SCRN Exam V2 Latest - Questions and Answers | Grade A | 100% Correct ...

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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