A nurse is preparing to give a bed bath to a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse plan to take?
Wash in a distal to proximal direction.
Use a circular motion with the washcloth.
Massage legs after completing the bath.
Disconnect the IV tubing prior to performing the bath.
The Correct Answer is A
Choice A rationale:
The nurse should wash the client in a distal to proximal direction during a bed bath after a cerebrovascular accident (CVA) to prevent the risk of clot dislodgement. This method ensures that any potential clots or debris are moved away from the central circulation, reducing the risk of harm.
Choice B rationale:
Using a circular motion with the washcloth can increase friction and potentially irritate the skin. Clients with a history of CVA might have reduced sensation or mobility, making them susceptible to skin breakdown. Hence, avoiding circular motions is important to prevent skin damage.
Choice C rationale:
Massaging the legs after completing the bath can also pose a risk of clot dislodgement. It is essential to avoid vigorous massage on areas affected by deep vein thrombosis (DVT) to prevent complications like pulmonary embolism.
Choice D rationale:
There is no need to disconnect the IV tubing before performing the bath unless specifically indicated by the healthcare provider. In general, clients receiving continuous IV infusions can continue the infusion while maintaining proper infection control measures during the bath.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
"I changed the floor plan of our home to accommodate my father's wheelchair.”.
Choice A rationale:
This statement indicates acceptance of the role change as a caregiver for the aging parents. Making changes to the home to accommodate the father's wheelchair demonstrates the client's willingness to adapt and provide a suitable environment for caregiving.
Choice B rationale:
Feeling stressed out and overwhelmed does not necessarily indicate acceptance of the role change. It may reflect the challenges and emotional burden that come with caregiving but does not necessarily signify acceptance.
Choice C rationale:
Expressing frustration with caregiving does not necessarily indicate acceptance of the role change. It is normal to feel frustrated at times, especially when dealing with chronic illnesses, but acceptance involves embracing the responsibilities that come with the role.
Choice D rationale:
While the statement shows a willingness to learn and adapt to caregiving, it does not explicitly indicate acceptance of the role change. Acceptance involves acknowledging and embracing the new responsibilities and challenges fully.
Correct Answer is C
Explanation
Choice A rationale:
Leflunomide is a disease-modifying antirheumatic drug (DMARD) used for rheumatoid arthritis, but it does not typically result in decreased swelling within one week. It usually takes several weeks or even months for its full effect to be observed.
Choice B rationale:
Applying hot packs directly to the joint for pain relief is not recommended for rheumatoid arthritis, as heat can exacerbate inflammation. Cold packs or other anti-inflammatory measures are more appropriate.
Choice C rationale:
Steroid medications, such as prednisone, can lead to bone density loss and an increased risk of osteoporosis. Taking calcium and vitamin D supplements helps to mitigate this risk.
Choice D rationale:
The Varicella vaccine is not directly related to rheumatoid arthritis. It is important for immune support, but it is not specifically required for rheumatoid arthritis treatment.
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