NR-325 Adult Health II - Set 3 - Part 2

Correct Answer: Right homonymous hemianopsia in both eyes

Homonymous hemianopsia wipes out the same half of the visual field in each eye, so a left-hemisphere stroke costs the client the right half of the world and the right half of the tray. Option a is incorrect because losing one whole eye involves the optic nerve before the chiasm, not the visual pathway behind it. That client would still see the full tray by turning slightly. Option b is incorrect because double vision arises when brainstem cranial nerves controlling eye movement are damaged, producing two overlapping images rather than a missing half. Nothing in this scenario points toward the brainstem. Option d is incorrect because central vision loss leaves the middle of the picture blank while peripheral vision survives. Such a client misses the print in front of them, not one whole side of the tray.

Correct Answer: "I will thicken his juice exactly the way the therapist showed us."

Thickened liquids move more slowly than thin ones, giving a weakened pharynx time to close the airway. Following the therapist's exact consistency is what keeps that protection in place at home. Option b is incorrect because sucking through a straw speeds thin liquid past a pharynx that cannot keep up. Straws are withheld from clients with dysphagia unless the swallowing specialist has approved them. Option c is incorrect because lying flat right after eating lets stomach contents and residue travel back toward the throat. Staying upright for thirty to sixty minutes is what prevents that reflux and aspiration. Option d is incorrect because conversation during a meal invites the client to open the airway while food is in the mouth. Company is welcome before and after the meal, not during each swallow.

Correct Answer: Subarachnoid hemorrhage from a ruptured aneurysm

A headache that explodes to maximum intensity within seconds, with vomiting, is the hallmark of subarachnoid hemorrhage. Blood escapes from a ruptured berry aneurysm into the space around the brain surface. Option a is incorrect because thrombotic strokes build on an atherosclerotic plaque and usually announce themselves gradually, often on waking. Severe headache is uncommon in them, and the deficit is weakness or speech loss rather than sudden agony. Option b is incorrect because a lacunar infarct is a tiny deep lesion in a penetrating arteriole territory. It produces pure motor or pure sensory findings with no cortical signs, and it does not cause explosive head pain. Option d is incorrect because transient ischemic attacks bring brief focal deficits that clear completely and leave no infarction behind. The client here has ongoing severe pain and vomiting, which points to active bleeding rather than a resolved warning.

Correct Answer: Raccoon eyes and the Battle sign

Periorbital bruising is called raccoon eyes and suggests an anterior fossa fracture, while mastoid bruising behind the ear is the Battle sign of a middle fossa fracture. Both typically appear after a delay. Option a is incorrect because a swollen optic disc is visible only through an ophthalmoscope and reflects pressure that has stayed high for days. Nothing about skin bruising can be seen on the retina. Option c is incorrect because blood behind the eardrum and a ringed stain on gauze are separate findings of the same fracture. Neither describes discoloration spreading across the eyelids and the mastoid. Option d is incorrect because unequal pupils and an upgoing great toe are neurologic responses elicited during examination. They say nothing about where blood has tracked under the skin after a fracture at the skull base.

Correct Answer: The second client most likely has bleeding

Headache, vomiting, and a falling level of consciousness with deficits that keep worsening point toward blood in the brain. An ischemic event more often arrives painlessly and is worst at the very first moment. Option a is incorrect because a clot dissolving drug is absolutely forbidden once bleeding is present. Assuming both clients qualify skips the imaging step that separates them and could prove fatal for the second one. Option b is incorrect because letting pressure run high protects threatened tissue only in ischemia. With an expanding hematoma the logic reverses, since a high reading pushes the bleed outward and worsens the injury. Option c is incorrect because the first description belongs to an embolic occlusion. Sudden weakness that is worst immediately, without pain or vomiting, fits a vessel plugged by traveling debris rather than a ruptured one.

Correct Answer: Activate emergency services for immediate stroke transport

Recognizing the event and getting the client into the stroke system is the action that preserves brain. Every reperfusion window runs from onset, and no clinic level task will shorten the transport delay. Option b is incorrect because intravenous access does matter once the client reaches the hospital and reperfusion is being prepared. Placing a line in the clinic delays the call that mobilizes imaging, the neurologist, and the pharmacy. Option c is incorrect because a phone call for history can happen from the ambulance or the emergency department. Treating it as the opening move trades minutes of salvageable tissue for information that can be gathered later. Option d is incorrect because charting is never the first response to an unfolding emergency. The record can be completed after help is summoned, and stopping to write while the clot sits in place costs the client neurons.

