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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Monitoring for occult blood in the stool is essential because long-term use of nonsteroidal anti- inflammatory drugs (NSAIDs) like ibuprofen can increase the risk of gastrointestinal bleeding and ulceration. Occult blood in the stool may indicate gastrointestinal bleeding, which can be a serious complication of chronic NSAID use.
B. While NSAIDs like ibuprofen can affect renal function and increase the risk of kidney damage, they are not directly associated with alterations in blood glucose levels.
C. Ibuprofen use is not typically associated with alterations in serum calcium levels
D. While monitoring urine for white blood cells may be relevant in the context of renal injury, it is not as specific or sensitive as other tests such as urinalysis or renal function tests.
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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