A nurse is creating a plan of care for a client who has left-sided hemiplegia. Which of the following interventions should the nurse include?
Rest the client's left arm over their chest.
Apply an orthotic boot to the client's left foot.
Place a thick pillow behind the client's head to increase cervical flexion.
Instruct the client to lean toward the left side when ambulating to avoid falls.
The Correct Answer is B
A. "Rest the client's left arm over their chest." Keeping the affected arm across the chest can lead to contractures and shoulder adduction deformities. Instead, the arm should be supported in a neutral position with pillows or a sling to prevent complications.
B. "Apply an orthotic boot to the client's left foot." Clients with hemiplegia are at risk for foot drop due to muscle weakness or paralysis. An orthotic boot helps maintain proper foot alignment, prevents contractures, and promotes mobility.
C. "Place a thick pillow behind the client's head to increase cervical flexion." Excessive cervical flexion can lead to poor airway alignment and discomfort. Instead, the client’s head should be in a neutral, midline position with proper support.
D. "Instruct the client to lean toward the left side when ambulating to avoid falls." Leaning toward the affected (weaker) side increases the risk of imbalance and falls. Instead, the client should be encouraged to maintain proper posture and use assistive devices (e.g., cane, walker) for stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Place the head of the bed flat before using the incentive spirometer." The client should be in a semi-Fowler’s or high-Fowler’s position (sitting upright) to maximize lung expansion.
B. "Hold your breath for 2 to 3 seconds when using the incentive spirometer." Holding the breath allows for maximum lung expansion and helps prevent atelectasis (lung collapse).
C. "Use the incentive spirometer every 3 hours while awake." The incentive spirometer should be used every 1 to 2 hours while awake to promote lung expansion and prevent complications such as pneumonia.
D. "Breathe in through your nose when using the incentive spirometer." The client should inhale deeply through the mouth, not the nose, to ensure proper lung inflation.
Correct Answer is A
Explanation
A. Ask the client if they understand the procedure. The nurse’s role in informed consent is to confirm that the client understands the procedure and voluntarily agrees to it. If the client has questions or does not understand, the nurse should notify the provider for further explanation.
B. Describe the procedure to the client. It is the provider’s responsibility to explain the procedure in detail, including what it entails. The nurse should not provide this explanation.
C. Inform the client about alternative treatment options. The provider must discuss alternative treatment options, not the nurse. The nurse can ensure that this discussion has occurred but does not provide the alternatives.
D. Explain the risks of the procedure to the client. The provider is responsible for explaining the risks, benefits, and expected outcomes of the procedure. The nurse’s role is to witness the consent and ensure the client understands.
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