SCRN Exam V2 (Latest 2025 / 2026) 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?
- Encouraging active range-of-motion exercises
- Elevating the head of the bed 30 degrees
- Turning the client every 2 hours
- 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. 1 / 3
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?
- Alert and oriented to person but not oriented to place or time
- Onset of facial drooping at 1430
- Right-sided grip stronger than left-sided grip
- 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.
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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?
- The client will maintain bedrest.
- The client will participate in therapies to prevent contractures.
- The client will improve communication techniques.
- 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.
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