Page 2058 - Saunders Comprehensive Review For NCLEX-RN

711. Answer: 1, 2, 4

Rationale: Hemiparesis is a weakness of one side of the body that may occur after
a stroke. It involves weakness of the face and tongue, arm, and leg on one side.
These clients are also aphasic, unable to discriminate words and letters. They are
generally very cautious and get anxious when attempting a new task. Complete
bilateral paralysis does not occur in hemiparesis. The client with right-sided
hemiparesis has weakness of the right arm and leg and needs assistance with
feeding, bathing, and ambulating.
Test-Taking Strategy: Focus on the subject, right-sided hemiparesis. Recalling that
hemiparesis indicates weakness on one side of the body and focusing on the subject
will direct you to the correct option. Also, noting the word complete in the question
will assist you in answering correctly.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Stroke
Priority Concepts: Functional Ability; Intracranial Regulation
Reference: Lewis et al. (2017), p. 1345.

712. Answer: 4

Rationale: Homonymous hemianopsia is loss of half of the visual field. The client
with homonymous hemianopsia should have objects placed in the intact field of
vision, and the nurse also should approach the client from the intact side. The nurse
instructs the client to scan the environment to overcome the visual deficit and does
client teaching from within the intact field of vision. The nurse encourages the use of
personal eyeglasses, if they are available.
Test-Taking Strategy: Focus on the subject, homonymous hemianopsia. Eliminate
options 2 and 3 first because they are comparable or alike. Recalling the definition of
homonymous hemianopsia will direct you easily to the correct option.
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Evaluation
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Stroke
Priority Concepts: Intracranial Regulation; Safety
Reference: Lewis et al. (2017), p. 1362.

713. Answer: 4

Rationale: Clients are evaluated as coping successfully with lifestyle changes after
a stroke if they make appropriate lifestyle alterations, use the assistance of others,
and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors;
option 3 indicates a not yet successful attempt to adapt.
Test-Taking Strategy: Note the strategic word, most, and focus on the subject,

2058