A nurse is planning care for a client who has left-sided hemiplegia. Which of the following actions should the nurse include in the plan?

Initiate frequent, short periods of exercise throughout the day.

Decrease the amount of range of motion performed if tightness occurs.

Perform range-of-motion exercises to the affected side once per day.

Avoid repetitive movements during exercise.

Answer and Explanation

The Correct Answer is A

A) Initiate frequent, short periods of exercise throughout the day: Frequent, short periods of exercise are beneficial for a client with left-sided hemiplegia. Regular movement helps maintain joint flexibility, muscle strength, and overall functional ability. This approach can prevent complications such as contractures and muscle atrophy.

B) Decrease the amount of range of motion performed if tightness occurs: If tightness occurs, rather than decreasing range of motion, it is important to address it through appropriate stretching and adjustments in exercise technique. Reducing range of motion could lead to further loss of mobility and function.

C) Perform range-of-motion exercises to the affected side once per day: Performing range-of-motion exercises only once per day is generally insufficient. To maintain or improve mobility and prevent contractures, range-of-motion exercises should be performed multiple times throughout the day, as directed by the care plan.

D) Avoid repetitive movements during exercise: Repetitive movements are not necessarily harmful and can be beneficial for improving motor function and muscle coordination. However, it is important to balance repetitive exercises with variety and adjust based on the client’s condition and tolerance.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A) Use petroleum jelly on a cotton ball to plug your ear when shampooing.
This method can help protect the ear from water exposure during showering or shampooing. However, it doesn't address trauma or hearing impairment prevention as effectively as avoiding pressure changes.

B) Clean dried blood in your ear canal with a cotton-tipped applicator.
Using cotton-tipped applicators can cause trauma to the ear canal and potentially disrupt the surgical site, increasing the risk of complications and impairing hearing.

C) Avoid blowing your nose for 1 month after surgery.
Avoiding nose blowing is crucial because it can create pressure changes in the ear that may disrupt the healing process and cause trauma to the surgical site, leading to potential hearing impairment.

D) Notify your provider if you have popping or crackling sensations in the affected ear.
Popping or crackling sensations can be normal as the ear heals and adjusts post-surgery. While it’s important to monitor symptoms, reporting them is not necessarily about preventing trauma or hearing impairment.

A. Decreased deep-tendon reflexes B. Regular heart rhythm C. Hypoactive bowel sounds D. Respiratory rate 10/min

Correct Answer is B

Explanation

A) Decreased deep-tendon reflexes: Decreased deep-tendon reflexes can indicate hyperkalemia, which occurs when potassium levels are too high. This is not a sign of effective potassium chloride supplementation for hypokalemia, as it suggests an imbalance in the opposite direction.

B) Regular heart rhythm: A regular heart rhythm is a key indicator that potassium levels are within the normal range. Potassium is crucial for proper cardiac function, and maintaining an adequate level helps prevent arrhythmias and supports effective heart rhythms.

C) Hypoactive bowel sounds: Hypoactive bowel sounds can be associated with various conditions, including electrolyte imbalances like hypokalemia. However, the presence of hypoactive bowel sounds does not directly indicate that potassium chloride supplementation is effective.

D) Respiratory rate 10/min: A respiratory rate of 10/min is below the normal range and can be a sign of respiratory depression or other issues. This finding does not relate to the effectiveness of potassium chloride supplements in treating hypokalemia.

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A nurse is planning care for a client who has left-sided hemiplegia. Which of the following actions should the nurse include in the plan?

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