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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. A 21-year-old client who had a normal Pap test one year ago. The American Cancer Society (ACS) and the U.S. Preventive Services Task Force (USPSTF) recommend that cervical cancer screening (Pap test) begin at age 21, regardless of sexual history. Screening should be done every 3 years for individuals aged 21-29, assuming results are normal. Since this client had a Pap test one year ago, they do not need immediate screening but should follow the standard 3-year interval.
B. A 32-year-old client who had a total vaginal hysterectomy last year. A total hysterectomy (removal of the uterus and cervix) for non-cancerous reasons generally means that Pap tests are no longer necessary. However, if the hysterectomy was due to cervical cancer, continued screening might be needed.
C. A 47-year-old client who had a negative combined Pap and HPV test 5 years ago. For clients 30-65 years old, Pap tests can be done every 3 years OR combined Pap and HPV (co-testing) every 5 years. Since this client had a negative co-test 5 years ago, they are due for screening now, but they would not have been referred earlier.
D. A 15-year-old client who recently completed the vaccine series for human papillomavirus (HPV). The HPV vaccine does not replace the need for Pap tests but helps reduce the risk of cervical cancer. Routine Pap testing does NOT begin before age 21, so this client does not yet need screening.

A. The client cannot change their mind after signing consent. B. The alternative treatments to the procedure should be explained. C. The time of the procedure should be indicated on the form. D. The charge nurse should review the form once it's signed.

Correct Answer is B

Explanation

A. The client cannot change their mind after signing consent. Clients have the right to withdraw consent at any time before the procedure begins.
B. The alternative treatments to the procedure should be explained. Informed consent includes information about alternative treatments and their risks/benefits so the client can make an informed decision.
C. The time of the procedure should be indicated on the form. The time of the procedure is not a required component of informed consent. The consent form should include the procedure details, risks, benefits, and alternatives
D. The charge nurse should review the form once it's signed. While nurses witness informed consent, they do not validate or review it. The provider performing the procedure is responsible for obtaining consent.

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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?

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