SCRN Exam V2 (Latest )
Questions and Answers | Grade A |
100% Correct (Verified Solutions)
Question:
The nurse is reviewing the plan of care for a client who is unresponsive
following a stroke. Which intervention should the nurse question?
a. Encouraging active range-of-motion exercises
b. Elevating the head of the bed 30 degrees
c. Turning the client every 2 hours
d. Monitoring lower extremities for symptoms of thrombophlebitis
Answer:
Encouraging active range-of-motion exercises
Each of the nursing implementations listed are appropriate for promoting
physical mobility.
However, the client is unresponsive and therefore cannot complete active
range-of-motion exercises; they would require passive range-of-motion
exercises.
,Question:
The nurse is reviewing documentation of a physical examination of a client
who is suspected of having a stroke. Which documentation requires follow-
up?
a. Alert and oriented to person but not oriented to place or time
b. Onset of facial drooping at 1430
c. Right-sided grip stronger than left-sided grip
d. Stroke scale completed
Answer:
Onset of facial drooping at 1430
Time of onset of stroke symptoms should be included in the client interview.
All other assessments are part of the physical assessment.
, Question:
The nurse is planning care for a client who has unilateral neglect and left-
sided paralysis after experiencing a thrombotic stroke. Which goal of care
should the nurse choose?
a. The client will maintain bedrest.
b. The client will participate in therapies to prevent contractures.
c. The client will improve communication techniques.
d. The client's blood pressure will remain within 40% of normal.
Answer:
The client will participate in therapies to prevent contractures.
Preventing contractures is a good goal for a client with left-sided paralysis and
unilateral neglect. The client will be taught active range-of-motion exercises
and ambulate as able, so maintaining bedrest is not appropriate. An
appropriate goal for blood pressure is within normal limits, rather than 40%
of normal. There is no indication that the client needs assistance with
communication.
Questions and Answers | Grade A |
100% Correct (Verified Solutions)
Question:
The nurse is reviewing the plan of care for a client who is unresponsive
following a stroke. Which intervention should the nurse question?
a. Encouraging active range-of-motion exercises
b. Elevating the head of the bed 30 degrees
c. Turning the client every 2 hours
d. Monitoring lower extremities for symptoms of thrombophlebitis
Answer:
Encouraging active range-of-motion exercises
Each of the nursing implementations listed are appropriate for promoting
physical mobility.
However, the client is unresponsive and therefore cannot complete active
range-of-motion exercises; they would require passive range-of-motion
exercises.
,Question:
The nurse is reviewing documentation of a physical examination of a client
who is suspected of having a stroke. Which documentation requires follow-
up?
a. Alert and oriented to person but not oriented to place or time
b. Onset of facial drooping at 1430
c. Right-sided grip stronger than left-sided grip
d. Stroke scale completed
Answer:
Onset of facial drooping at 1430
Time of onset of stroke symptoms should be included in the client interview.
All other assessments are part of the physical assessment.
, Question:
The nurse is planning care for a client who has unilateral neglect and left-
sided paralysis after experiencing a thrombotic stroke. Which goal of care
should the nurse choose?
a. The client will maintain bedrest.
b. The client will participate in therapies to prevent contractures.
c. The client will improve communication techniques.
d. The client's blood pressure will remain within 40% of normal.
Answer:
The client will participate in therapies to prevent contractures.
Preventing contractures is a good goal for a client with left-sided paralysis and
unilateral neglect. The client will be taught active range-of-motion exercises
and ambulate as able, so maintaining bedrest is not appropriate. An
appropriate goal for blood pressure is within normal limits, rather than 40%
of normal. There is no indication that the client needs assistance with
communication.
