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 C

Explanation

A. Inform the client they cannot refuse the surgery once the consent form has been signed. A client has the right to refuse treatment at any time, even after signing a consent form.
B. Explain the risks of the surgery to the client. The provider is responsible for explaining the risks, benefits, and alternatives of the procedure. The nurse's role is to witness consent and ensure the client understands.
C. Ensure the client has advance directives on file. Since the client has a serious, life-threatening illness (stage 4 cancer) and is undergoing surgery, it is important to verify whether they have advance directives, such as a living will or durable power of attorney for healthcare. These documents ensure that their wishes regarding medical treatment are followed.
D. Ask the client if they wish to be resuscitated in the event they stop breathing. While this is an important conversation, it is typically initiated by the provider. The nurse should confirm whether the client has a Do Not Resuscitate (DNR) order or advance directives in place.

A. Report the incident to the pharmacy. B. Notify the client's provider. C. Measure the client's respiratory rate. D. Complete an incident report.

Correct Answer is C

Explanation

A. Report the incident to the pharmacy. While the pharmacy may need to be informed, client safety is the priority. The immediate concern is monitoring the client for opioid overdose effects.
B. Notify the client's provider. The provider should be notified, but assessing the client's condition comes first so that the nurse can provide accurate information about any potential adverse effects.
C. Measure the client's respiratory rate. The priority action is to assess the client for signs of opioid toxicity, especially respiratory depression. Morphine can cause decreased respiratory rate, sedation, and hypotension. If the respiratory rate is dangerously low (e.g., below 12 breaths per minute), interventions such as administering naloxone (Narcan) may be necessary.
D. Complete an incident report. An incident report should be completed, but client safety and assessment take priority before documentation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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