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 B
Explanation
A. Assessing the pedal pulses does not provide relevant information about the irregularity of the radial pulse.
B. Assessing the apical pulse for a full minute is appropriate in this situation, as it provides a more accurate measurement of the heart rate and rhythm, especially when the radial pulse is irregular.
C. Assessing the popliteal pulses with a Doppler device is not necessary and does not directly address the irregular radial pulse.
D. While a pulse oximeter can provide information about oxygen saturation, it does not assess heart rate or rhythm.
Correct Answer is C
Explanation
A. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.
B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.
C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.
D. Grimacing is an objective observation by the nurse, not a subjective report from the client.