A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Reposition the client without the use of assistive devices.

Raise the side rails on both sides of the client’s bed during repositioning.

Discuss the client’s preferences for determining a repositioning schedule.

Evaluate the client’s ability to help with repositioning.

Answer and Explanation

The Correct Answer is D

This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort. The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.

Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.

The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.

Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.

The nurse should use assistive devices that are appropriate for the client’s condition and weight.

Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.

The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.

The nurse should also involve the client in the care plan and respect their preferences whenever possible.

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Correct Answer is C

Explanation

This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically.
It also shows empathy and respect for the client’s perspective.
Choice A is wrong because engaging the panic alarm is not the first action to take when interacting with an agitated client.
The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures.
Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.
Choice B is wrong because using a face shield with a mask when providing care to the client is not relevant to the situation.
This is personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation.
Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.
Choice D is wrong because initiating the seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly.
Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.
It should be used only as a last resort when less restrictive measures have failed or are contraindicated, and only with a provider’s order and close monitoring.
Secluding an agitated client may escalate their behavior and violate their rights.
Normal ranges for agitation are not applicable, as agitation is not a quantifiable parameter.
However, some tools that can be used to assess agitation include the Richmond Agitation- Sedation Scale (RASS), which ranges from -5 (unarousable) to +4 (combative), and the Agitated Behavior Scale (ABS), which ranges from 14 (no agitation) to 56 (severe agitation).

A. Moving both crutches with the stronger leg forward first. B. Supporting his body weight while leaning on the axillary crutch pads. C. Stepping with his affected leg first when going up stairs. D. Positioning both hands on the grips with his elbows slightly flexed.

Correct Answer is D

Explanation

The correct answer is choice D. Positioning both hands on the grips with his elbows slightly flexed.

Choice A rationale:

Moving both crutches with the stronger leg forward first is not correct because in a three-point gait, the two crutches and the affected leg move together, followed by the stronger leg.

Choice B rationale:

Supporting body weight while leaning on the axillary crutch pads is incorrect as this can cause nerve damage under the arms. Weight should be supported by the hands while using crutches.

Choice C rationale:

Stepping with the affected leg first when going up stairs is incorrect. When ascending stairs, the unaffected (stronger) leg should be moved first, followed by the affected leg and crutches.

Choice D rationale:

Positioning both hands on the grips with elbows slightly flexed is correct as it allows for proper weight distribution through the arms and hands, which is essential for balance and safety while using crutches.

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A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

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