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 D
Explanation
A. The severity of the condition may correlate with pain but is not a direct measure of the individual's pain experience.
B. Vital signs can change due to pain but are not specific indicators of pain intensity or presence.
C. Nonverbal behavior can provide clues about pain but is subjective and can vary greatly between individuals.
D. Self-rating of pain is considered the most reliable indicator of pain because it reflects the individual's personal experience and perception of their pain, making it the gold standard for assessing pain intensity.
Correct Answer is D
Explanation
A. Checking pupillary response to light assesses cranial nerve II (optic nerve).
B. Observing for facial symmetry primarily assesses cranial nerves VII (facial nerve) and possibly V (trigeminal nerve).
C. Testing for sense of smell assesses cranial nerve I (olfactory nerve).
D. Eliciting the gag reflex assesses cranial nerve IX (glossopharyngeal nerve) and also cranial nerve X (vagus nerve), making it the correct action to assess cranial nerve IX.