NCLEX
Oral herpes simplex type I is more often manifested by lesions on the lips or nose (cold sores/fever blisters) and is contagious, but not through
The birth canal Birth canal would be type II
A client presents to the emergency department (ED) reporting fever, cough, and malaise. The nurse notes that the client has a rash appearing as vesicles, most prominently on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do?
The client may have smallpox, which is very contagious. The smallpox can also as a weapon in biological warfare. The first thing the nurse should do is place the client into a negative pressure room. Doing this first will protect others from potential exposure.
How do you remove hair before surgery? Shave, clip, cream?
Use clippers or depilatory cream (Nair) Do NOT use razors
Treatment for glaucoma
Use of a prostaglandin agonist eye drop The color of the eye (the iris may darken) may change, but they client is to only administer drops to the effected eye. The lashes in the eye being treated will lengthen as opposed to the untreated eye.
BMI Calcuation
Wt in pounds x 703 / (ht in inches) squared
A client was admitted to the psychiatric unit with delusions and a history of auditory hallucinations. The client reports, "The FBI has been watching my house and are going to raid it and arrest me." What is the nurse's best response?
"I believe your thoughts are very disturbing to you" DO NOT SAY "tell me more about your thoughts" because that is reinforcing a false reality
Normal Lithium Level
0.5-1.2
Important teaching topics for parents related to child safety
Everyone should know the basics of swimming (floating, moving through the water) Parents should know cardiopulmonary resuscitation (CPR). Create and practice a family fire escape plan, and involve kids in the planning. Make sure everyone knows at least two ways out of every room and identify a central meeting place outside. Falls on playgrounds are common and can cause serious injury. Wood chips or sand, not dirt or grass should be under playground equipment. Having a gate at the top and bottom of stairs can prevent falls.
Dobutamine
For CHF Blood pressure support It can treat heart failure Help the heart pump blood
The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client?
Low thyroid clients have constipation so they must increase fiber.
My chicken has TB
Measles Chicken pox Herpes zoster TB
My chicken has TB (Airborne)
Measles Chicken pox Herpes Zoster TB
The nurse is assessing a client for crutches. How does the nurse choose the correct size of crutches for a client?
Measuring the client from 3 finger widths below the axilla to 6 inches lateral to the client's heel correctly measures a client for crutches
Which signs/symptoms should the nurse assess for when caring for a client diagnosed with bulimia nervosa?
Muscle cramps Tingling of lips Constipation The typical abnormalities associated with bulimia are hypokalemia and metabolic alkalosis. Muscle cramps, weakness, fatigue, constipation, arrhythmias. Hypokalemia leads to metabolic alkalosis.
Both cyclosporine and azathioprine are immunosuppressants. Clients should be taught to
Protect themselves from sources of infection - avoid crowds Vaccinations are not given to immunocompromised clients These drugs may lead to bleeding - use soft bristle tooth brush These drugs are teratogenic - use two forms of contraception Clients should avoid pregnancy while on these medications.
Vitamin B 6?
Pyroxidine Given to prevent peripheral neuropathy with isoniazid use to treat TB
What is the only fibrinolytic approved by the FDA to treat thrombotic occusions.
Alteplase Tissue plasminogen activator (abbreviated tPA or PLAT) is a protein involved in the breakdown of blood clots
Wearing ppe in order:
Hand wash Gown Mask Goggles Gloves
DKA
May have abdominal pain Kussmauls Fruity breath
Indomethacin is used after a CABG to treat
Pain Inflammation Fever
The nurse is caring for a primipara client at 27 weeks gestation. Which client learning need should the nurse identify as priority at this stage of pregnancy?
S/s of preterm labor
What should be included in sex teaching to college students
Safe sex practices Proper use of a condom Sexual abstinence
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?
The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium
Normal Digoxin Level
1.5-2.5
Potassium chloride should be diluted and administered to infuse no faster than
20 mEq per hour
Pheochromocytoma
Characterized by hypertension, hypermetabolism, hyperglycemia, and headache due to increased release of epinephrine and norepinephrine.
Don't give beta blockers if: HR < BP <
HR < 60 BP < 90/60
Duchennes muscular dystrophy
Waddling gait Walking on toes
How do native americans deal with pain
"Im doing fine. Pain is not bad" The Native American client is likely to be quiet and less expressive of pain. Native Americans tend to tolerate high levels of pain.
What to consider when making room assignments if private rooms are not available
1. Similar disease 2. Same sex 3. Same age
A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B12 intramuscularly. What should the nurse include in discharge instructions?
B12 injections will be continued for the rest of the child's life With pernicious anemia, the client lacks the intrinsic factor. Without the intrinsic factor, B12 cannot be absorbed. The client will require B12 shots throughout the lifespan.
Chicken pox
Direct contact Indirect contact Airborne
The home health nurse is admitting a client with Parkinson's disease to the home healthcare service. In planning care for this client, which nursing diagnosis has priority?
Impaired physical mobility related to muscle rigidity and weakness. (Not ineffective breathing pattern, this is not an issue with Parkinsons)
How do you teach a patient about an upper GI
In an upper GI series, the client swallows barium contrast while x-rays are taken. Pt will have to drink contrast while x-rays are taken
The nurse is caring for a client while fluorouracil is being infused. The client reports burning at the intravenous (IV) site. What should the nurse do first?
Stop the infusion Put on an ice pack
Which information should the nurse plan to teach to family members of a client diagnosed with hepatitis B to decrease their risk of exposure?
Do not share personal items such as razors or toothbrushes
Meningitis
Droplet
Normal INR
2-3
What is a clinical pathway
A set of practice guidelines based on a specific client diagnosis, which provides an overview of the multidisciplinary plan of care. Used by case managers
What kind of comments should the nurse expect from a client exhibiting clang associations?
