The nurse is assigned to care for a client with complete right-sided hemiparesis [weakness] from a stroke (brain attack).
admitting diagnosis
cerebrovascular attack
Right-sided hemiparesis
Which characteristics are associated with this condition? Select 2 that apply.
The client has complete bilateral paralysis of the arms and legs.
The client has lost the ability to move the right arm but is able to walk independently.
The client has lost the ability to move the right arm but is able to walk independently.
The client has weakness on the right side of the face and tongue.
The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance.
The client has weakness on the right side of the body.
Correct Answer : D,F
A. This statement indicates complete paralysis of both sides, which does not apply to hemiparesis, where one side is affected.
B. While this could describe some patients, it does not accurately represent "complete" right-sided hemiparesis.
C. This option is a repeat and also does not accurately reflect complete right-sided hemiparesis.
D. Weakness on the right side of the face and tongue is consistent with right-sided hemiparesis, as the stroke may affect motor control in those areas.
E. This describes a client who is less severely affected and may not apply to someone with complete right-sided hemiparesis.
F. Weakness on the right side of the body is a direct characteristic of right-sided hemiparesis.
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Correct Answer is ["C","D","E"]
Explanation
A. Numbness in the right arm is not a risk factor for skin cancer; it is more related to neurological issues or circulation problems.
B. While working in a beauty parlor may involve exposure to certain chemicals, it is not a significant risk factor for skin cancer compared to other options.
C. A client with a fair skin complexion and blue eyes has a higher risk for skin cancer due to lower melanin levels, making them more susceptible to UV damage.
D. Smoking is primarily associated with lung cancer; however, it can also contribute to skin damage and increased risk for skin cancer, particularly squamous cell carcinoma.
E. A roofer who spends a lot of time outdoors and experiences blistering sunburns is at significant risk for skin cancer due to excessive UV exposure and history of severe sunburns.
Correct Answer is A
Explanation
A. Asking the client to identify scented aromas assesses cranial nerve I (olfactory nerve), which is responsible for the sense of smell.
B. Reading a Snellen chart assesses cranial nerve II (optic nerve), which is related to vision.
C. Listening to the client's speech evaluates the function of cranial nerves V (trigeminal) and XII (hypoglossal), which are related to mastication and tongue movement, respectively.
D. Asking the client to clench his teeth tests cranial nerve V, which innervates the muscles of mastication.