Page 2053 - Saunders Comprehensive Review For NCLEX-RN

5. The client has lost the ability to move the right arm but is
able to walk independently.
6. The client has lost the ability to ambulate independently but

is able to feed and bathe herself or himself without assistance.
712. The nurse has instructed the family of a client with stroke (brain attack) who
has homonymous hemianopsia about measures to help the client overcome
the deficit. Which statement suggests that the family understands the
measures to use when caring for the client?
1. “We need to discourage him from wearing eyeglasses.”
2. “We need to place objects in his impaired field of vision.”
3. “We need to approach him from the impaired field of vision.”
4. “We need to remind him to turn his head to scan the lost visual
field.”
713. The nurse is assessing the adaptation of a client to changes in functional
status after a stroke (brain attack). Which observation indicates to the nurse
that the client is adapting most successfully?
1. Gets angry with family if they interrupt a task
2. Experiences bouts of depression and irritability
3. Has difficulty with using modified feeding utensils
4. Consistently uses adaptive equipment in dressing self
714. The nurse is teaching a client with myasthenia gravis about the prevention of
myasthenic and cholinergic crises. Which client activity suggests that
teaching is most effective?
1. Taking medications as scheduled
2. Eating large, well-balanced meals
3. Doing muscle-strengthening exercises
4. Doing all chores early in the day while less fatigued
715. The nurse is instructing a client with Parkinson’s disease about preventing
falls. Which client statement reflects a need for further teaching?
1. “I can sit down to put on my pants and shoes.”
2. “I try to exercise every day and rest when I’m tired.”
3. “My son removed all loose rugs from my bedroom.”
4. “I don’t need to use my walker to get to the bathroom.”
716. The nurse has given suggestions to a client with trigeminal neuralgia about
strategies to minimize episodes of pain. The nurse determines that the client
needs further teaching if the client makes which statement?
1. “I will wash my face with cotton pads.”
2. “I’ll have to start chewing on my unaffected side.”
3. “I should rinse my mouth if toothbrushing is painful.”
4. “I’ll try to eat my food either very warm or very cold.”
717. The client is admitted to the hospital with a diagnosis of Guillain-Barré
syndrome. Which past medical history finding makes the client most at risk
for this disease?
1. Meningitis or encephalitis during the last 5 years
2. Seizures or trauma to the brain within the last year
3. Back injury or trauma to the spinal cord during the last 2 years
4. Respiratory or gastrointestinal infection during the previous

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