The client may use rhyming words, such as dog, bog, cog, jog
Which client should the nurse recognize as being at greatest risk for the development of cancer?
Cancer has a high incidence in the immune deficiency client and in the older adult. This one is highest.
Most stable assistive device for a client with an unsteady gait?
A walker, with four wide, sturdy legs
A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide?
AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual. individual who is not otherwise immunosuppressed (PCP, candidacies, crytpococcus, cryptosporidiosis, Kaposi's sarcoma, CNS lymphomas)
A client diagnosed with cancer has been losing weight. What should the nurse teach the client regarding methods for improving nutritional needs to maintain weight?
Add butter to foods. Spread peanut butter on apples and bananas. Add powdered creamer to milkshake. Use biscuits to make sandwiches. Put honey on top of hot cereal.
At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure reading was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night. What action should the nurse take first?
Administer PRN prescription of nifedipine (Procardia) sublingually. Sublingual Procardia lowers blood pressure very quickly, and this should be done first
A client is admitted to the intensive care unit after overdosing on meperidine. What is the nurse's first priority?
Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn.
A client's dose of isosorbide dinitrate (Imdur) is increased from 40 mg to 60 mg PO daily. When the client reports the onset of a headache prior to the next scheduled dose, which action should the nurse implement?
Administer the 60 mg dose of Imdur and a PRN dose of acetaminophen (Tylenol). Imdur is a nitrate which causes vasodilation. This vasodilation can result in headaches, which can generally be controlled with acetaminophen until the client develops a tolerance to this adverse effect
Calcium Gluconate
Calcium gluconate is administered IVP very slowly The max rate is 1.5- 2 mL/min. It counteracts the effects of hyperkalemia on cardiac excitability. "I will monitor for hypophosphatemia after administering this medication."Calcium and phosphorus have an inverse relationship to each other. As calcium goes up, phosphorus goes down. "This medication is given to reverse the effects of hypermagnesemia."
Chickenpox is transmitted from person to person by directly touching the blisters, saliva or mucus of an infected person (Direct contact). Chickenpox can be spread indirectly by touching contaminated items freshly soiled, such as clothing, from an infected person (Indirect contact). The virus can also be transmitted through the air by coughing and sneezing (Airborne).
Airbone transmission of infectious agents occurs either by: Airborne droplet nuclei (small particles of 5 mm or smaller in size); Dust particles containing infectious agents. Microoganisms carried in this manner remain suspended in the air for long periods of time and can be dispersed widely by air currents. Because of this, there is risk that all the air in a room may be contaminated. Some examples of microorganisms that are transmitted by the airborne route are: M. tuberculosis, rubeola, varicella and hantaviruses.
A positive (not negative) Ortolani's sign indicates
Congenital hip dislocation So this is normal for a healthy baby to have NEGATIVE Ortolani's sign
Neuroleptic malignant syndrome is a rare, but fatal complication of neuroleptic drugs. Routine assessments should include temperature and observation for parkinsonian symptoms. Symptoms include
Hyperpyrexia up to 107 degrees, tachycardia, tachypnea, fluctuations in BP, diaphoresis, coma.
The primary healthcare provider has prescribed hydromorphone 2 mg IV every 4 hours for post-op pain. When should the nurse plan to administer the analgesic to the client?
Prior to onset of intense pain and before acute pain has fully developed.
Guthrie test
The purpose of this test is to determine the presence of phenylketonuria, sickle cell, MCADD, TSH, etc in the blood. A positive test indicates a metabolic disorder. To conduct this test, a sample of blood is taken from the baby's heel. A lack of protein intake can interfere with the test. The test is done when the newborn is 6-7 days old
The nurse is teaching a newly diagnosed diabetic about the action of regular insulin. The nurse verifies that teaching has been successful when the client verbalizes being at greatest risk for developing hypoglycemia at what time following the 8:00 a.m. dose of regular insulin?
11:00 AM. Regular insulin peaks 2-3 hours after administration. Clients are at risk for hypoglycemia when insulin is at its peak.
Children should not sit in the front seat until age
12 years old
If FHT best heard above umbilicus, what position is the baby in
Breech
NPH Peak Long acting peak
NPH Peak: 6-8 Long acting peak: 8-12
Therapeutic range of Digoxin
0.5-2
Circurmoral cyanosis is bluish discoloration of and around the lips. It is an indicator of
Cyanotic heart defect.
A common side effect of SSRIs is
Increased sweating
Dopamine
It can treat symptoms of shock by improving blood flow.
A client in active labor has an epidural catheter inserted for management of pain. Which finding should the nurse report to the primary health care provider?
BP: 90/62 Hypotension is an adverse effect of epidural analgesia.
Alpha and beta adrenergic agonists, such as epinephrine and dopamine, are sympathomimetics used in the treatment of
Shock
T/F "Gloves do not have to be worn when taking a client's vital signs or passing out meal trays."
T
The primary healthcare provider should be notified if
The primary healthcare provider should be notified if 1. Harm is brought to the client 2. Death occurs as a result of the medication incident 3. Incorrect dosage to the client.
What is true about Ebola
"I canNOT get a vaccine to prevent getting the Ebola virus." "Ebola is not spread through casual contact, so my risk of getting the virus is low." "The Ebola virus is passed from person to person through blood and body fluid." "Ebola viruses are mainly found in primates in Africa.
The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider?
"I had rheumatic fever when I was 10 years old" Client with Hx of rheumatic fever will need to be pre-medicated with antibiotics prior to any surgical or dental procedure to prevent a recurrence.
A new mother asks the clinic nurse why her baby should receive recommended vaccinations. What is the best response by the nurse concerning vaccinations?
