Nurb 445 Exam 2

The client is diagnosed with ALS. Which client problem would be most appropriate for this client? 1. Disuse syndrome. 2. Altered body image. 3. Fluid and electrolyte imbalance. 4. Alteration in pain.

1. Disuse syndrome is associated withcomplications of bedrest. Clients withALS cannot move and repositionthemselves, and they frequently havealtered nutritional and hydration status.

The nurse has given suggestions to a patient with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the patient needs further education if the patient makes which statement? 1. " I will wash my face with cotton pads" 2. "I will have to start chewing on my unaffected side" 3. " I will try to eat my food either very warm or very cold" 4. " I should rinse my mouth if toothbrushing is painful"

3. " I will try to eat my food either very warm or very cold"

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? a) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." b) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." c) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved." d) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."

"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.

The primary health care provider diagnoses that a patient has a cluster headache. Which statements made by the patient support the health care provider's diagnosis? Select all that apply .1 "My cheeks also ache during the headache." 2 "I feel like my limbs are moving during the headache." 3 "I don't feel like sitting in one place during the headache." 4 "My skin appears pale during the headache." 5 "I have a strong desire to eat ice cream and chocolates during the headache."

1,3,4 A cluster headache is manifested by pain in the cheeks, gums, nose, and forehead. Cluster headache is also associated with restlessness and pallor (skin paleness). Feelings of limb movement and food cravings are clinical manifestations of migraine headache.

Which of the following nursing diagnosis is likely to be a priority in the care of a patient with myasthenia graves (MG)? 1. Acute Confusion 2. Bowel incontinence 3, Activity intolerance 4. Disturbed sleep pattern

3, Activity intolerance

The client newly diagnosed with multiple sclerosis (MS) states, "I don't understand how I got multiple sclerosis. Is it genetic?" On which statement should the nurse base the response? 1. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus. 2. There is no evidence suggesting there is any chromosomal involvement in developing MS. 3. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS. 4. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome,so only fathers can pass it on.

1. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus.

The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess?Select all that apply. 1. Muscle flaccidity. 2. Lethargy. 3. Dysmetria. 4. Fatigue. 5. Dysphagia.

1. Muscle flaccidity. 3. Dysmetria. 4. Fatigue. 5. Dysphagia.

The client diagnosed with Guillain-Barré syndrome is admitted to the rehabilitation unit after 23 days in the acute care hospital. Which interventions should the nurse implement?Select all that apply. 1. Refer client to the physical therapist. 2. Include the speech therapist in the team. 3. Request a social worker consult. 4. Implement a regimen to address pain control. 5. Refer the client to the Guillain-Barré Syndrome Foundation

1. Refer client to the physical therapist. 3. Request a social worker consult. 4. Implement a regimen to address pain control. 5. Refer the client to the Guillain-Barré Syndrome Foundation

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. 1.Keep suction equipment at the bedside. 2.Elevate the head of the bed 30 degrees. 3.Keep the client lying in a supine position. 4.Keep the head and neck in good alignment. 5.Administer prescribed respiratory treatments as needed

1.Keep suction equipment at the bedside. 2.Elevate the head of the bed 30 degrees. 4.Keep the head and neck in good alignment. 5Administer prescribed respiratory treatments as needed.

The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1.Padding the side rails of the bed 2.Placing an airway at the bedside 3.Placing the bed in the high position 4.Putting a padded tongue blade at the head of the bed 5.Placing oxygen and suction equipment at the bedside 6.Having intravenous equipment ready for insertion of an intravenous catheter

1.Padding the side rails of the bed 2.Placing an airway at the bedside 5.Placing oxygen and suction equipment at the bedside 6.Having intravenous equipment ready for insertion of an intravenous catheter

The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first? 1. Elevate the head of the bed 30 degrees. 2. Administer oxygen via nasal cannula. 3. Assess the client's lung sounds. 4. Obtain a pulse oximeter reading.

2. Oxygen should be given immediatelyto help alleviate the difficulty breathing. Remember that oxygenation is priority.

Which statement by the client supports the diagnosis of Guillain-Barré syndrome? 1. "I just returned from a short trip to Japan." 2. "I had a really bad cold just a few weeks ago." 3. "I think one of the people I work with had this." 4. "I have been taking some herbs for more than a year."

