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Difficulty: HardBasic Care and Comfort

A nurse is coordinating care for an older adult client who is recovering from a right middle cerebral artery (MCA) infarction. The client exhibits left-sided hemiplegia, moderate dysphagia, and episodes of evening agitation. Which intervention demonstrates the correct application of basic care and comfort principles?

  1. A
    Position the client in a low-Fowler's position of 15 to 20 degrees to promote rest during continuous enteral feedings.
  2. B
    Delegate the task of evaluating the client's tolerance to pureed oral intake to the unlicensed assistive personnel (UAP).
  3. C
    Document the client's evening agitation as an expected, age-related cognitive change that requires no further investigation.
  4. Begin morning dressing routines by placing clothing on the client's affected left arm and leg first.Answer

Answer

Begin morning dressing routines by placing clothing on the client's affected left arm and leg first.
For a client with unilateral weakness or hemiplegia, basic care principles dictate that clothing should always be put on the affected (weak) side first and removed from the unaffected (strong) side first. This sequence minimizes the need to move or stretch the paralyzed limbs awkwardly, thereby reducing the risk of joint subluxation, contractures, or pain. It also empowers the client to use their functional strong side to assist the nurse with the remainder of the dressing process.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has left-sided hemiplegia due to a right MCA stroke, dysphagia, and behavioral changes.
Understanding the specific deficits is required to determine safe and effective basic care interventions.
2
Evaluate the safety and scope of practice for each proposed intervention.
Delegating evaluation to a UAP is unsafe. Positioning at 15 degrees during feeding risks aspiration. Dismissing agitation ignores potential pathology.
Nursing care must prioritize airway safety, correct delegation principles, and accurate clinical assessment.
3
Identify the standard protocol for dressing a client with unilateral weakness.
The correct protocol is to undress the unaffected side first, and dress the affected side first.
This technique minimizes excessive stretching or manipulation of the paralyzed limb, preventing joint subluxation and promoting client comfort.

Key Concept

Basic care and comfort for clients with unilateral hemiplegia involves specific dressing sequences to protect impaired limbs.
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Topics

Basic Care and Comfort

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