The client who has had a stroke combs her hair only on the right side of her head and washes only the right side of her face. What is the nurse's interpretation of these actions?
A. The client has poor left-sided motor control.
B. The client has paralysis or contractures on the left side.
C. The client's visual perception of the left fields is limited.
D. The client is unaware of the existence of her left side.
D
Clients who have experienced a right hemisphere stroke often have neglect syndrome, in which they are unaware of the existence of the paralyzed side.
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The nurse in an inner city clinic is providing a health screening for a homeless client with a history of drug abuse. The client has a chronic non-productive cough. For which should the nurse expect to screen this client?
A) Herpes zoster B) Sickle cell disease C) Sick sinus syndrome D) Tuberculosis
The nurse, preparing to administer eardrops to a client, questions the order because of which of the following assessment findings?
a. The client states he is hard of hearing. b. The client's tympanic membrane is perforated. c. The client has wax in the ear. d. The client states he has an earache.
A client is seen in the emergency department in shock. X-rays reveal protrusion of a portion of the fetus through the maternal abdomen. The nurse hypothesizes that the client has experienced which of the following?
a. Placenta previa c. Abruptio placentae b. Uterine rupture d. Umbilical cord pro-lapse
A client is receiving antiemetic therapy for a history of frequent nausea and vomiting. In caring for this client the nurse should:
a. assess the client's skin for areas of breakdown. b. encourage the client to gradually become more active. c. turn the client at least every two hours. d. monitor for fluid and electrolyte imbalances.