Difficulty: Medium
Average Score: 90%
Simulated
The nurse is caring for the client who had a stroke affecting the right hemisphere of the brain. The nurse should assess for which problem initially?
Correct answer
C
Rationale
A stroke affecting the right hemisphere may produce left, not right hemiparesis. Motor fibers in the brain cross over in the medulla before entering the spinal column. This client may or may not have aphasia because the center for language is located on the left side of the brain in 75% to 80% of the population; this client had a stroke involving the right hemisphere. Even though the client may have expressive aphasia, it is more important to assess for poor impulse control due to the risk for injury. The client with a stroke affecting the right side of the brain often exhibits impulsive behavior and is unaware of the neurological deficits. Poor impulse control increases the clientÔÇÖs risk for injury. Tetraplegia (quadriplegia) is associated with an SCI; tetraplegia usually does not occur from a stroke.