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.

Answer and Explanation

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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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.

A. Oxygen saturation 96% at 2 L/min via nasal cannula B. Disoriented to person, place, and time C. Blood pressure 100/50 mm Hg D. Hct 45% E. Pink-tinged urine F. Butterfly rash

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

Explanation

A) An increase in oxygen saturation to 96% at a reduced oxygen flow rate indicates potential improvement in respiratory function, which can be a positive sign of recovery from a UTI.
B) Disorientation to person, place, and time suggests a potential worsening of the condition, as UTIs can cause confusion, especially in older adults and those with dementia.
C) A drop in blood pressure to 100/50 mm Hg could indicate potential worsening, as it may suggest dehydration or sepsis, both of which can complicate a UTI.
D) A decrease in hematocrit (Hct) to 45% is within the normal range and could indicate an improvement if previously elevated due to dehydration.
E) Pink-tinged urine may indicate the presence of blood, a sign of potential worsening, as it could suggest a more severe infection or other complications.
F) A butterfly rash is not typically associated with a UTI and may be unrelated to the current diagnosis; in this scenario it is related to the patient’s history of systemic lupus erythematosus.

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A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

Explanation

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