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."

Answer and Explanation

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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Correct Answer is B

Explanation

B. Seizures can result in sudden and uncontrollable movements, which may increase the risk of injury if the client strikes against the side rails of the bed during a seizure episode. Padding the upper two side rails helps minimize the risk of injury by providing a softer surface.
A. Maintaining peripheral IV access ensures that these medications can be administered promptly. However, other routes such as rectal can also be used therefore not a priority
C. Assisting personnel should not be trained in the proper application of restraints as it is not within the scope of their practice.
D. Introduction of objects during a seizure is not recommended as it increases the risk of injury.

A. Chlorpromazine B. Dobutamine C. Mannitol D. Propranolol

Correct Answer is C

Explanation

C. Mannitol is a osmotic diuretic that is commonly used in the management of increased intracranial pressure (ICP) following a head injury. It works by drawing fluid out of brain tissue and into the bloodstream, thereby reducing cerebral edema and lowering ICP.
A. Chlorpromazine is an antipsychotic medication that does not have direct effects on reducing ICP and is not commonly used in this clinical scenario.
B. Dobutamine is a medication primarily used for increasing cardiac output in patients with heart failure or shock.
D. Propranolol is a beta-blocker medication commonly used to treat conditions such as hypertension, angina, and certain cardiac arrhythmias.

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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?

Nursing Test Bank

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