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. Triiodothyronine (T3) is one of the thyroid hormones, and in Graves' disease, there is excessive production of thyroid hormones, including T3. Therefore, T3 levels are often elevated in individuals with Graves' disease due to the hyperthyroid state.
A. Phosphorus levels are typically not significantly affected by Graves' disease.
C. In Graves' disease, there is typically suppression of TSH secretion due to the negative feedback from elevated levels of thyroid hormones. Therefore, TSH levels are typically decreased (low) in individuals with Graves' disease.
D. Calcium levels are typically not directly affected by Graves' disease.

A. Use moisturizing lotion while massaging the client's bony prominences. B. Instruct the client to sit on a rubber ring when seated in a chair. C. Place pillows between the client's knees when in a side-lying position. D. Raise the head of the client's bed to a 90° angle.

Correct Answer is C

Explanation

C. Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment of the hips and prevents the affected leg from crossing over the midline, which could lead to muscle
contractures or discomfort. It also helps prevent pressure on bony prominences and reduces the risk of skin breakdown.
A. Keeping the bony prominences too moist could lead to increased risk of skin breakdown.
B. This is not recommended as it could exacerbate muscle weakness or discomfort on the affected side and may not provide adequate support for proper alignment.
D. Raising the head of the bed to a 90° angle is not typically indicated for clients with hemiplegia. It may increase the risk of aspiration

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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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