2. "I had a really bad cold just a few weeks ago."

Which statement by the client supports the diagnosisof myasthenia gravis (MG)? 1. "I have weakness and fatigue in my feet and legs." 2. "My eyelids droop, and I see double everything." 3. "I get chest pain and faint after I walk in the hall." 4. "I gained 3 pounds this week, and I am spitting up pink frothy

2. "My eyelids droop, and I see double everything."

What nursing management is the most important for Bells Palsy? 1. Support 2. Eye protection ( eye patch) 3. Comfort 4. impatient treatment

2. Eye protection ( eye patch) dark glasses, artificial tears, eye ointments, and eye patch can all be used. Eye patch provides the most protection

Common risk factors for MS include which of the following? 1. Male. 2. Female 3. temperate climates 4. Young children

2. Female 3. temperate climates

The client diagnosed with Guillain-Barré syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff? 1. Provide an erase slate board for the client to write on. 2. Instruct the client to blink once for "no" and twice for "yes." 3. Refer to a speech therapist to help with communication. 4. Leave the call light within easy reach of the client.

2. Instruct the client to blink once for "no" and twice for "yes."

What is an appropriate nursing diagnosis for a patient with advanced Parkinson's disease? 1. risk for injury related to limited vision 2. risk for aspiration related to impaired swallowing 3. urge incontinence related to effects of drug therapy 4. ineffective breathing pattern related to diaphragm fatigue

2. risk for aspiration related to impaired swallowing

Which complaint made by the patient indicates that the individual may be suffering from a cluster headache? 1"The pain is constant." 2"The pain is followed by nausea." 3"The pain disturbs my sleep at night." 4"The pain lasts for longer than eight hours.

3 Cluster headaches usually occur at night and causes sleep disturbances. Therefore, the patient's complaint about sleep-disturbing pain is a sign of a cluster headache. Constant pain is a characteristic of tension-type headaches. Migraine headaches are associated with nausea and vomiting; they usually exist for 4 to 72 hours.

Which type of arthritis is considered a medical emergency ? A. Osteoarthritis B. Septic Arthritis C. Gouty Arthritis D. Arthritic lupus

B. Septic Arthritis

The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two(2) times in the month. Which question is most important for the nurse to ask the client? 1. "Have you experienced any difficulty with your menstrual cycle?" 2. "Have you noticed a rash across the bridge of your nose?" 3. "Do you get tired easily and sometimes have problems swallowing?" 4. "Are you taking birth control pills to prevent conception?"

3. "Do you get tired easily and sometimes have problems swallowing?"

The nurse is providing care for a patient who has been diagnosed with Guillain-barre syndrome. Which of the following assessments should the nurse prioritize? 1. Pain assessment 2. Glasgow Coma Scale 3. Respiratory assessment 4. Musculoskeletal assessment

3. Respiratory assessment

A nurse is interviewing a patient who is seeking relief for frequent headaches. Which description is consistent with symptoms of a migraine headache? 1 Extreme tenseness in the area of the neck and shoulders. 2Tears flow from one eye and nasal drainage occurs with the headache. 3 The pain of the headache wakes the patient from sleep. 4The pain throbs and is synchronous with the patient's pulse.

4 A migraine headache is caused by a series of neurovascular events that result from some trigger stimulus. The pain usually is one-sided, throbbing in nature, and synchronous with the patient's pulse. Palpable tenseness in the neck and shoulders occurs with a tension headache. A cluster headache awakens the patient from sleep and involves tearing of one eye with nasal drainage on the same side.

The client is being evaluated to rule out ALS. Which signs/symptoms would thenurse note to confirm the diagnosis? 1. Muscle atrophy and flaccidity. 2. Fatigue and malnutrition. 3. Slurred speech and dysphagia. 4. Weakness and paralysis.

4. ALS results from the degeneration anddemyelination of motor neurons in thespinal cord, which results in paralysisand weakness of the muscles.

Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? 1. An exaggerated startle reflex and memory changes. 2. Cogwheel rigidity and inability to initiate voluntary movement. 3. Sudden severe unilateral facial pain and inability to chew. 4. Progressive ascending paralysis of the lower extremities and numbness.

