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.
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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Related Questions
Correct Answer is C
Explanation
A. Incorrect. Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.
B. Incorrect. Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.
C. Correct. Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.
D. Incorrect. Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.
Correct Answer is D
Explanation
A. Instructing the client about the importance of regular medical appointments is important, but not the priority. The nurse should first ensure that the client knows how to manage their blood glucose levels and administer insulin at home.
B. Encouraging the client to participate in daily exercise is beneficial, but not the priority. The nurse should first ensure that the client knows how to monitor their blood glucose levels and adjust their insulin dose accordingly.
C. Explaining proper foot care techniques to the client is essential, but not the priority. The nurse should first ensure that the client knows how to prevent and treat hypoglycemia and hyperglycemia, which can have serious complications.
D. Ensuring that the client understands the medication regimen is the priority. The nurse should teach the client about the types, actions, doses, and administration times of insulin, as well as how to store and dispose of it safely.
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