"They will help your baby to produce antibodies against disease causing organisms." Vaccines are suspensions of antigen preparations intended to produce a human immune response to protect the person from future encounters with the organism.
The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety?
Administration of a medication that the client is allergic to could result in harm to the client. The primary healthcare provider should be notified immediately of a medication prescription that conflicts with the client's list of medication allergies. The medication should be discontinued on the medication administration record, and the client's allergy band checked against the list of allergies documented in the medication record for accuracy.
The nurse is caring for a client who is preparing to undergo a total hysterectomy for advanced cervical cancer. The client is crying and states, "I want to have more children, and I am unsure if I should have the procedure." What should the nurse do?
Allow the client to discuss her fears, and encourage her to talk more with her primary healthcare provider. Can freeze eggs, NOT ovaries`
Parkinsons
Blank affect. Decreased ability to swing arms Pill-rolling tremor Stiff muscles
Who should have a private room
Client who has antibodies for Hep C should be in a PRIVATE room Presence of antibodies for Hepatitis C indicates HCV infection and possibly impaired immune function due to liver damage. Hepatitis C is transmitted by contact with body fluids and it is likely that lochia will be found on toilet surfaces. It is also common for postpartum women to have some kind of wound (perineal laceration or episiotomy) and they will be at increased risk of HCV contaminated lochia coming into contact with their wound.
What statements by a client diagnosed with a hiatal hernia would indicate to the nurse that the discharge teaching was effective?
Clients with a hiatal hernia should eat six small frequent meals, because large meals cause them to be symptomatic with heartburn and other symptoms. Sitting up for one hour after eating will keep the stomach down as much as possible. If they lie down, the stomach will go upward and cause regurgitation, heartburn, nausea, and fullness. Placing 10 inch blocks under the bed also helps keep the stomach downward and reduces symptoms when the client sleeps. One of the major causes and aggravating actions for a hiatal hernia is straining. Therefore, the clients do not need to be lifting heavy objects. Client may be prescribed laxatives so that the patient does not strain at stool.
A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 pounds (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse do?
Consult with the pharmacy for a different medication concentration. This would require 5.4 mL to be injected. This would require 3 injections. Max is 2 mL per IM injection. The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy.
Phototherapy for baby with hyperbili
Dark urine is expected
A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action?
Decrease stimuli in the room. A stimulating environment may increase anxiety.
Precautions for meningococcal meningitis
Droplet
The only time you perform a venipuncture on an AV shunt is
During dialysis (do not perform if you're assessing if patent)
Primapara
Giving birth for the first time
PPE Removal:
Gloves Goggles Gown Mask
A client returned to the unit following a total hip replacement. What statement by the client would indicate to the nurse that teaching has been successful?
I will not elevate HOB. Patient should not work out for 3-6 months. The legs should be kept in an abducted (legs apart) position following surgery to keep the head of the femur in the acetabulum (hip in the socket). An abductor pillow is often used to accomplish this and prevent the legs being close together or crossing.
The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit?
Jaundiced conjunctiva
What to expect with Nitroglycerin
Nitroglycerin is to be taken sublingually. Do not swallow. The medication may or may not burn or fizz when placed under the tongue. Because hypotension occurs due to vasodilation, the client should sit or lie down when taking. The most common side effect is headache.
The nurse will be admitting a client from the operating room following a left pneumonectomy for adenocarcinoma. Which type of chest drainage should the nurse anticipate that the client will have?
No chest drainage will be Pneumonectomy means the ENTIRE lung has been removed...Where does a chest tube go? Into a pleural space. If your lung is gone, then the pleural space is gone.
A client is being treated in the emergency department for dehydration. Which central venous pressure (CVP) reading would the nurse identify as the desired response to treatment?
Normal CVP is 2-6mmHg
A pregnant client has been receiving daily heparin injections for a history of deep vein thrombosis (DVTs) during pregnancy. Which laboratory test result should be immediately reported to the primary healthcare provider?
PTT 22 The test that monitors the efficacy of heparin is the PTT. The normal range for a PTT is 30-40 seconds, but desired outcome of heparin therapy is PTT of 1.5-2.5 times the control without signs of hemorrhage.
A nurse attaches a client to continuous cardiac monitoring due to a potassium level of 2.8 mEq (2.8 mmol). The nurse should monitor for which dysrhythmia?
PVCs The earliest EKG change is often premature ventricular contractions (PVCs), which can deteriorate into ventricular tachycardia or fibrillation (VT/VF) without appropriate potassium replacement.
A pediatric nurse notes a "chubby" toddler who is pale. According to the parent, the toddler is easily fatigued. Based on this data, what initial question should the nurse ask the parent?
Pale and chubby - Think iron deficiency anemia. The best question to ask to assess intake: "How much milk does your toddler drink in a day?"
Risk factors for varicose veins
Sitting or standing for prolonged periods of time, obesity, female gender, wearing high-heeled shoes
Inhaler use
The client should exhale completely before using the inhaler The client should inhale slowly and push down firmly on the inhaler when administering the medication The client should rinse the mouth after using the inhaler to prevent thrush The client should use the bronchodilator before the steroid inhaler For inhaled quick-relief medication (beta2-agonists), wait about one minute between puffs
Which interventions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing?
Warm cleansing solutions to body temperature. Clean the wound when there is drainage present. Use sterile forceps when cleaning the wound. Using cleansing solutions at body temperature enhances the healing process by not lowering the temperature of the wound. Drainage should be removed so that it does not become infected. Sterile forceps should be used so that contaminated hands/gloves do not increase the risk of infection at the wound site.
The nurse administers an intramuscular injection to a client. When the nurse aspirates prior to injecting, the nurse notices a small amount of blood in the syringe. Which action is most appropriate for the nurse to take?
Withdraw the needle and restart the process with new medication and equipment.