Correct Answer: Localization of a painful stimulus

Moving the hand purposefully toward the source of the stimulus is localization, a higher and better response than simply pulling away. It earns five points in the motor column. Option a is incorrect because withdrawal is a simple pull away from the stimulus with no movement toward its source. The hand reaching the shoulder shows purpose, which scores one point higher. Option c is incorrect because abnormal flexion means the arms curl rigidly inward toward the chest without any aim. That posture is decorticate, and it sits two steps below what this client demonstrated. Option d is incorrect because no response at all means flaccidity, the worst possible finding in the motor column. This client moved deliberately, which places the score near the top of the range.

Correct Answer: A blood pressure of 192 over 108

After thrombolysis the pressure must stay at or below 180 over 105 for a full day. A reading above that ceiling threatens the freshly reperfused vessels and calls for a titratable intravenous agent now. Option a is incorrect because that pressure sits comfortably under the post treatment ceiling. Nothing needs to be done for it, and dropping a reading like this would risk starving tissue that is still recovering. Option b is incorrect because a mildly raised temperature is worth treating in stroke care but is not the most urgent item here. Antipyretics and a source search can follow once the pressure is controlled. Option c is incorrect because that glucose falls inside the range commonly targeted during acute stroke. It needs monitoring rather than a rescue intervention, and it poses no threat to the vessel wall after a thrombolytic.

Correct Answer: "I can stop the pills myself once I feel completely well."

Stopping an antiseizure drug abruptly is the leading cause of breakthrough seizures and status epilepticus, even after years without an event. Any change is tapered slowly under the supervision of the provider. Option b is incorrect because contacting the clinic first is exactly the behavior the teaching aims for. Dose changes, refill problems and being kept nothing by mouth all deserve a phone call rather than a guess. Option c is incorrect because fixed daily timing is what holds the serum level steady between doses. Alarms, pill organizers and linking doses to meals are the strategies nurses teach for this. Option d is incorrect because a new rash can announce Stevens Johnson syndrome, which is why prompt reporting is taught with every one of these drugs. This client has the message right.

Correct Answer: Give the ordered lorazepam if jerking returns

Medication administration, and emergency benzodiazepines above all, sits outside assistive personnel scope in every state. The registered nurse gives the drug and then watches respirations, blood pressure and level of consciousness closely. Option a is incorrect because obtaining postictal vital signs appears on the course list of delegated tasks. The measurement itself is routine, while interpreting what the numbers mean stays with the nurse. Option b is incorrect because hygiene after incontinence is basic care that assistive personnel provide every shift. Doing it promptly and without comment protects the dignity of a client who is often deeply embarrassed. Option d is incorrect because immediate reporting of seizure activity to the registered nurse is explicitly delegated. Reporting asks the worker only to say what happened, not to decide what it signifies.

Correct Answer: Stop the meal and suction the mouth

Airway comes before everything else. Stopping the meal prevents another bolus from entering an unprotected airway, and suctioning clears what is already pooling in the mouth and pharynx before the client draws it deeper. Option a is incorrect because calling the provider takes time the client does not have while food sits in the pharynx. The call belongs after the airway is cleared and the client is stable. Option b is incorrect because continuing to feed a client who is actively aspirating adds more material to the lungs. Charting an event while it is still happening reverses the order of nursing action entirely. Option c is incorrect because a radiograph may later confirm aspiration pneumonia, yet imaging changes nothing at the bedside in this moment. Diagnostics follow the immediate physical intervention rather than replacing it.

Correct Answer: Interpret the readings and assess the client

Assistive personnel may obtain postictal vital signs, but interpretation belongs to the nurse, who pairs the numbers with an airway check, neurologic comparison and injury survey before deciding anything further. Option b is incorrect because a fixed hourly schedule ignores how this client is actually doing. Monitoring frequency follows the nurse's judgment about recovery, and repeat checks may be needed far sooner than that. Option c is incorrect because postictal sleep is the brain recovering, and forcing wakefulness serves no purpose. History taking waits until the client is alert, oriented and able to answer questions reliably. Option d is incorrect because deciding when a provider must be notified is clinical judgment the nurse cannot hand off. Unlicensed staff report their findings promptly, and the nurse makes the call from there.

Correct Answer: Feeding the client following the established plan

Once the nurse has assessed the client and coached the aide on positioning, pacing, and warning signs, feeding a stable client with a set plan is a task assistive personnel may carry out. Option a is incorrect because the swallow screen is a nursing assessment that decides whether the airway is safe. Assessment cannot be handed off, no matter how experienced the assistive personnel happens to be. Option c is incorrect because advancing a diet texture rests on the speech therapist's evaluation and the nurse's judgment. An aide who upgrades the tray is making a clinical decision outside the assistive role. Option d is incorrect because interpreting a finding as aspiration requires clinical judgment about deterioration. Assistive personnel report what they observe, such as coughing or a change in voice, and the nurse draws the conclusion.