4. Progressive ascending paralysis of the lower extremities and numbness.

The nurse and a licensed practical nurse (LPN) are caring for a group of clients.Which nursing task should not be assigned to the LPN? 1. Administer a skeletal muscle relaxant to a client diagnosed with low back pain. 2. Discuss bowel regimen medications with the HCP for the client on strict bed rest. 3. Draw morning blood work on the client diagnosed with bacterial meningitis. 4. Teach self-catheterization to the client diagnosed with multiple sclerosis.

4. Teach self-catheterization to the client diagnosed with multiple sclerosis.

Which response to the Tensilon (edrophoniumchloride) injection indicates the client has myastheniagravis? 1. The client has no apparent change in theassessment data. 2. There is reduced amplitude of electrical stimulation in the muscle. 3. The anti-acetylcholine receptor antibodies are present. 4. The client shows a marked improvement of muscle strength.

4. The client shows a marked improvement of muscle strength.

The nurse admits a patient with advanced Parkinson's disease at the outpatient clinic with a cough and fever. During the assessment of the patient, the nurse would expect to find? 1. slurred speech, visual disturbances, and ataxia 2. muscle atrophy, spasticity, and speech difficulties 3. muscle weakness, double vision, and reports of fatigue 4. drooling, stooped posture, tremors, and a propulsive gait

4. drooling, stooped posture, tremors, and a propulsive gait

The client is experiencing a myasthenic crisis. Which of the following is a priority action of the following ordered actions? A) Insert NG tube B) Administer Ativan C) Monitor I&O D) Immediately stop anticholinesterase medications

A) Insert NG tube

During a patient's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A) National Institutes of Health Stroke Scale (NIHSS) score B) Race C) LOC at time of admission D) Gender E) Age

A) National Institutes of Health Stroke Scale (NIHSS) score C) LOC at time of admission E) Age

The client diagnosed w/ myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others? A) discuss ways to help prevent choking episodes B) Explain how to care for a client on a ventilator C) Teach how to perform passive ROM exercises D) Demonstrate how to care for the client's feeding tube

A) discuss ways to help prevent choking episodes

The client diagnosed w/ MG is admitted w/ an acute exacerbation. Which interventions should the nurse implement? SELECT ALL APPLY. A) Assist the pt. to turn and cough every 2 hrs B) Place client in high/ semi fowlers C) assess client's pulse ox reading every shift D) Plan meals to promote medication effectiveness E) Monitor client's serum anticholinesterase levels

A,B,D

The nurse provides home care instructions to a client with systemic lupus erythematous and tells the client about methods to manage fatigue. Which statement by the client indicated a need for further instructions? A. "I should take a hot bath because they are relaxing." B. "I should sit whenever possible to conserve my energy." C. " I should avoid long periods of rest because it causes joint stiffness." D. "I should do some exercises, such as walking, when I am not fatigued."

A. "I should take a hot bath because they are relaxing."

You are assessing a women who has come to an orthopedic clinic complaining of knee pain. Which of the following assessment would indicate an increased risk for OA? A. Being overweight by 30 Ibs B. Having a hx of falls C. Eating a diet high in calcium D. Walking 30 minutes each day

A. Being overweight by 30 Ibs

A patient has experienced right side brain damage. You note the patient is experiencing neglect syndrome. What nursing intervention will you include in the patient's plan of care? A. Remind the patient to use and touch both sides of the body daily. B. Offer the patient a soft mechanical diet with honey thick liquids. C. Ask direct questions that require one word responses. D. Offer the bedpan and bedside commode every 2 hours.

A. Remind the patient to use and touch both sides of the body daily.

The nurse is assessing an older adult client. Which finding should cause the nurse to suspect the client has Parkinson disease (PD)? (Select all that​ apply.) A. The client has hand tremors at rest. B. The client does not remember what he ate for breakfast. C. The​ client's blood pressure increases when the client stands up. D. The client has a slurred speech. E. The​ client's facial expression shows no emotion.

A. The client has hand tremors at rest. B. The client does not remember what he ate for breakfast. D. The client has a slurred speech. E. The​ client's facial expression shows no emotion.

