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?
Provide a nonskid mat to reduce plate movement.
Encourage the use of wide grip utensils.
Remind that the client look for food on the left side of the tray.
Encourage the client to use her right hand when feeding herself.
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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
A. A blood pressure of 80/40 mm/Hg indicates hypotension, which is a contraindication for administering furosemide. The medication can further lower blood pressure and increase the risk of adverse effects.
B. An oxygen saturation of 95% is within normal limits and does not indicate a need to withhold furosemide.
C. A serum sodium level of 140 mEq/L is normal and would not warrant withholding the medication.
D. A serum potassium level of 4.8 mEq/L is also normal and safe for furosemide administration, as the medication may cause potassium loss but does not require withholding if the level is within range.
Correct Answer is ["A","B","D"]
Explanation
A. Pain behind the ear is a common early symptom of Bell's palsy due to inflammation of the facial nerve.
B. Muscle distortion occurs as the facial muscles on the affected side weaken or become paralyzed, leading to an asymmetrical appearance.
C. Facial twitching is not a common manifestation of Bell's palsy; rather, it involves muscle paralysis or weakness.
D. Impaired taste, especially in the anterior two-thirds of the tongue, can occur due to facial nerve involvement.
E. Hearing loss is not typically associated with Bell's palsy; it usually affects facial motorfunction, not auditory function.