Correct Answer: Insert a nasogastric tube for feeding

A tube passed through the nose can travel through a fracture in the cribriform plate and enter the cranial vault. Gastric access is obtained by the oral route in these clients. Option a is incorrect because a loosely applied pad catches the fluid without blocking it. Packing the nostril would trap cerebrospinal fluid, raise pressure, and invite organisms upward toward the meninges. Option b is incorrect because raising the upper body reduces the pressure driving the leak and helps venous blood leave the skull. Many protocols specify exactly this position for a draining fracture. Option d is incorrect because imaging without contrast is the first study after any significant head trauma. It shows blood, fracture lines, and mass effect quickly, which is precisely what this client needs.

Correct Answer: Hold the aspirin and clarify with the provider

Antiplatelet and anticoagulant drugs are withheld for a full day after a thrombolytic, with repeat imaging first. Giving one at eight hours stacks bleeding risk on a brain that has just been reperfused. Option a is incorrect because the route is not the problem. Any antiplatelet inside the first day after thrombolysis raises the chance of bleeding into the infarct, and a sip of water changes none of that. Option b is incorrect because crushing the tablet and pushing it down a tube delivers the same drug at the same forbidden hour. Placing a tube during this period also creates a fresh bleeding site. Option c is incorrect because watching for bruises after the fact does not undo an unsafe administration. The nurse prevents harm by questioning the timing rather than by observing more closely once the tablet is swallowed.

Correct Answer: It decides whether clot dissolving therapy is possible

Every reperfusion window is counted from the last normal moment, so that single time decides eligibility. Within three hours the drug is offered, and selected clients qualify out to four and a half hours. Option a is incorrect because heredity is explored through family history, not through the hour a deficit appeared. Genetic questions belong to long term prevention counseling and have no bearing on what happens in the next sixty minutes. Option c is incorrect because recovery is predicted from stroke severity, infarct size, and the response to treatment over weeks. Onset time shapes what can be offered today rather than forecasting the final level of function. Option d is incorrect because bed assignment follows acuity and available resources rather than a timestamp. Knowing the last normal hour changes the treatment plan itself, which is a far larger question than where the client sleeps.

Correct Answer: Continue monitoring and document the reading

Without a thrombolytic on board, pressure is allowed to run high because the tissue around the infarct depends on it. Treatment is reserved for readings at or above 220 over 120. Option a is incorrect because lowering pressure here shrinks flow through the collateral vessels feeding the threatened rim. That converts salvageable tissue into dead tissue and enlarges the very deficit the team is trying to limit. Option b is incorrect because a reading in this range after ischemic stroke is expected rather than alarming. Calling it an emergency invites a treatment that would reduce flow to tissue still hanging on. Option d is incorrect because an unordered fluid bolus treats hypotension, the opposite of what this client has. Adding volume to an already high pressure offers no benefit and could worsen swelling in the injured brain.

Correct Answer: Refer her to respite services and a support group

Caregiver strain sinks discharge plans more often than any medical complication. Respite, a stroke support group, and a social work referral spread the load and keep this wife able to continue. Option b is incorrect because private duty care is expensive and out of reach for many families. Pushing a costly solution first ignores the community services and home health benefits already available to them. Option c is incorrect because dismissing exhaustion as temporary leaves a caregiver carrying the same load tomorrow. Strain that goes unaddressed ends in illness, resentment, or a readmission nobody planned for. Option d is incorrect because trimming chores addresses only one slice of a much larger role change. The wife has absorbed the driving, the finances, and the physical care, so the answer has to be broader.

Correct Answer: Keep the client nothing by mouth and call speech therapy

A failed screen means the swallow is unsafe until a specialist says otherwise. The client stays nothing by mouth, the diet and oral drugs are held, and speech therapy is called for a full evaluation. Option a is incorrect because pudding is still an oral bolus that a failing pharynx has to move. Choosing a softer vehicle for the tablets sidesteps the screen result instead of respecting it. Option b is incorrect because raising the bed helps a safe swallow but cannot create one. Starting a regular diet after a failed screen sends thin liquids and solid pieces toward an unprotected airway. Option d is incorrect because handing the tray to a relative shifts the risk without removing it. Family members cannot compensate for a pharynx that has already demonstrated it cannot manage a sip.

Correct Answer: A level of consciousness that keeps dropping

The rule is steady improvement. A client who instead sinks deeper may be in nonconvulsive status epilepticus, which shows no motor signs and needs urgent evaluation, so the provider is called now. Option a is incorrect because headache and muscle soreness follow the sustained contraction of a convulsion in almost every client. Ordered analgesia and repositioning handle them, and neither one signals a worsening brain. Option c is incorrect because amnesia for the event is universal after loss of consciousness. The nurse simply tells the client what happened, in plain words, and repeats it whenever the question comes back. Option d is incorrect because focal weakness that clears on its own is Todd paralysis, a temporary exhaustion of the cortex that seized. It is documented and reported, yet its resolution is reassuring.