An older client is demonstrating signs of a brain attack. What will the nurse do to assess the degree of cerebral infarct?
1. Assess the client's ability to cry
2. Assess the client's motor strength
3. Assess the client's ability to sleep
4. Assess the client's ability to digest food
2. Assess the client's motor strength
Explanation: 1. Although some clients experience sudden mood changes, such as suddenly going from crying to laughing, assessing the ability to cry is not common when determining the degree of cerebral infarction.
2. Usually, the National Institutes of Health (NIH) Stroke Scale is used to gauge the degree of cerebral infarction by determining motor strength, among other elements, such as gaze and facial palsy.
3. Although sleep problems are common after a stroke, assessing the ability to sleep is not common when determining the degree of cerebral infarction.
4. The ability to swallow food should be assessed in determining the degree of cerebral infarction in a client, but the ability to digest food would not.
You might also like to view...
The nurse is preparing an older widowed patient with several chronic illnesses for discharge to home. The nurse addresses the primary nursing outcome for this patient when
a. assuring the patient that social services will arrange for help with medical ex-penses. b. arranging for in-home assistance in areas of activities of daily living (ADLs) and nursing care as needed. c. educating the patient regarding the safety risks caused by these conditions. d. identifying barriers to ensure adherence to the prescribed drug therapies.
For the client experiencing xerostomia, the nurse should:
a. provide frequent lip lubrication with a water-soluble gel. b. increase the client's IV fluids until specific gravity is greater than 1.010. c. instruct the client not to use aspirin. d. provide the client with a soft-bristled toothbrush.
The daughter of a patient tells the nurse that her mother was sitting at the kitchen table and then went totally limp and was disoriented. Currently, the daughter is pacing in the emergency room cubicle and continues to try to arouse her mother
Which of the following should the nurse do? 1. Explain to the daughter that her mother is in the best place to figure out what has happened to cause her to become disoriented. 2. Ask the daughter to have a seat in the waiting room until the doctor has finished examining her mother. 3. Encourage the daughter to return home to wait for information. 4. Tell the daughter that being obviously stressed out will not help her mother.
Discharge planning for an 8-year-old child with a patched eye after a corneal abrasion should include:
a. removing the patch after 8 hours for instillation of antibiotic ointment. b. gently massaging the affected eye to prevent edema. c. instilling antibiotic ointment after patching for 24 hours. d. returning after 7 days of patching for reas-sessment.