A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?
Instruct the client to sit on a rubber ring when seated in a chair.
Raise the head of the client's bed to a 90° angle.
Use moisturizing lotion while massaging the client's bony prominences.
Place pillows between the client's knees when in a side-lying position.
The Correct Answer is D
A) Instructing the client to sit on a rubber ring may provide comfort for those with hemorrhoids or perineal discomfort but is not directly related to managing hemiplegia.
B) Raising the head of the client's bed to a 90° angle may be uncomfortable and may not address the specific needs related to hemiplegia.
C) Using moisturizing lotion while massaging the client's bony prominences is important for skin integrity but does not directly address the positioning needs of a client with hemiplegia.
D) Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment, prevents pressure ulcers, and promotes comfort for the client with hemiplegia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["Pain level","ECG results"]
Explanation
The client's pain level should be addressed first based on the principle of prioritizing interventions according to the client's immediate needs and potential severity of the condition. Chest pain, especially when radiating to the left arm, is a concerning symptom that can indicate myocardial ischemia or infarction. It is essential to promptly assess and manage the client's pain to provide relief and potentially mitigate further cardiac damage. In this scenario, the client rates the pain as 7 out of 10, indicating moderate to severe discomfort, which warrants immediate attention.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
A) Elevated iron levels are directly related to hemochromatosis and could indicate a worsening condition if they continue to rise, as this condition causes iron to accumulate in the body, leading to further liver damage.
B) An increased albumin level could be a sign of potential improvement, as low albumin levels are common in liver disease due to the liver's reduced ability to synthesize proteins.
C) A productive cough may be unrelated to the diagnosis of cirrhosis but could be indicative of an additional respiratory issue that needs to be addressed.
D) Ascites, the accumulation of fluid in the abdomen, is a common complication of cirrhosis and would suggest a potential worsening of the condition.
E) Hematemesis is a serious symptom often associated with advanced liver disease and significant bleeding in the gastrointestinal tract, indicating a potential worsening of the patient's condition.
F) Spontaneous bruising can occur due to decreased production of clotting factors by the liver, also suggesting a worsening condition.
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