The nurse is caring for a client with left-sided hemiparesis after a stroke. Which action should the nurse take to safely assist the client with ambulation?
Provide support on the unaffected side.
Hook an arm under the client's left arm.
Use a gait belt standing on affected side.
Hold the gait belt with palms facing down.
The Correct Answer is C
Rationale:
A. Provide support on the unaffected side: Supporting from the unaffected side gives less control if the weak side gives out. Assistance should be on the affected side to better prevent falls and provide stabilization.
B. Hook an arm under the client's left arm: This is unsafe and risks injury to both the client and nurse. It provides poor leverage, may dislocate the shoulder, and does not allow controlled support during ambulation.
C. Use a gait belt standing on affected side: This is the safest technique. Standing on the affected side offers direct support and balance while the gait belt allows secure, ergonomic assistance during movement.
D. Hold the gait belt with palms facing down: Gait belts should be held with palms facing up, which provides a more secure grip and better control if the client loses balance during ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Duration of sensation: This helps to determine if the symptoms are acute, intermittent, or continuous, which can provide clues about the severity of nerve compression or irritation. Changes in duration, frequency, or intensity can indicate worsening nerve impingement or the development of a new neurological deficit requiring immediate attention.
B. Precipitous activity: While it's useful to know what activity triggered the symptoms, this is secondary to understanding the timeline and progression of neurological signs, which carry more urgency.
C. Time of last analgesic: Pain control is important, but the priority is evaluating potential nerve compromise. Numbness and tingling may reflect compression or damage that cannot be addressed by analgesia alone.
D. Gait coordination: Assessing gait coordination is important to evaluate the functional impact of the neurological symptoms, which could indicate more severe nerve compression affecting motor pathways. However, it is an assessment of a motor function. The client is describing sensory symptoms.
Correct Answer is ["B","D"]
Explanation
Rationale:
A. Lentils: Lentils are high in fiber and are not part of a full liquid diet because they require chewing and contain residue. They are appropriate for a soft or regular diet, not a full liquid one.
B. Tea: Tea is a clear liquid and is included in a full liquid diet. It requires no chewing and leaves no residue, making it suitable postoperatively.
C. Whole grain breads: Breads are solid foods and not permitted on a full liquid diet. They require chewing and do not meet the consistency guidelines for this diet type.
D. Potato soup: Smooth, blended soups like potato soup are appropriate for a full liquid diet as long as there are no chunks. They provide calories and are easy to swallow.
E. Cheese: Cheese is a solid food and is not permitted on a full liquid diet.
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