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The nurse is caring for a client who has recently had a cerebrovascular accident (CVA). When positioning the client and supporting her extremities, the nurse must remember that when voluntary control of muscles is lost:
- A. the feet will maintain a position of eversion.
- B. the upper extremities will rotate externally.
- C. the hip joint will rotate internally.
- D. flexor muscles will become stronger than extensors.
Correct Answer: D
Rationale: After a CVA, flexor muscles become stronger than extensors, leading to flexion contractures, requiring careful positioning to prevent deformities.
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The client recently diagnosed with glaucoma tells the nurse, 'I'm having difficulty remembering to insert my eye drops. I don't have any pain or vision changes when I forget them.' Which statement is the best response?
- A. You should be diligent in inserting the eye drops; if not, then you will need surgery.
- B. You wouldn't have pain, but untreated glaucoma will eventually lead to vision loss.
- C. Tell me about your day; planning a time with a daily activity often helps as a reminder.
- D. I know this must be hard for you; not everyone is able to remember everything.
Correct Answer: C
Rationale: This is a broad opening statement and can assist the client to problem-solve an activity that could serve as a reminder to take the eye drops. The other statements are either belittling, partially incorrect, or do not help with adherence.
The nurse is concerned that the Caucasian client experiencing a stroke may have impaired hearing. Which observations of the client's behavior prompted this concern? Select all that apply.
- A. Nods and agrees to all statements made by the nurse
- B. Asks for more information about the therapy schedule
- C. Slow to respond verbally but answers questions appropriately
- D. Speaks in an excessively loud tone of voice
- E. Leans in toward the nurse when the nurse speaks
Correct Answer: A,D,E
Rationale: Nodding and agreeing to all statements, speaking loudly, and leaning toward the speaker suggest hearing impairment. Asking for schedule details and slow but appropriate responses do not indicate hearing issues.
The client following removal of a right-sided acoustic neuroma by a translabyrinthine approach calls the nurse to report pain. The nurse finds that the client has new-onset right-sided facial drooping and numbness. Place the nurse's actions in priority order.
- A. Close the client's right eye and place a patch over it.
- B. Assess the operative incision site and assess the arms for drift.
- C. Contact the stroke team and the HCP.
- D. Medicate the client for pain unless contraindicated.
Correct Answer: B,C,D,A
Rationale: Assess the incision and arms for drift first (B), then contact the stroke team and HCP for possible complications (C), medicate for pain (D), and finally patch the eye due to inability to close it (A).
Which teaching instruction should the nurse discuss with students who are on the high school swim team when discussing how to prevent external otitis?
- A. Do not wear tight-fitting swim caps.
- B. Avoid using silicone ear plugs while swimming.
- C. Use a drying agent in the ear after swimming.
- D. Insert a bulb syringe into each ear to remove excess water.
Correct Answer: C
Rationale: A drying agent (e.g., alcohol-based drops) prevents external otitis by removing moisture. Swim caps and ear plugs are protective, and bulb syringes risk trauma.
The nurse is questioning the client about vision changes. Which symptom indicates that the client may be developing a cataract?
- A. Blurred vision, worsening at night
- B. Shooting pain in the back of one eye
- C. Increased frequency of headaches
- D. Seeing spots in the vision field of one eye
Correct Answer: A
Rationale: The lens opacity from a developing cataract diminishes vision. Blurriness and decreased night vision are early symptoms. Shooting eye pain is often associated with a subarachnoid hemorrhage, not a cataract. Headaches are not associated with cataract formation. Floating dark spots in the vision field are associated with bleeding within the eye that occurs with detached retina.