A nurse is creating a plan of care for a client who has left-sided weakness following a stroke.

Which of the following interventions should the nurse include in the plan?

Massage bony prominences on the client's left side.

Support the client's left arm on a pillow while sitting.

Position the bedside table on the client's left side.

Place the client's cane on their left side while ambulating.

Answer and Explanation

The Correct Answer is B

- A is incorrect because massaging bony prominences on the client's left side can increase the risk of skin breakdown and pressure ulcers. The nurse should avoid applying pressure to areas with impaired circulation or sensation.

- B is correct because supporting the client's left arm on a pillow while sitting can prevent edema, contractures, and nerve damage. The nurse should also encourage the client to perform active and passive range of motion exercises on their left arm.

- C is incorrect because positioning the bedside table on the client's left side can discourage the client from using their right side, which can lead to neglect and learned nonuse. The nurse should position the bedside table on the client's right side and encourage them to reach for items with their right hand.

- D is incorrect because placing the client's cane on their left side while ambulating can cause instability and falls. The nurse should place the cane on the client's right side and instruct them to move their left leg and cane together, followed by their right leg.

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

Explanation

A. Firmly massaging the uterine fundus helps promote uterine contraction and reduce postpartum hemorrhage.
B. Providing emotional support helps address the client’s anxiety and distress.
C. Administering oxygen supports tissue perfusion, especially as the client is showing signs of hypovolemic shock.
D. Weighing perineal pads helps quantify blood loss and assess the severity of hemorrhage.
E. Inserting an indwelling urinary catheter ensures accurate output measurement and prevents bladder distension, which can interfere with uterine contraction.

A. Keep the client's television on with the volume low B. Insert an indwelling urinary catheter to minimize interaction with the client C. Consult the provider regarding administering a mild sedative on a schedule D. Move the client to a room near the nurses' station

Correct Answer is D

Explanation

Move the client to a room near the nurses' station.

A. Keep the client's television on with the volume low: This is incorrect because it does not address the client's safety or agitation. The television might also be a source of confusion or stimulation for the client.
B. Insert an indwelling urinary catheter to minimize interaction with the client: This is incorrect because it is an invasive and unnecessary procedure that increases the risk of infection and trauma. It also violates the client's dignity and autonomy.
C. Consult the provider regarding administering a mild sedative on a schedule: This is incorrect because it is not the first action to take. The nurse should first assess the client's condition and identify possible causes of disorientation and combativeness, such as pain, infection, medication side effects, or delirium. Sedatives should be used as a last resort and only with informed consent.
D. Move the client to a room near the nurses' station: This is correct because it allows for close observation and supervision of the client, which can prevent injury and promote safety. It also facilitates frequent interaction and reassurance from the staff, which can reduce anxiety and agitation.

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A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is D

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A nurse is creating a plan of care for a client who has left-sided weakness following a stroke.

Which of the following interventions should the nurse include in the plan?