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The nurse is reviewing the care plan of a client diagnosed with having the deficits associated with a right-sided stroke. The nurse notes documentation that the client has unilateral neglect with left-sided deficits. The nurse plans care with the understanding that which action would be least helpful?
- A. Place bedside articles on the left side.
- B. Approach the client from the right side.
- C. Teach the client to scan the environment.
- D. Move the commode and chair to the left side.
Correct Answer: B
Rationale: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. Personal care items, belongings, a bedside chair, and a commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and caregivers as well.
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A client has a reddened area over a bony prominence. The nurse finds a nursing assistant massaging this area. The nurse should:
- A. Reinforce the nursing assistant's use of this intervention over the bony prominence.
- B. Explain to the nursing assistant that massage is effective because it improves blood flow to the area.
- C. Inform the nursing assistant that massage is even more effective when combined with the use of lotion.
- D. Instruct the nursing assistant that massage is contraindicated because it decreases blood flow to the area.
Correct Answer: D
Rationale: Massage over a reddened area on a bony prominence is contraindicated as it can further damage tissue and reduce blood flow, increasing the risk of pressure ulcers. The nurse should instruct the assistant to stop massaging the area to prevent harm.
Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tissue perfusion related to interruption of arterial flow? Select all that apply.
- A. Extremities warm to touch.
- B. Improved respiratory status.
- C. Decreased muscle pain with activity.
- D. Participation in self-care measures.
- E. Lungs clear to auscultation.
Correct Answer: A,C,D
Rationale: Warm extremities, reduced muscle pain, and self-care participation indicate improved perfusion; respiratory outcomes are unrelated.
A client with a history of rheumatoid arthritis is prescribed methotrexate. The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hyperkalemia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, requiring regular liver function tests.
Communicating with parents and children about health care has become increasingly significant because:
- A. Consumers of health care cannot keep up with rapid advances in science.
- B. The influence of the media and specialization have increased the complexity of managing health.
- C. Nurse educators have recognized the value of communication.
- D. Clients are more demanding that their rights be respected.
Correct Answer: B
Rationale: Media influence and medical specialization have increased healthcare complexity, making clear communication essential to ensure understanding and informed decision-making.
A client develops an irregular heart rate. Which statement made by the client who has developed an irregular heart rate indicates to the nurse that the client is ready for learning?
- A. I feel weak with an irregular pulse.
- B. What is it like to have a pacemaker?
- C. All my medications will be changed now.
- D. How can this heart rate problem affect me?
Correct Answer: D
Rationale: Learning depends on two things: physical and emotional readiness to learn. A good time to teach is when the client indicates an interest in learning, is motivated, and is physically capable of concentrating on learning. Option 4 addresses the client's readiness because the client is directly asking about the disorder. Option 1 indicates that the client is potentially physically incapable of learning at this time. The client indicates wanting to learn about pacemakers in option 2; however, the client has formed a hasty conclusion because the need for a pacemaker has not been determined. In option 3, by assuming that the medications will change, the client is emotionally unprepared for learning because the statement is based on incomplete data.