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.
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Related Questions
Correct Answer is B
Explanation
A) Using a communication board with colored pictures might not effectively facilitate communication for someone who primarily uses sign language.
B) Requesting an interpreter during the initial assessment ensures effective communication between the nurse and the client.
C) Familiarizing themselves with commonly used signed language may help the nurse in the long term but may not be feasible or effective during the immediate admission process.
D) Asking a family member to be present during the admission may help but may not provide the necessary communication support for effective assessment and care.
Correct Answer is C
Explanation
A) This is not a standard intervention for bladder spasms post-TURP.
B) Securing the urinary catheter to the abdomen does not address the immediate issue of potential catheter blockage.
C) Performing an intermittent bladder irrigation using sodium chloride is appropriate in this case. This is because bladder spasms and a scant amount of fluid in the urinary drainage bag may indicate a blockage in the catheter. Intermittent bladder irrigation can help to remove any clots or debris that may be causing the blockage.
D) Encouraging the client to urinate is not applicable as the client cannot urinate normally due to the surgery.
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