A nurse is creating a plan of care for a client who has left-sided hemiplegia. Which of the following interventions should the nurse include?
Rest the client's left arm over their chest.
Apply an orthotic boot to the client's left foot.
Place a thick pillow behind the client's head to increase cervical flexion.
Instruct the client to lean toward the left side when ambulating to avoid falls.
The Correct Answer is B
A. "Rest the client's left arm over their chest." Keeping the affected arm across the chest can lead to contractures and shoulder adduction deformities. Instead, the arm should be supported in a neutral position with pillows or a sling to prevent complications.
B. "Apply an orthotic boot to the client's left foot." Clients with hemiplegia are at risk for foot drop due to muscle weakness or paralysis. An orthotic boot helps maintain proper foot alignment, prevents contractures, and promotes mobility.
C. "Place a thick pillow behind the client's head to increase cervical flexion." Excessive cervical flexion can lead to poor airway alignment and discomfort. Instead, the client’s head should be in a neutral, midline position with proper support.
D. "Instruct the client to lean toward the left side when ambulating to avoid falls." Leaning toward the affected (weaker) side increases the risk of imbalance and falls. Instead, the client should be encouraged to maintain proper posture and use assistive devices (e.g., cane, walker) for stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Insert the IV catheter using the Z-track technique." The Z-track technique is used for intramuscular (IM) injections, not IV therapy.
B. "Insert the IV catheter with the bevel down." The bevel should be up to facilitate smooth vein entry.
C. "Remove the roller clamp from the tubing prior to IV insertion." The roller clamp should remain in place to control fluid flow and prevent air from entering the tubing.
D. "Apply the tourniquet 5 to 10 cm (about 2 to 4 in) above the IV insertion site." This placement helps distend the vein for easier cannulation without restricting arterial blood flow.
Correct Answer is D
Explanation
A. "A narrow base of support is recommended for effective lifting." A wide base of support provides more stability and balance, reducing the risk of injury.
B. "Make sure to bend at the waist when lifting objects more than 30 pounds." Bending at the knees, not the waist, helps maintain a neutral spine and prevents back strain.
C. "Use a twisting motion when moving objects to prevent back strain." Twisting while lifting can cause spinal injuries; instead, move the entire body by pivoting the feet.
D. "Stand close to a heavy object before attempting to lift it." Standing close to the object reduces strain on the back and improves control during lifting.
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