A nurse is caring for a client who has impaired mobility from right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement?

Obtain a soft mattress for the client's bed.

Position soft pillows against the bottom of the feet.

Use a special boot to maintain dorsiflexion of the feet.

Cross the client's legs at the ankles.

Answer and Explanation

The Correct Answer is C

A. Obtain a soft mattress for the client's bed: Soft mattresses do not provide the support needed to prevent pressure ulcers in immobilized clients.
B. Position soft pillows against the bottom of the feet: Pillows at the bottom of the feet may cause plantar flexion, leading to foot drop.
C. Use a special boot to maintain dorsiflexion of the feet: Boots or footboards help maintain neutral alignment and prevent foot drop, a common complication in paralyzed or immobile clients.
D. Cross the client's legs at the ankles: Crossing legs can impede circulation and increase the risk of pressure injury or deep vein thrombosis (DVT).

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Correct Answer is C

Explanation

A. "I'll carry objects close to my body.": Carrying objects close to the center of gravity reduces strain on the back.
B. “I'll do exercises that strengthen my abdominal muscles.": Strong core muscles support the spine and prevent injury.
C. "When standing for a long period of time. I should keep my feet flat on the floor.": This statement indicates a need for further instruction. One foot should be slightly elevated on a footrest or step to reduce lumbar strain.
D. "I'll wear low-heeled shoes from now on.": Low-heeled shoes provide better spinal alignment and reduce back stress.

A. One nurse lifting as the client pushes with his feet B. Two nurses lifting the client under the shoulders C. One nurse lifting the client’s legs as the client uses a trapeze bar. D. Two nurses using a draw sheet or other tension reducing device

Correct Answer is D

Explanation

A. One nurse lifting as the client pushes with his feet: This method increases the risk of musculoskeletal injury to the nurse and lacks adequate support.
B. Two nurses lifting the client under the shoulders: This can cause nerve damage to the client and is not a safe lifting technique.
C. One nurse lifting the client’s legs as the client uses a trapeze bar: If the client is only partially assisting, additional help is needed to avoid injury.
D. Two nurses using a draw sheet or other tension reducing device: This is the safest and most effective method to move a partially assisting client, minimizing strain and promoting safety.

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A nurse is caring for a client who has impaired mobility from right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement?

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