A nurse is teaching about safe positioning with the caregiver of a client who has right-sided hemiplegia following a stroke. Which of the following statements by the caregiver indicates an understanding of the teaching?
"I will ensure their neck is flexed backwards when they're lying on their stomach."
"I will support their feet with a rolled pillow when they are lying on their back."
"I will rest their heels on the mattress when they are sitting up in bed."
"I will use a thick pillow under their head to support the neck."
The Correct Answer is B
B. Supporting the feet with a rolled pillow helps prevent foot drop (a common issue in hemiplegia). It maintains the ankle in a neutral position, preventing contractures.
A. When lying on the stomach (prone position), the neck should be neutral (neither flexed nor extended). Flexing the neck backward can strain the cervical spine and compromise airway alignment.
C. For a client with right-sided hemiplegia, the affected leg (right leg) should be supported to prevent foot drop.
D. A thick pillow under the head can cause neck hyperextension.
The head should be supported with a small, firm pillow to maintain a neutral neck position.
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Related Questions
Correct Answer is A
Explanation
A. Neurovascular assessment should be the nurse's priority assessment. Postoperative patients, especially those who have undergone orthopedic surgery such as ORIF of the femur, are at risk for neurovascular compromise due to factors such as positioning during surgery, edema, and postoperative pain.
B. Pain assessment is important for overall patient comfort and well-being, but in the immediate postoperative period following ORIF of the femur, neurovascular assessment takes priority.
C. The Braden scale is used to assess a patient's risk for pressure ulcers. While pressure ulcer risk assessment is important for overall patient care, it is not the priority assessment for a patient who is postoperative following ORIF of the femur.
D. The Morse Fall Risk scale is used to assess a patient's risk for falls. While fall risk assessment is important for patient safety, it is not the priority assessment for a patient who is postoperative following ORIF of the femur.
Correct Answer is A
Explanation
A. Joint inflammation(arthritis) is a common manifestation of systemic lupus erythematosus. SLE can cause inflammation in the joints, leading to symptoms such as pain, swelling, stiffness, and decreased range of motion. It often affects the small joints of the hands, wrists, and knees.
B. Tophi are deposits of uric acid crystals that form under the skin in people with chronic gout.
C. Esophagitis, or inflammation of the esophagus, can occur in systemic lupus erythematosus as part of gastrointestinal involvement. However, it is not one of the most common manifestations of SLE.
D. "Bull's eye" lesion, also known as erythema multiforme, is a skin manifestation seen in conditions such as Lyme disease and certain drug reactions. It is not typically associated with systemic lupus erythematosus.
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