Droplet Precautions SSS PPP IDER MMM An
private room mask S - Sepsis S - Scarlet fever S - Streptococcal pharyngitis P - Parvovirus B19 P - Pertussis P - Pneumonia I - Influenza D - Diptheria (Pharyngeal) E - Epiglottitis R - Rubella M - Mumps M - Meningitis M - Mycoplasma or meningeal pneumonia An - Adenovirus
The nurse is teaching a client regarding buspirone. The nurse recognizes that teaching has been effective when the client makes which statements?
"I should not drink alcohol while taking this medication." "I will rise slowly from lying to sitting or standing." "I will notify my primary healthcare provider of a sore throat, fever, or unusual bleeding." Buspirone (Buspar) is a psychotropic anxiolytic
What would you teach a client who is going for hemodialysis about their nutrition HEMO D (DECREASE DECREASE DECREASE)
(D) The client will get dialyzed every other day so restrict fluid intake. (D) Restrict sodium to decrease thirst and fluid excess (D)Restrict potassium to decrease the risk of heart arrhythmias associated with hyperkalemia Normal protein intake Low phosphorus foods are needed because phosphorous foods are high in protein.
Cycle of Abuse
1. In the tension-building phase, minor physical violence may occur as well as verbal arguments (Ex: Shoving and yelling) 2. The acute battering phase includes the release of tension through extreme physical violence. 3. The honeymoon phase is characterized by remorse with promises never to hurt the victim again.
Regular insulin peaks how long after administration? Clients are at risk for hypoglycemia when insulin is at its peak.
2-3 hours It has an onset of 30 minutes. Peak is 2-3 hours.
A client with a history of peptic ulcer disease arrives at the emergency department reporting weakness, and vomiting "a lot of dark coffee-looking stomach contents." The client's skin is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Which primary healthcare provider prescription will the nurse perform first?
2L/min NC Always Oxygen first Oxygen needs to be initiated first because of decreased blood volume
Once the seat belt fits properly-typically when the child reaches _______ inches, the child can sit in the back seat
57 inches tall
Ovulation ceases with Depo-Provera use. It may take how long to reestablish normal ovulation and menstruation.
6 to 18 months
Which dosing schedule should the nurse teach the client to observe for a controlled-release oxycodone prescription?
A controlled-release oxycodone provides long-acting analgesia to relieve moderate to severe pain, so a dosing schedule of every 12 hours provides the best around-the-clock pain management. Controlled-release oxycodone is not prescribed for breakthrough pain on a PRN or as needed schedule.
Methylergometrine is a smooth muscle constrictor that mostly acts on the
Acts on the uterus. Used to prevent or control 1. Excessive bleeding following childbirth and spontaneous or elective abortion 2. Expulsion of retained products of conception after a missed abortion (miscarriage in which all or part of the fetus remains in the uterus) and to help deliver the placenta after childbirth Cardiovascular side effects have included palpitations, hypertension, hypotension, acute myocardial infarction, transient chest pains, arterial spasm (coronary and peripheral), bradycardia, and tachycardia. These need to be reported to the primary healthcare provider.
The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action?
All hazardous materials must have a MSDS, which includes the identity of the chemical, the physical and chemical characteristics, the physical and health hazards, primary routes of entry, exposure limits, precautions for safe handling, controls to limit exposure, emergency and first-aid procedures, and the name of the manufacturer or distributor.
A decision-making flowchart that uses the if/then method is the definition of
An algorithm
Rubella non-immunity carries risks only to
An unborn fetus (In the first 12 weeks)
Buspar (Buspirone)
Anxiolytic psychotropic drug Treats GAD (General Anxiety Disorder)
A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?
Are you ever alone when you hear the voices? Determining if the client is alone when she hears voices will assist in differentiating between hallucinations and hearing loss; this is especially important in the aging population
The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? Assess patency of endotracheal tube. Auscultate lungs for adventitious breath sounds. Check for fluid in the ventilator tubing. Determine if ventilator settings are correct as prescribed.
Assess patency of endotracheal tube. With restlessness, think hypoxia. Start assessment with ABCs. Check for patency of the ET tube. That is the airway. Assess ET tube, then auscultate lungs, then check the tubing, then check the vent settings. Start with the patient first. Then move toward the ventilator. Always assess client first.
The nurse assesses a multigravida who is four hours postpartum. Findings include fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority? Massage fundus or assist client to void?
Assist client to void Fundus is firm (stated in the question) A distended bladder will displace the uterus, usually to the right.
Which discharge instructions should the nurse provide a client after cataract surgery?
Avoid bending over, as intraocular pressure can increase. Slip on shoes would eliminate the need to bend over. Hair can be washed as long as the client is in an upright position (in the shower) Avoid bending over a sink or tub to wash hair. It's normal to feel itching and mild discomfort for a couple of days after surgery. Avoid rubbing or pushing on the eye The client may be instructed to remove the protective shield placed from eye within several hours after the procedure The client will need to tape the shield back over the eye at night or during naps, for protection while recovering from cataract surgery. Should only have "wavy" vision for ONE hour
What medications should the nurse hold prior to sending a client to hemodialysis?
B complex vitamins Diltiazem Certain types of drugs will pass through the dialysis machine and not provide benefits to the client. These drugs are any type of water-soluble vitamins, so they should also be held before treatments. B complex vitamins are water soluble so will be lost during dialysis. Because the client's BP will drop during treatments, all antihypertensive drugs should be held before hemodialysis. Diltiazem is an antihypertension medication, so should be held since dialysis will also lower BP. (Hold ALL BP meds)
Which medication does the nurse expect will help decrease tremors in a client diagnosed with hyperthyroidism?
