A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?
A measure the calves for symmetry
B palpate the bladder
C Place a pillow between the knees and ankles
D Check the gag reflex
The Correct Answer is C
Choice A Rationale: Measuring the calves for symmetry is not directly related to preventing complications after repositioning.
Choice B Rationale: Palpating the bladder is important for assessing urinary retention but is not the immediate action to prevent complications after repositioning.
Choice C Rationale: Placing a pillow between the knees and ankles is the correct action to prevent complications such as pressure ulcers and skin breakdown when a client is in a side-lying position.
Choice D Rationale: Checking the gag reflex is unrelated to repositioning and preventing complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: Hemiplegia involves paralysis of one side of the body and is typically associated with brain injuries or lesions, not spinal cord injuries.
Choice B Rationale: Quadriplegia involves paralysis of all four limbs and is more commonly associated with higher spinal cord injuries, not T2-T3.
Choice C Rationale: Paresthesia refers to abnormal sensations, such as tingling or numbness, and may be present in various spinal cord injuries, but it is not a type of disability.
Choice D Rationale: Paraplegia involves paralysis of the lower extremities and trunk, and it is commonly associated with spinal cord injuries at the T2-T3 level.
Correct Answer is B
Explanation
Choice A Rationale: Sedatives may not be the first choice for managing behavioral issues in clients with Alzheimer's disease, as they can increase confusion and fall risk.
Choice B Rationale: Antipsychotics may be considered in cases where behavioral issues pose a safety concern. They can help manage agitation, aggression, and other challenging behaviors.
Choice C Rationale: Cholinesterase inhibitors are used to treat cognitive symptoms of Alzheimer's disease but may not directly address behavioral issues.
Choice D Rationale: Serotonin reuptake inhibitors are typically used to manage mood disorders and may not be the first-line choice for behavioral issues in Alzheimer's disease.
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