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 ["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.

A. Apply a cold compress to the suprapubic area. B. Secure the urinary catheter to the upper left quadrant of the client's abdomen. C. Use 0.9% sodium chloride to perform an intermittent bladder irrigation. D. Encourage the client to urinate every 2 hr.

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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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 nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's Select... followed by the client's Select...ECG results

Correct Answer is ["Pain level","ECG results"]

Explanation

Correct Answer is C

Explanation

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