When a patient is experiencing a cluster headache, the nurse will plan to assess for a. nuchal rigidity .b. projectile vomiting. c. unilateral eyelid swelling. d. throbbing, bilateral facial pain.

ANS: C Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increases in intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

Which of the following terms refer to the failure to recognize familiar objects perceived by the senses? a) Agnosia b) Perseveration c) Apraxia d) Agraphia

Agnosia Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.

A male client with Bell's palsy asks the nurse what has caused this problem. The nurse's response is based on an understanding that the cause is: a. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem b. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia c. Primary genetic in origin, triggered by exposure to meningitis d. Primarily genetic in origin, triggered by exposure to neurotoxins

Answer A. Bell's palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown, but may include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these factors.

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke? A) White female, age 60, with history of excessive alcohol intake B) White male, age 60, with history of uncontrolled hypertension C) Black male, age 60, with history of diabetes D) Black male, age 50, with history of smoking

B) White male, age 60, with history of uncontrolled hypertension

The pediatric nurse specialist provides teaching to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information ? A. "The femur is the most common site of this sarcoma." B. "The child does not experience pain at the primary tumor site." C. "Limping, if a weight bearing limb is affected, is a clinical manifestation " D. "The symptoms of the disease in the early stage are almost always attributed to normal growing pain"

B. "The child does not experience pain at the primary tumor site."

You're assisting a patient who has right side hemiparesis and dysphagia with eating. It is very important to: A. Keep the head of bed less than 30′. B. Check for pouching of food in the right cheek. C. Prevent aspiration by thinning the liquids. D. Have the patient extend the neck upward away from the chest while eating.

B. Check for pouching of food in the right cheek.

You receive a patient who is suspected of experiencing a stroke from EMS. You conduct a stroke assessment with the NIH Stroke Scale. The patient scores a 40. According to the scale, the result is:* A. No stroke symptoms B. Severe stroke symptoms C. Mild stroke symptoms D. Moderate stroke symptoms

B. Severe stroke symptoms

The nurse advises the patient with osteoporosis to A. Lose weight B. Stop smoking C. Eat a high protein diet D. Start swimming for exercise

B. Stop smoking

You are monitoring the lab reports for a patient with an acute attack of gout. Which of the following measurements would you expect to be elevated? A. Hematocrit B. Uric Acid C. Alkaline phosphate D. Creatinine

B. Uric Acid

The nurse is teaching a client about the cause of a transient ischemic attack​ (TIA). Which should the nurse​ include? A.Brief period of a neurologic deficit B.Vascular blockage C.Sudden intracranial bleed D.Formation of a clot in a blood vessel

Brief period of a neurologic deficit A TIA is a type of ischemic stroke resulting from a localized neurologic deficit lasting 24 hours or less. Vascular blockage is the cause of an embolic stroke. Intracranial bleeds cause hemorrhagic strokes. A thrombotic stroke is the result of the formation of a clot in a blood vessel.

What is a potential complication of both osteoporosis and osteomalacia? A. Infection B. Blood clots C. Fractures D. Contractures

C. Fractures

The patient with myasthenia gravis is complaining about dealing with muscle weakness. Which of the following could the nurse do for this patient? A) Administer antispasmodic medication B) Teach the patient to do physical exercise for several hours each day to help strengthen muscles C) Teach the patient it is important to avoid all forms of physical activity whenever possible D) Help the patient form a plan to take medications on time

D) Help the patient form a plan to take medications on time

A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? A) Report this finding to the physician as an indication of decreased metabolism. B) Provide more stimulation to the patient and monitor the patient closely. C) Recognize this as the expected clinical course of a hemorrhagic stroke. D) Report this to the physician as a possible sign of clinical deterioration.

D) Report this to the physician as a possible sign of clinical deterioration.

