A nurse is performing a dressing change on a client and observes granulation tissue. Which of the following findings should the nurse document?

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.

1. Assist the client into a sitting position in a chair. Ensures comfort and stability before starting foot care.
2. Soak the client's feet in warm water. Softens the skin and makes cleaning easier.
3. Rub callused areas of the client's feet using a washcloth. Helps remove dead skin and promotes circulation.
4. Gently dry the client's feet and areas between the toes with a towel. Prevents moisture buildup, which can lead to fungal infections.
5. Apply lotion to the client's feet. Moisturizes the skin but should not be applied between the toes to prevent excessive moisture retention and fungal growth.