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Pulling up the client under the left shoulder when getting the client out of bed to a chair
A nurse is observing a nursing assistant who is providing care to a client with left-sided paralysis. Which of the following actions by the nursing assistant requires the nurse to provide further instruction?
Observe for symmetry of the client's soft palate and uvula.
A nurse is caring for an older adult client with a history of stroke who has been prescribed several medications and expresses reluctance to take them because of his difficulty swallowing. Which of the following actions is the nurse's priority?
Sliding the client to move up in the bed
The nurse is providing teaching to a client's family member after a stroke. The nurse knows to intervene if which of the following techniques is witnessed when the nurse family changes a client's position in bed if the client has hemiparalysis?
Schedule for a STAT computed tomography (CT) scan of the head
A 78-year old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
Assess the time and onset of the stroke
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (PA) administration. in planning care for this client, the nurse knows to first:
Autonomic dysreflexia
A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What would the nurse immediately suspect?
Monitor the client for black, tarry stools.
A nurse is caring for a client who has a prescription for clopidogrel. Which of the following actions should the nurse plan to take?
Elevate the head of the bed
The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action would the nurse take?
22 mmHg
The nurse is caring for a client with a head injury who has an intracranial pressure (ICP) monitoring device. The nurse would become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding?
Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord
The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What would the nurse anticipate to promote during the bowel retraining program?
The client with a C6 spinal cord injury who is complaining of dyspnea and has crackles in the lungs
The nurse is caring for clients on the rehabilitation unit. Which client should the nurse assess first after receiving the change-of-shift report?
•Assist the client to use flash cards with pictures • Speak tot he client at a slow rate Speak to the client in a loud voice Complete sentences that the client cannot finish •Give instructions one step at a time
The nurse is contributing to the plan of care for a client who has global aphasia. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply
•Assess for the presence of a swallow reflex Place the food on the affected side of the mouth •Assist the client with eating •Thicken liquids •Provide ample time for the client to chew and swallow
The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which would the nurse include in the plan? Select all that apply.
On the overbed table on the left side
The nurse is encouraging self-care in a client who experienced a thrombotic stroke and who now has right-sided hemiparesis. The nurse best accomplishes this goal by placing personal hygiene items in which area?
Red skin areas under the jacket
At the beginning of the work shift, the nurse assesses the status of a client wearing a halo device. The nurse determines that which assessment finding requires intervention?
Decorticate rigidity
The nurse is performing an assessment on a client with a head injury and notes that the client is assuming this posture. The nurse contacts the primary health care provider and reports that the client is exhibiting which posture? Refer to figure.
Give the client thin liquids
The nurse is planning care for a client who experienced a cerebrovascular accident (CA) with residual dysphagia. The nurse knows to avoid which of the following actions in the plan of care?
No reflex activity below the waist
In assessing a client with a thoracic (T12) spinal cord injury (SCI), which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock?
Administer a stool softener BID
The nurse is providing care for a client diagnosed with a subarachnoid hemorrhage who is status post craniotomy for repair of a ruptured aneurysm. Which intervention will the nurse implement?
Complete a neurological assessment
The 85-year-old client who has been diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement a. Start an intravenous infusion of D5W at 100mL/hr
Place the bedside table on the right side of the bed
The nurse is providing teaching to a group of students regarding a client with left homonymous hemianopsia. The nurse knows that teaching has been effective if the student's state to implement which of the following interventions?
Pupil size and pupillary response
The nurse is providing teaching to a group of students regarding priority nursing assessments in the first 24-hours following a thrombotic stroke. The nurse knows that teaching has been effective if the students state which of the following?
Have the client wear ankle-high tennis shoes at intervals throughout the day
The nurse is providing teaching to a group of students regarding residual paralysis from a stroke. The nurse knows that teaching has been effective the students state which of the following is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis?
Restricting the diet to liquids until swallowing improves Maintaining an upright position while eating Cutting food into large pieces of finger food Keeping distractions to a minimum Introducing foods on the unaffected side of the mouth
The nurse is providing teaching to the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies should the nurse include in the teaching plan? Select all that apply.
Explaining the equipment and procedures on an ongoing basis
The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention would the nurse plan to incorporate into the care routine for the client and family?
Call the primary health care provider
a client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98° F (37.2° C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99° F (36.7° C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse would take which action first?
An oral anticoagulant medication
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?
Applying a hypothermia blanket Administering acetaminophen per protocol Giving tepid sponge baths
A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply.
Altered breathing pattern
A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem?
Acknowledge the client's anger and continue to encourage participation in care
A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse would perform which action? a. Leave the client alone until ready to participate so the client and nurse are safe.
Tinnitus
A nurse in an urgent care center is collecting data from a client who reports taking an excessive amount of aspirin. Which of the following findings should the nurse identify as an indication of salicylism?
Re-establish communication.
A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan?
Log roll the client every 2 hr.
A nurse is assisting with the plan of care for a client who is 1 day postoperative following spinal fusion. Which of the following interventions should the nurse include in the plan?
Logroll the client every 2 hr.
A nurse is caring for a client following a lumbar laminectomy. Which of the following actions should the nurse take? a. Have the client wear a cervical collar for the first 12 hr.
Encourage the client to use her right hand when feeding herself.
A nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? a. Provide a nonskid mat to reduce plate movement.
Prevent bladder distention.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
Suction saliva from the client's mouth.
A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority? a. Perform passive range of motion on each extremity.
"If I crush it you might experience a stomach ache or indigestion."
A nurse is preparing to administer enteric-coated aspirin to an older adult client who had a cerebrovascular accident and has difficulty swallowing medications. The client asks the nurse if she will crush the medication to make it easier to swallow. Which of the following responses should the nurse make?
"I need to catheterize myself once a day."
A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching?
Turn the head from side to side when walking
A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which of the following does the nurse identify as the primary safety precaution to use?
Encourage the client to move the affected side Instruct the client to hold the fingers in a fist Turn and reposition the client every shif Perform quadriceps exercises three (3) times per day
The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.
Obtain a raised toilet seat for the client's bathroom
The client has been diagnosed with a cerebrovascular accident (VA). The client's husband is concerned about his wife's generalized weakness.Which home modification should the nurse suggest to the husband prior to discharge?
Assess for bladder distention
The client with a C6 spinal cord injury is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. In planning care for this client, the nurse knows which intervention should be implemented?
Leaving the client in an unchilled area of the room
The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)?
The nursing student places a hand under the client's right axilla to move up in bed
The nurse and nursing student are caring for a client with right-sided paralysis. Which action by the nursing student requires the nurse to intervene?
The client has weakness on the right side of the body The client is aphasic The client has weakness on the right side of the face and tongue
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. This study source
Confusion
The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (IC). Which finding, if noted in the client, would indicate an early sign of increased ICP?
Administer low-dose subcutaneous anticoagulants per MD orders
The rehabilitation LVN is providing care for a client diagnosed with a lumbar spinal cord injury. In developing the plan of care for this client, the nurse knows to implement which of the following?