How is the causative organism for Lyme disease spread? A. through the bite of an infected mosquito B. By brief contact with an infected tick C. Primarily by droplets from infected people D. By an infected tick embedded for > 24 hours

D. By an infected tick embedded for > 24 hours

The nurse is conducting health screening for osteoporosis. Which client is a greatest risk of developing this disorder? A. 25 year old woman who jogs B. 36 year old man who has asthma C. 70 year old man who consumes excess alcohol D. Sedentary 65 year old woman who smokes cigarettes

D. Sedentary 65 year old woman who smokes cigarettes

A client was diagnosed with a thrombotic stroke of the vertebral artery. Which assessment does the nurse expect to​ make? A.Stupor B.Global aphasia C.Contralateral paralysis D.Dysphagia

Dysphagia Dysphagia is the clinical manifestation that is associated with a stroke that affects the vertebral artery. The other clinical manifestations are seen with internal carotid and middle cerebral artery involvement.

Which of the following is accurate regarding a hemorrhagic stroke? a) It is caused by a large-artery thrombosis. b) One of the main presenting symptoms is numbness or weakness of the face. c) Main presenting symptom is an "exploding headache." d) Functional recovery usually plateaus at 6 months.

Main presenting symptom is an "exploding headache." One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face

The nurse is reviewing documentation of a physical examination of a client who is suspected of having a stroke. Which documentation requires​ follow-up? A.Alert and oriented to person but not oriented to place or time B.Onset of facial drooping at 1430​ C.Right-sided grip stronger than​ left-sided grip D.Stroke scale completed

Onset of facial drooping at 1430 Time of onset of stroke symptoms should be included in the client interview. All other assessments are part of the physical assessment.

A patient arrives at the emergency department with slurred speech, right facial droop, and right arm weakness. Which of these actions by the healthcare provider is the priority? A.Call the speech pathologist to the emergency department B.Prepare the patient for a computerized tomography (CT) scan of the head C.Transfer the patient to the neurological care unit D.Prepare to administer a thrombolytic medication

Prepare the patient for a computerized tomography (CT) scan of the head

The nurse on the stroke rehabilitation unit is planning care for a client who is experiencing vision and equilibrium​ deficits, altered​ proprioception, hemianopia, and neglect syndrome. Which nursing therapy is the most important to​ include? A.Maintaining​ fluid, oxygen, and nutritional status B.Providing reassurance and support C.Developing an alternate means of communicating D.Providing behavioral and cognitive therapy when the condition stabilizes

Providing reassurance and support The client with​ sensory-perceptual deficits needs reassurance and support. There is no indication that the client cannot maintain​ fluid, oxygen, and nutritional​ status, cannot communicate​ well, or has cognitive or behavioral changes.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a) Footdrop and external hip rotation b) Severe headache and early change in level of consciousness c) Weakness on one side of the body and difficulty with speech d) Confusion or change in mental status

Severe headache and early change in level of consciousness The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly. (less)

The nurse taught a group of clients recovering from a stroke how to perform active​ range-of-motion exercises. Which client requires further​ teaching? A.The client performing​ flexion, extension, and hyperextension of the hips bilaterally B.The client with​ right-sided paralysis flexing and extending only the left knee C.The client performing extension and hyperextension of the neck D.The client with​ left-sided paralysis using the right arm to help flex and extend the left wrist

The client with​ right-sided paralysis flexing and extending only the left knee The client can use the left side to help flex and extend the right knee. Both sides should be exercised. All the other​ range-of-motion exercises are appropriate.

A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? a) Cerebral aneurysm b) Transient ischemic attack c) Left-sided stroke d) Right-sided stroke

Transient ischemic attack A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? a) Footdrop and external hip rotation b) Vomiting and seizures c) Severe headache and early change in level of consciousness d) Weakness on one side of the body and difficulty with speech

Weakness on one side of the body and difficulty with speech The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.

The nurse is observing the unlicensed assistive personnel​ (UAP) helping a client with unilateral neglect of the right side perform​ self-care. Which statement by the UAP requires an intervention by the​ nurse?​ A."When getting​ dressed, first put clothing on the left​ side."​ B."Use the left arm to​ bathe, brush​ teeth, comb​ hair, and​ eat."​ C."The occupational therapist will teach you how to promote upper extremity​ strength."​ D."The occupational therapist will assist you in learning to walk using a​ walker."

​"When getting​ dressed, first put clothing on the left​ side." The client should be taught to dress the affected extremities first and then the unaffected extremities. This will enable the client to dress herself with minimal assistance. The other options are all appropriate instructions to teach the client to perform​ self-care.