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Difficulty: HardAccident, Error, and Injury Prevention

A practical nurse (PN) is evaluating home safety for an older adult client who recently had a cerebrovascular accident (stroke). The client has right-sided hemiparesis and a complete loss of tactile sensation in the right extremities. Which statement by the family caregiver requires the PN's immediate intervention to prevent a severe accidental injury?

  1. I apply a heating pad to their right leg on a high setting because that side always feels cold to the touch.Answer
  2. B
    When they get suddenly confused and agitated, I assume it is just normal aging and leave them alone to rest.
  3. C
    I lock their wheelchair tray table securely in place when I leave the room so they cannot stand up and fall.
  4. D
    I asked the home health aide to assess if their swallowing has improved enough to start taking whole pills.

Answer

The statement about applying a heating pad to the right leg requires immediate intervention because it directly exposes the client to severe thermal burns.
The correct answer identifies the most immediate and direct threat of physical harm. A client with a complete loss of tactile sensation cannot feel temperature extremes. Applying a heating pad on a high setting to this extremity will result in severe thermal burns, as the client will not experience pain or reflexively pull away from the heat source. This represents an absolute contraindication and a critical injury hazard.

Step-by-Step Solution

1
Analyze the client's specific clinical profile.
The client has right-sided hemiparesis and a complete loss of tactile sensation in the right extremities following a stroke.
Identifying the client's specific vulnerabilities is essential for predicting and preventing individualized injury risks.
2
Evaluate each caregiver statement for potential safety hazards.
All four statements represent unsafe practices: a burn hazard, a missed assessment of acute delirium, an inappropriate physical restraint, and an out-of-scope delegation.
Caregivers often unknowingly implement unsafe practices that require nursing education and correction.
3
Prioritize the hazard that poses the most direct, immediate threat of physical harm based on the client's deficits.
The heating pad statement is identified as the highest priority.
Applying heat to an insensate limb is an absolute contraindication. The client's inability to feel excessive heat guarantees that a thermal burn will occur if the pad is too hot, making this an imminent, active threat to tissue integrity.

Key Concept

Thermal Injury Prevention in Sensory-Impaired Clients
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Topics

Accident, Error, and Injury Prevention

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