a client who had a stroke combs her hair only on the right side of her head and washes only the right side of her face how does the nurse interpret th
Logo

Nursing Elites

ATI RN

Endocrinology Exam

1. How does the nurse interpret the client's actions of combing her hair only on the right side of her head and washing only the right side of her face after a stroke?

Correct answer: D

Rationale: The client's selective grooming and washing habits indicate a condition known as 'unawareness of the existence of her left side,' also called hemispatial neglect. This condition is characterized by a lack of awareness or attention to one side of the body or space, typically the left side in stroke patients. Choices A, B, and C are incorrect because the client's actions are not due to poor motor control, paralysis, contractures, or limited visual perception. Instead, they are indicative of a specific cognitive deficit related to neglecting one side of the body.

2. The nurse is planning care for a client with epilepsy. Which precautions does the nurse implement to ensure the safety of the client while in the hospital? (Select one that doesn't apply.)

Correct answer: D

Rationale: For a client with epilepsy, it is essential to avoid restraining them with strict bed rest as it can lead to complications like muscle atrophy, thrombosis, and pressure ulcers. Having suction equipment at the bedside is important in case of seizures to prevent aspiration. Keeping bed rails up can prevent falls during a seizure. Ensuring that the client has IV access is crucial for administering medications such as antiepileptic drugs or emergency medications if needed. Therefore, maintaining the client on strict bed rest is not a recommended precaution for a client with epilepsy.

3. The nurse is caring for a client who has had surgery the previous day. The client tells the nurse, "Breathing in using this thing (incentive spirometer) is a ridiculous waste of time."? What is the nurse's best response?

Correct answer: B

Rationale: The correct answer is, '"The spirometer will help your lungs expand."?' Incentive spirometry is used postoperatively to help prevent atelectasis by expanding the lungs and improving lung function. Choice A is incorrect because the primary purpose of the spirometer is not to help cough effectively. Choice C is incorrect because while deep breathing with the spirometer can indirectly help prevent blood clots by improving lung function, its primary purpose is not to prevent blood clots directly. Choice D is incorrect because although using the spirometer can improve ventilation and oxygenation, its main purpose is not to improve blood flow in the lungs.

4. A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?

Correct answer: C

Rationale: In a client with a head injury, assessing the respiratory status is the priority as airway and breathing are essential for life. Immediate attention to respiratory status is crucial to ensure adequate oxygenation. While assessing pupil response and motor function are also important in head injuries, ensuring the client's ability to breathe takes precedence. Short-term memory assessment is not a priority in the emergent phase of care for a client with a head injury.

5. The healthcare professional is assessing a client with hypertension. Which client outcome is indicative of effective hypertension management?

Correct answer: C

Rationale: The correct answer is 'No indication of renal impairment.' Effective hypertension management aims to prevent complications such as renal impairment. Checking for signs of kidney issues, like abnormal renal function tests, is crucial in monitoring the client's condition. Choices A, B, and D are not specific indicators of effective hypertension management. Pedal edema, sexual dysfunction, and a single blood pressure reading are important but do not solely determine the effectiveness of managing hypertension.

Similar Questions

The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?
The nurse teaches a client who is newly diagnosed with coronary artery disease. Which instruction does the nurse include to minimize complications of this disease?
A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing oxygen therapy?
A client is diagnosed with varicella (chickenpox). The nurse places the client on which precautions?
A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation alerts the nurse to the possibility of a complication from the UTI?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses