A nurse is caring for a client who experienced a right-hemispheric stroke and has extreme muscle weakness on the affected side. Which nursing intervention is most appropriate for this client?

Encouraging the client to use a cane as needed for mobility

Encouraging the client to use their right hand for daily activities

Encouraging the client to consume a soft diet and thickened liquids

Encouraging the client to complete all activities of daily living (ADLs) independently

Answer and Explanation

The Correct Answer is A

A. A client with extreme muscle weakness on the affected side should use a cane or other assistive devices to aid in mobility and ensure safety. This intervention helps the client maintain stability and prevent falls.
B. The client with muscle weakness should use the unaffected hand for daily activities to ensure safety and improve functional outcomes. Using the affected hand may increase the risk of injury.
C. A soft diet and thickened liquids are generally recommended for clients with dysphagia, which is not specifically indicated in the context of muscle weakness due to a stroke.
D. Encouraging the client to complete all ADLs independently may not be feasible or safe due to the muscle weakness. Support and assistance with ADLs are likely needed.

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Correct Answer is ["A","B","D"]

Explanation

A. Encourage the client to increase fluid intake: This is important to prevent dehydration, which can be a complication of influenza.
B. Wear a mask when caring for the client: Influenza is a highly contagious virus, and wearing a mask can help prevent the spread of infection.
C. Prepare to administer an antibiotic to the client: Antibiotics are not typically used to treat influenza, which is a viral infection. However, if a bacterial infection develops as a complication, antibiotics may be necessary.
D. Place the client in a private room: Isolating the client in a private room can help prevent the spread of influenza to other patients and healthcare workers.
E. Place the client on contact precautions: Influenza is primarily spread through respiratory droplets, so droplet precautions are appropriate. Contact precautions are not necessary for influenza.

A. Performing hand hygiene before, during, and after direct contact with the client B. Changing the client's bed linens each day C. Controlling the client's blood glucose level D. Placing the client in a room with positive-pressure airflow

Correct Answer is A

Explanation

A. Performing hand hygiene before, during, and after direct contact with the client is the most effective strategy for preventing the transmission of infections. Hand hygiene interrupts the transmission of pathogens and is a cornerstone of infection control practices.
B. Changing the client's bed linens each day is a standard practice for maintaining cleanliness but does not specifically prevent infection transmission. The primary goal of infection control is to reduce pathogen transmission rather than just maintaining general cleanliness.
C. Controlling the client's blood glucose level is important for overall health and wound healing but does not directly prevent infection transmission. It is not an infection control strategy.
D. Placing the client in a room with positive-pressure airflow is used to protect immunocompromised patients from infections by preventing outside air from entering the room. However, it is not appropriate for preventing the transmission of an infection from a client to others.

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A nurse is caring for a client who experienced a right-hemispheric stroke and has extreme muscle weakness on the affected side. Which nursing intervention is most appropriate for this client?

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