Beta Blockers help decrease anxiety and tremors with hyperthyroidism (Iodine compounds decrease the production of thyroid hormone but are not helpful for tremors)
Preterm Labor Drugs
Betamethasone is used to stimulate maturation of the baby's lungs in case preterm birth occurs. Magnesium sulfate is given to stop preterm labor Terbutaline is given to stop preterm labor, however, if delivery is imminent, then Betamethasone should be given to stimulate maturation of the baby's lungs. Methotrexate is used to stop the growth of the embryo in ectopic pregnancy so that the fallopian tube can be saved.
The nurse is providing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider?
Blurred vision, difficulty waking up, vomiting
While performing a vaginal examination on a client in labor, the nurse feels soft, squishy tissue instead of a head. What conclusion should the nurse make based on this assessment finding?
Breech position
How to add calories and protein for a cancer patient
Butter and oils added to foods adds calories. Spread peanut butter or other nut butters, which contain protein and healthy fats, on toast, bread, apple or banana slices, crackers or celery. Use croissants or biscuits to make sandwiches which provides more calories. Add powered creamer or dry milk powder to hot cocoa, milkshakes, hot cereal, gravy, sauces, meatloaf, cream soups, or puddings to add more calories. Top hot cereal with brown sugar, honey, dried fruit, cream or nut butter
uerto Rican clients tend to cope with pain
By loud and outspoken reports of pain.
A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain?
Carbon dioxide used intraperitoneally is irritating the phrenic nerve. Phrenic nerve irritation can result in referred pain to the left shoulder.
The client taking a monamine oxidase inhibitor (MAOI) such as tranylcypromine should avoid foods rich in tyramine or tryptophan. These include:
Cured foods, those that have been aged, pickled, fermented, or smoked. These can precipate a hypertensive crisis if eaten with MAOIs.
Do not use TPN if it looks
Do NOT use if looks curdled, oily, or has particles in it. TPN can infuse for 24 hours. Dressing should be dry and secured TPN should be at room temperature.
Independent nursing actions
Do not require an order Example: Monitor, assess, evaluate, educate (NOT " Administer medications as prescribed" because the nurse requires an order) If it requires an order, the nurse is not doing it independently
What should a nurse include when teaching a client diagnosed with shigellosis regarding how to prevent the spread of the infection to others?
Do not return to work until authorized by local health department. Do not prepare food for others while you are sick. Avoid swimming until fully recovered. No sex until several days after diarrhea has stopped
A client diagnosed with new onset atrial fibrillation has been prescribed dabigatran. What should the nurse teach this client?
Do not take with other anticoagulants PTT INR will not need to be monitored Take this medication with food Dabigatran decreases the risk of stroke and systemic embolism in clients with atrial fibrillation that is not associated with a cardiac valve problem. Take this medication with food to decrease gastric side effects such as dyspepsia and gastritis.
Dobutamine (Dobutrex) is an emergency drug most commonly prescribed for a client with which condition?
Dobutamine is a beta-1 adrenergic agonist that is indicated for short term use in cardiac decompensation or heart failure related to reduced cardiac contractility due to organic heart disease or cardiac surgical procedures. Beta agonist Helps the heart pump if CHF
A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate?
Droplet precautions Elevate HOB 30 degrees Pad side rails Provide sponge bath if temperature greater than 101 degrees F (38.3 degrees C) Darken room An acute onset of fever, headache, stiff neck, n/v, and mental status changes are consistent with bacterial meningitis. HOB elevated to promote comfort and decrease ICP. Increased risk for seizures, so pad the side rails. Sponge bath is appropriate for fever. Darken room as client with meningitis usually has photophobia.
A client is taking NSAIDs for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts the nurse to the possibility that the client is chronically losing small amounts of blood?
Elevated reticulocyte count Elevated reticulocyte count indicates increased production of RBCs. If a client is chronically losing blood, the body's response is to increase RBC production, so the retic count would increase.
S/S of? Petechiae on the trunk. Increasing CVP with decreasing BP. Pericardial friction rub. Widening pulse pressure.
Endocarditis: Petechiae on the trunk. Hallmark sign of Cardiac Tamponade: Increasing CVP with decreasing BP. Pericarditis: Pericardial friction rub. Increased intracranial pressure: Widening pulse pressure.
A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client?
Even though all are educational points that need to be provided to the client, this is the most important educational point to make. Keratitis, or the inflammation of the cornea, is one of the most dangerous complications for a client with Bell's palsy. As a precautionary measure, the nurse must ensure that the cornea is protected even if the eyelids will not close. Physical therapy will be needed, however care to prevent eye injury takes priority.
T/F "When caring for a client who has a suppressed immune response, a N95 mask should be worn."
F Standard precautions are needed. If there is a risk for coming in contact with client secretions or excretions, a standard mask may be worn.
Which signs and symptoms will the nurse include when teaching a client about indicators of recurrent nephrotic syndrome?
Foamy urine, which may be caused by excess protein in the urine, is seen with nephrotic syndrome. Swelling (edema), particularly around the eyes (periorbital) and in the ankles and feet, are symptoms. Proteinuria in lab results.
Ego Integrity versus Despair is the major task of those over 65: to review one's life and derive meaning from both positive and negative events, while achieving a positive sense of self.
Generativity versus Stagnation is the major task for 30-65 year olds: To achieve the life goals established for oneself while also considering the welfare of future generations. Intimacy versus Isolation is the objective from 20-30 year olds to form an intense, lasting relationship or a commitment to another person. Industry versus Inferiority is the major task for 6-12 year olds to achieve a sense of self confidence by learning, competing, performing successfully, and receiving recognition from significant others, peers, and acquaintances.
