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 A

Explanation

A. Clients with flail chest often experience compromised respiratory function due to the paradoxical movement of the chest wall. Providing humidified oxygen can help improve oxygenation and maintain airway patency, especially if the client is experiencing hypoxia.

B. Administering antibiotic medication is not a primary intervention for a flail chest unless there is evidence of an associated infection, such as pneumonia
C. Fluid restriction is not typically indicated for a client with a flail chest unless there are specific indications, such as heart failure or renal dysfunction.

D. While managing pain is important, flail chest often requires more aggressive pain management strategies, such as opioid analgesics or regional anesthesia, especially if the pain is severe and affects respiratory effort. Acetaminophen alone may not be sufficient for effective pain control in this situation.

A. Maintain peripheral IV access. B. Pad the upper two side rails of the client's bed. C. Teach assistive personnel how to apply restraints. D. Keep a padded tongue blade at the client's bedside.

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.

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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?

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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?