A practical nurse is providing basic care for a client who is 3 days postoperative following a surgical evacuation of a subdural hematoma. The client has residual right-sided hemiplegia and severe dysphagia, requiring maximum assistance with activities of daily living. Which care interventions should the nurse implement? Select all that apply.
- Place the client's right arm on a pillow in slight abduction and external rotation while they are supine.Cevap
- Guide the client to tuck their chin downward toward the chest when swallowing pureed foods.Cevap
- Begin putting garments on the right side of the client's body first when assisting with dressing.Cevap
- DPosition the wheelchair parallel to the client's right side during bed-to-chair transfers.
- EPlace a tightly rolled washcloth in the client's right palm to prevent flexion contractures of the fingers.
- FOffer fluids to the client through a straw to help them bypass pooling in the oral cavity.
Cevap
The appropriate interventions include placing the affected arm in slight abduction and external rotation, guiding the client to tuck their chin when swallowing, and dressing the affected right side first.
Supporting the flaccid limb in slight abduction and external rotation prevents adduction contractures and painful shoulder subluxation. Tucking the chin during swallowing protects the airway by widening the valleculae and directing food away from the trachea, preventing aspiration. When assisting a client with hemiplegia to dress, putting garments on the affected side first prevents unnecessary stretching, pulling, and potential dislocation of the paralyzed joints.
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Anahtar Kavram
Basic care for clients with hemiplegia and dysphagia requires synthesizing principles of joint alignment, airway protection during feeding, and maximizing safety during ADLs.
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