If you break sterile field while attempting to insert a urinary catheter,
Get on call light and ask for new catheter and sterile gloves Do not turn your back on your sterile field It is more cost efficient to have someone bring the nurse another catheter and pair of sterile gloves rather than getting an entire sterile kit
Hep B is spread by
Hepatitis B is spread when blood, semen, or other body fluid infected with the Hepatitis B virus enters the body of a person who is not infected. People can become infected with the virus during activities such as: 1. Birth (spread from an infected mother to her baby during birth) 2. Sex with an infected partner
Difference between Histoplasmosis Lyme disease Toxoplasmosis TB
Histoplasmosis is a fungal infection transmitted through ingestion of soil contaminated by bird manure (cough, fever, dyspnea, and hemoptysis) The classic symptom of Lyme disease is usually an expanding target-shaped or "bull's-eye" rash which starts at the site of the tick bite. Fever, headache, muscle aches and joint pain may also occur. Toxoplasmosis occurs from contact with cat feces. Symptoms may be influenza-like: swollen lymph nodes, headaches, fever, and fatigue, or muscle aches and pains. TB is often suspected however, the primary difference is exposure to bird feces.
A client diagnosed with mania and hypertension is hospitalized due to confusion and polyuria. Based on current data, what interventions should the nurse implement?
Hold the lithium carbonate dose. Notify primary healthcare provider of lithium level. Connect client to heart monitor. Pad the siderails of the client's bed. Symptoms of lithium toxicity begin to appear at blood levels greater than 1.5 mEq/L. Additionally, concurrent administration of lithium and diuretics such as furosemide increase the chance of toxicity. At serum levels of 1.5-2.0 mEq/L: blurred vision, ataxia, tinnitus, persistent nausea and vomiting, severe diarrhea. At serum levels of 2.0-3.5: excessive output of dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness. At serum levels above 3.5: impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction, cardiovascular collapse. Arrhythmias and seizures can occur with toxicity. So the lithium dose should be held and the healthcare provider notified. The client is at risk for arrhythmias, so connect to a heart monitor. The client is also at risk for seizures, so pad the siderails.
A child is being admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent?
Hx of pharyngitis approximately 4 weeks ago Rheumatic fever is often the result of untreated or improperly treated group A β-hemolytic streptococcal infections (GABHS), such as pharyngitis. Therefore, the history of pharyngitis or upper respiratory infection is a key assessment finding for establishing a diagnosis of rheumatic fever. Subsequent development of rheumatic fever usually occurs 2 to 6 weeks following the GABHS
An alert client presents to the emergency department with vomiting for 3 days, and unable to keep food or fluids down for the last 24 hours. What imbalance does the nurse suspect this client has?
Hypokalemia Metabolic Alkalosis Clients who vomit lose acid; therefore, they will have metabolic alkalosis. A client who is not eating and is vomiting will lose potassium.
After a retropubic prostatectomy for treatment of benign prostatic hyperplasia, a client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. On the initial assessment of the urine in the indwelling urinary catheter bag, the nurse observes the drainage is dark red. Which action should the nurse take first?
Increase the flow rate of the irrigation solution until the urine is a light pink. An expected urine color would be dark red. The nurse would need to increase the irrigation rate until the urine becomes light pink. (There is nothing here to indicate that the client is hemorrhaging)
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?
Infuse 10 percent dextrose and water at 54 ml/hr TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate will keep the client from experiencing hypoglycemia until the next TPN solution is available. TPN can only hang for 24 hours
What infection control interventions should the nurse include when planning care for a client post heart transplant?
Instruct visitors to wash hands prior to entering the room. Maintain strict aseptic technique. Initiate pulmonary hygiene measures. Provide for early ambulation.
A client newly diagnosed with insulin dependent diabetes mellitus is started on insulin aspart protamine suspension/insulin aspart solution mixture. The nurse would teach the client that the insulin should start to lower the blood sugar in how many minutes?
Insulin aspart protamine suspension works in 15 minutes
What interferes with hypothyroid treatment?
Iron supplements (wait 4 hours to give) Soy milk Antacids that contain calcium or aluminum hydroxide, or calcium supplements
The nurse is caring for a client with tuberculosis receiving isoniazid therapy. Because of the possible peripheral neuropathy that can occur, which supplementary nutritional agents would the nurse expect to administer?
Isoniazid?? Give Pyroxidine (Vitamin B 6) Vitamin B6 is given to prevent the peripheral neuropathy with isoniazid use.
The newborn can contract the virus through direct skin contact with the lesions so you should teach the mother not to
Kiss the infant
What is in practice for an LPN? Out our practice for an LPN?
LPN can Reinforce how to perform perineal care to a primipara who is four hours postpartum. Client teaching may be reinforced by an LPN/VN. Administering IV medications is out of the scope of practice of LPN/VN. Drawing lab work is outside the scope of practice of an LPN/VN. Drawing routine admission labs is out of the scope of practice of LPN/VN.
A client diagnosed with a duodenal ulcer is prescribed lansoprazole and sucralfate. What should the nurse teach the client about how to take these medications?
Lansoprazole (PPI) - 30 min - Sucralfate (Antacid) When prescribed a medication and sucralfate, avoid taking the medication at the same time you take sucralfate. Sucralfate can make it harder for your body to absorb lansoprazole. Wait at least 30 minutes after taking this medicine before you take sucralfate
A client with distended and tortuous veins along the inner aspects of both legs, asks the nurse how to decrease the development of these veins. What should the nurse advise?
Low sodium diet These are varicose veins. Get moving. Walking is a great way to encourage blood circulation to the legs. Low-heeled shoes work calf muscles more, which is better for veins. To improve circulation in legs, take several short breaks daily to elevate legs above the level of the heart. Do not cross legs as it decreases circulation distally.
A client admitted to the psychiatric unit after a suicide attempt is placed on suicide precautions. Which nursing interventions would be appropriate?
