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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "Your family member has the right to refuse care." Every competent adult has the legal and ethical right to make decisions about their own medical treatment, including the right to refuse care, even if it results in death.
B. "To continue treatment, you must be appointed as your family member's health care surrogate." The client is still competent and capable of making their own decisions, so a surrogate is not necessary or legally allowed to override their wishes.
C. "We should discuss different treatment options when your family member is not present." Discussing medical decisions behind the client’s back would be unethical and violate the principle of autonomy.
D. "I can submit your request to the ethics committee." There is no ethical dilemma here, as the client has the right to refuse treatment, and their decision must be respected.

A. "An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids." B. "An AP may count the respirations of a client who is going to have surgery later the same day." C. "An AP may take orthostatic blood pressure measurements from a client who reports dizziness." D. "An AP may perform a central line dressing change for a client who is ready for discharge."

Correct Answer is B

Explanation

A. "An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids." –
Monitoring IV sites requires assessment skills and clinical judgment, which are within the scope of a licensed nurse, not assistive personnel.
B. "An AP may count the respirations of a client who is going to have surgery later the same day." –
Counting respirations is a basic task within the AP’s scope of practice. However, the nurse is responsible for interpreting the findings.
C. "An AP may take orthostatic blood pressure measurements from a client who reports dizziness." –
Measuring orthostatic blood pressure requires critical thinking and assessment of the client’s condition, which falls under the nurse’s responsibilities.
D. "An AP may perform a central line dressing change for a client who is ready for discharge." –
Performing a central line dressing change is a sterile procedure that requires nursing assessment and should be completed by a licensed nurse.

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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?

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