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 C
Explanation
A) Beef stew do not contain significant amounts of vitamin K and thus have a lesser impact on INR levels.
B) Orange juice do not contain significant amounts of vitamin K and thus have a lesser impact on INR levels.
C) Warfarin's effectiveness can be influenced by vitamin K, which is found in high amounts in kale and other green leafy vegetables. Consistent intake of vitamin K is crucial as fluctuations can affect the International Normalized Ratio (INR), a measure of blood clotting.
D) Yogurt do not contain significant amounts of vitamin K and thus have a lesser impact on INR levels.
Correct Answer is B
Explanation
A) Generalized abdominal pain reported by a client with peritonitis indicates visceral pain.
B) Pain in the left shoulder reported by a client with pancreatitis is an example of referred pain, as it occurs at a site distant from the actual pathology.
C) Substernal chest pain reported by a client with angina indicates cardiac pain, not referred pain.
D) Incisional pain reported by a postoperative client is localized and does not indicate referred pain.
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