Make rounds at frequent, irregular intervals to avoid predictability. Clients should not be left alone for long periods of time. A private room close to the nurses' station is best. Close supervision is necessary during medication administration and when eating. Increased feelings of self-worth may be experienced when the client feels accepted unconditionally regardless of thoughts or behavior. Remove harmful objects from the client's access, such as sharp objects, straps, belts, ties, glass items, and alcohol.
The nurse is developing a teaching plan for a female client who is taking one of the thiazolidinediones for the treatment of type 2 diabetes. What instruction should be included in the teaching plan?
Make sure that you use effective contraception while taking this drug. The drug may reduce the plasma concentration of the contraceptives. Post-menopausal women may resume ovulation.
A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, the nurse crushes the tablet and mixes it into 3 ounces of applesauce, the student nurse proceeds to the client's room. What priority action should the supervising nurse take?
Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce new food during an illness
The circulating nurse prepares the sterile field in the operating room (OR). Fifteen minutes later, the nurse is informed the surgery will be delayed for 20 minutes because the surgeon is working at another hospital. Which is the best action for the nurse to take?
Monitor the sterile field while awaiting the surgeon.
Naloxone hydrochloride is
Narcan Dose is 0.4 mg IV q 2-3 min PRN for opioid overdose
A client is admitted to the coronary care unit with a medical diagnosis of acute myocardial infarction. Which medication prescription decreases both preload and afterload?
Nitro
The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
Observe for an asymmetrical Moro (startle) reflex. The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.
The nurse is caring for a client prescribed ondansetron due to postoperative nausea. Which side effect is the nurse most worried about the client experiencing with administration of this medication?
Ondansetron (Zofran) Torsades de pointes is a life threatening dysrhythmia which can occur with administration of ondansetron.
Which signs/symptoms should the nurse assess for valvular heart disease?
Orthopnea Paroxysmal nocturnal dyspnea.
Prevention and avoidance measures for otitis externa include
Otitis Externa: Thorough ear canal drying and use of acidifying or astringent drops after swimming or bathing Increases risk for Otitis MEDIA: Contact with siblings Day care attendance Season of the year Breastfeeding decreases risk Risk factor if under 5
Peripheral IV lines must be changed every PICC lines may remain in place for
Peripheral IV lines must be changed every 72-96 hours. PICC lines may remain in place for a year or more
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan?
Place a pillow between the knees during sleep. This will help prevent dislocation of the hip.
The nurse is caring for a client in the outpatient infusion unit. What should the nurse do after administering a chemotherapeutic drug intravenously (IV)?
Place in chemo waste container. The disposable items such as the IV bag and tubing should remain intact and be disposed of in a securely sealed chemotherapy waste container. Tubing should never be disconnected from an IV bag containing a hazardous drug because of the risk of splashing.
What should the client avoid eating while on Spironolactone?
Potassium Rich Foods: Bananas, oranges, tomatoes, potatoes Foods high in Sodium: Cheese and crackers, soups, processed foods
Primagravida
Pregnant for the first time
Which prescriptions would the nurse recognize as being appropriate for the client with shingles?
Private room Negative-pressure airflow Respirator mask
A child is being admitted to the hospital with a diagnosis of acute glomerulonephritis. In performing the history and physical, what would be a priority assessment that the nurse should include when questioning the child and caregivers?
RECENT SORE THROAT Acute post-streptococcal glomerulonephritis (APSGN) results from a group A beta-hemolytic streptococci infection that originates typically in the throat (strep throat) or the skin (impetigo). The strep bacterial infection can cause the filtering units of the kidneys (glomeruli) to become inflamed and results in a decreased ability of the kidneys to filter the urine. The disorder may develop 1 - 2 weeks after an untreated throat infection, or 3 - 4 weeks after a skin infection.
Do you want a reactive or non-reactive stress test?
Reactive - You want HR to rise 15 beats for 10 seconds A non-reactive test is when the FHR accelerates less than 15 beats per minute above baseline. This may indicate fetal compromise
The nurse is assisting in decontaminating a client who was recently involved in a chemical exposure event. What should the nurse do first?
Remove clothing from the client. Significant decontamination can be accomplished by removal of clothing. Complete decontamination involves clothing removal, complete flushing of the skin with water, and wrapping the client in a sheet or protective cover.
Patient is admitted for a total hip replacement. What do you want to prevent?
Respiratory complications Respiratory is the highest priority because of the possibility of sudden death from the complications of deep vein thrombosis and pulmonary embolism.
A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal pain. The nurse palpates an enlarged liver, an x-ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis?
Sequestration
S/S of a right hip fracture
Severe pain in the right hip and groin. Inability to bear weight on the right leg. Right leg slightly shorter in length than the left leg. External rotation of right lower leg. Bruising and swelling around the right hip.
Example of foods high in tyramine
Smoked turkey, parmesan cheese, tea, liver. DO NOT EAT WITH MAOIs
Which intervention is most important for the nurse to implement when administering a medication through a nasogastric (NG) tube?
Stop the feeding for 30 minutes prior to medication administration. Do not mix medications in the enteral feeding solution. Instead, stop the feeding for 30 minutes, give the medication, flush the tube with appropriate facility approved fluid, and resume feedings after one hour. Stop feeding - wait 30 min - give med - wait 1 hour - resume feeding
Patient is receiving a whole unit of blood and develops back pain. What does the RN do?
Stop the transfusion Take the client's vital signs Change the IV tubing Collect a urine specimen Assume the worst, and stop the transfusion first Then continue with the assessment. Low back pain is a sign of an acute hemolytic reaction. This is the most dangerous and potentially life-threatening type of transfusion reaction Get lab tests for presence of hemoglobin, which indicates hemolytic reaction
T/F: UAPs are not allowed to turn off tube feeding and turn it back on when repositioning the patient
T The nurse must come turn off, reposition, check placement of tube, then turn back on
A client is being treated for osteoporosis with alendronate (Fosamax), and the nurse has completed discharge teaching regarding medication administration. Which morning schedule would indicate to the nurse that the client teaching has been effective?
