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 A
Explanation
A. The carotid pulse should not be assessed bilaterally at the same time, as simultaneous palpation can lead to a decrease in heart rate or cause syncope due to stimulation of the carotid sinus.
B. The radial pulse can be assessed bilaterally without risk.
C. The brachial pulse can also be assessed bilaterally without concern.
D. The femoral pulse is typically assessed one side at a time, but there is no risk in palpating both femoral arteries simultaneously as there is with the carotid.
Correct Answer is B
Explanation
A. Lordosis is an exaggerated inward curvature of the lumbar spine.
B. Scoliosis is a lateral curvature of the spine, often characterized by an "S" or "C" shape when viewed from behind. This is the disorder depicted in the image.
C. Kyphosis is an exaggerated outward curvature of the thoracic spine, often leading to a hunchback appearance.
D. Funnel chest (pectus excavatum) is a condition where the breastbone sinks into the chest, creating a sunken appearance.