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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.

B.

Encourage the use of wide grip utensils.

C.

Remind that the client look for food on the left side of the tray.

D.

Encourage the client to use her right hand when feeding herself.

Answer and Explanation

The Correct Answer is C

A. A nonskid mat might be helpful for plate stability, but it does not address the visual deficit related to homonymous hemianopsia.  

 

B. Wide grip utensils are useful for motor difficulties, but the primary issue here is a visual field deficit, not motor impairment.  

 

C. Homonymous hemianopsia results in loss of vision in the same half of the visual field in both eyes. Encouraging the client to turn her head or look for food on the affected side (left side of the tray) can help compensate for the visual loss.  

 

D. While using the right hand may be important after a right-sided stroke, the more pressing issue here is addressing the visual field deficit, not hand preference.


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Correct Answer is C

Explanation

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B. An allergy to nitroglycerin typically presents as a rash or breathing difficulty, not a headache.

C. Nitroglycerin commonly causes headaches due to the dilation of blood vessels in the brain, which usually lessens over time as the body adjusts.

D. A headache does not indicate tolerance to the medication. Tolerance develops when the body becomes less responsive to the medication's effects, which usually involves a reduced effect on chest pain, not the onset of a headache.

Correct Answer is B

Explanation

A. A contrecoup injury is a true injury and can be significant; stating it is not considered "true" is incorrect and indicates a lack of understanding.

B. This statement accurately describes coup and contrecoup injuries, where a coup injury occurs at the site of impact and a contrecoup injury occurs on the opposite side of the brain.

C. This statement is incorrect because a coup injury does not occur secondary to the contrecoup; they can happen simultaneously during trauma.

D. Contrecoup injuries can be just as severe as coup injuries, and the healing process varies; stating they are easier to heal from is misleading and reflects a misunderstanding.

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