Take medication, go for a 30 minute morning walk, then eat breakfast.
Which class of antiinfective drugs is contraindicated for use in children under 8 years of age?
Tetracyclines (B) cause enamel hypoplasia and tooth discoloration in children under 8 years of age.
A 16 year old has a child who requires an invasive procedure. Who can give the consent?
The 16 year old mother An emancipated or unemancipated minor parent who has actual custody of his/her biological child can provide consent for medical, dental, psychological or surgical treatment for the biological child only.
A 12 year old female, with a history of juvenile rheumatoid arthritis, is being admitted for re-evaluation. The child reported these symptoms for the last week: temperature of 102.9ºF/39.4ºC at 4:00 pm every day, increased pain in joints, loss of appetite, and fatigue. What would be an appropriate room assignment by the charge nurse?
The appropriate answer is to room her with the 10 year old being worked up for sickle cell disease. This is an acceptable age/sex to pair as roommates. Each has a chronic illness and this allows them to see how another person with limitations adjusts.
While preparing a fact sheet for a client diagnosed with a vancomycin-resistant enterococcus (VRE) urinary tract infection (UTI), the home health nurse should include which instructions?
The bathroom and kitchen should be cleaned with warm water and bleach to decrease contamination. The client should wash hands after using the bathroom and before preparing food. Bleach must be used to ensure decontamination
A client admitted with biliary atresia has just arrived on the pediatric unit. The unit is very busy and the other RNs are busy with other clients at this moment. What action by the charge nurse would be most appropriate?
The best answer is to have the LPN/VN initiate the assessment and let the RN complete the assessment once he/she has completed the present task. Assessment on the new client should be completed by an RN within eight hours of arriving on the unit. It is acceptable to let the LPN/VN initiate the process. It would be best if a licensed person did a brief initial assessment on the child instead of the UAP. The RN will verify the data.
A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change and the nurse formulates the diagnosis, "Confusion related to ICU psychosis." Which intervention is best to implement?
The critical care environment confronts clients with an environment which provides stressors heightened by treatment modalities that may prove to be lifesaving. These stressors can result in isolation and confusion. The best intervention is to provide the client with rest periods Best intervention for ICU delirium is rest!* (Not family, or moving equipment, or decreasing stimuli)
Client is taken Phenytoin. Why would the nurse question Furosemide, Oral contraceptives, Cimetidine and Omeprazole?
The efficacy of furosemide and oral contraceptives is impaired by concurrent use of phenytoin. Cimetidine and omeprazole will increase phenytoin serum levels. Many antibiotics cannot be given with phenytoin such as sulfa drugs and doxycycline, however metronidazole is not listed as one of them.
When is the most unstable time for a newborn?
The second period of reactivity, which occurs after the period of deep sleep approximately 3-5 hours after delivery is the most unstable for the newborn. This is when they are most likely to bring up and gag on mucus and may aspirate.
A client with chronic alcoholism has been admitted to the intensive care unit after overdosing on alcohol. Which medication should the nurse prepare to administer?
Thiamine 50-100 mg IV or IM is indicated twice a day for clients with chronic alcoholism It is usually given for several days, followed by 10-20 mg once a day until a therapeutic response is obtained. Thiamine B1 may treat - alcoholism, encephalopathy
An unresponsive 13 year old is brought into the emergency department. Based on the nursing assessment and current lab data, which interventions would be appropriate for the nurse to initiate? (HHNS)
This client is exhibiting Kussmaul respirations. Potassium and glucose are high. The client has ketones which are an acid. Blood gases reveal metabolic acidosis related to diabetic ketoacidosis and hypovolemic shock. This client needs isotonic solutions and regular insulin to decrease glucose and decrease potassium. The client needs fluid resuscitation due to polyuria seen with DKA. Foley catheter needed to measure urine output.
A nurse is caring for a client who was brought into the ED with a gunshot wound to the chest. There is an occlusive dressing in place and the client is receiving high flow oxygen. The nurse notes a deviated trachea, asymmetrical chest wall movement and decreased breath sounds bilaterally. What action should the nurse take first?
This is a tension pneumo Remove the dressing to decrease the pressure
A client was prescribed thioridazine hcl five days ago and presents to the emergency department with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication does the nurse suspect? Pseudoparkinsonism may appear 1 to 5 days following initiation of antipsychotic medications: occurs most often in women, the elderly, and dehydrated clients. Symptoms include
Tremor, shuffling gait, drooling, and rigidity.
How to prevent cutaneous anthrax
Universal precautions Cutaneous anthrax is typically not contagious; however, it can be spread to others in rare events if the wound is draining. Universal precautions should protect the individual.
Post Partum Interventions
Use witch hazel compresses on rectal areas for hemorrhoids. Take ibuprofen for pain. Apply topical anesthetics to perineal area. Avoid sexual intercourse until episiotomy has healed. Ice can ease discomfort and should be applied during the first 48 hours. Take sitz baths at a temperature between 38-40 degrees C (100-104 degrees F).
When should a child be in a booster seat in the car
Using a booster seat for children age 5 until the seat belt fits properly - lap belt across thighs, not abdomen & shoulder belt over shoulder, not neck 18 kg
Hemianopia is blindness.
in half of the visual field. The client has lost half of the visual field in the left eye. To avoid startling the client and so the client can better view the food, the nurse should approach the client from the right side. Neglect of the left side can occur. Encourage client to look at the left side of the body to avoid neglect. If it says "left hemianopia" it means that the client cannot see on that side. Which means that they had a right sided stroke.
