplegia from a right brain CVA increases risk for visual-spatial deficits, as the right hemisphere processes spatial awareness, unlike speech (left hemisphere), behavior, or hearing.
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An adult had a thyroidectomy under local anesthesia and is now in the postanesthesia care unit. Which finding is of most concern to the nurse?
- A. The client complains of a sore throat.
- B. The client's hand involuntarily clenches when the nurse checks the blood pressure.
- C. The client is sitting upright in the bed.
- D. The client asks for a drink of water.
Correct Answer: B
Rationale: Involuntary hand clenching (Trousseau's sign) suggests hypocalcemia from parathyroid damage during thyroidectomy, a serious complication requiring immediate attention. Sore throat, upright position, or thirst are less urgent.
A male client calls for a nurse because of chest pain. Which statement by the client would require the most immediate action by the nurse?
- A. When I take in a deep breath, it stabs like a knife.'
- B. The pain came on after dinner. That soup seemed very spicy.'
- C. When I turn to the left, it feels like my heart is being squeezed.'
- D. The pain radiates to my jaw and left arm.'
Correct Answer: D
Rationale: Chest pain radiating to the jaw and left arm is a classic symptom of myocardial infarction, requiring immediate action to assess for a life-threatening cardiac event.
The nurse is caring for a client who has bleeding esophageal varices. What should the nurse expect might develop in this client? Select all that apply.
- A. Confusion
- B. Tarry stools
- C. Lower abdominal pain and pressure
- D. High blood pressure
- E. Tremors
- F. Hallucinations
Correct Answer: A,B
Rationale: Bleeding varices cause blood loss, leading to tarry stools (melena) from digested blood and confusion from hepatic encephalopathy due to liver dysfunction. Abdominal pain, hypertension, tremors, or hallucinations are less directly related.
The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply.
- A. Apply a water-based lubricant to the enema tube before insertion
- B. Assist the client into left lateral position with right knee flexed
- C. Encourage the client to retain the enema for as long as possible
- D. Keep the enema solution refrigerated until ready to administer
- E. Stop the infusion briefly if the client reports abdominal cramping
Correct Answer: A,B,C,E
Rationale: Lubricating the tube (A), left lateral positioning (B), retaining the enema (C), and pausing for cramping (E) are correct for safe administration. Refrigerating the solution (D) is incorrect; it should be at body temperature.
The nurse is caring for a client who was recently prescribed methadone for chronic, severe back pain. The client indicates taking extra tablets in the last 6 hours when the pain recurred. Which findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply.
- A. Falls asleep when the nurse is talking
- B. Frequently scratches from pruritus
- C. Has third emesis since taking medication
- D. Monitor shows occasional premature ventricular contractions
- E. Pulse oximetry reading is 92%
Correct Answer: A,C,D
Rationale: Falling asleep (A), vomiting (C), and premature ventricular contractions (D) indicate possible methadone overdose or toxicity, requiring extended monitoring. Pruritus (B) is a common side effect, and 92% oxygen saturation (E) is not critical.