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Zorluk: OrtaBasic Care and Comfort

A nurse is developing a plan of care for an adult client recovering from a right-sided cerebrovascular accident (stroke), which has resulted in left-sided hemiplegia and dysphagia. Which basic care and comfort interventions should the nurse include in the client's plan? Select all that apply.

  1. Position the client upright at 90 degrees with the chin tucked slightly downward during meals.Cevap
  2. B
    Delegate the initial evaluation of the client's swallowing ability to the unlicensed assistive personnel (UAP).
  3. Support the affected left arm with pillows while the client is resting in a chair.Cevap
  4. D
    Return the client to a flat, supine position immediately after nutritional intake to facilitate rest.
  5. E
    Apply soft wrist restraints immediately if the client becomes confused and attempts to pull at the intravenous (IV) line.
  6. Perform passive range-of-motion (ROM) exercises on the affected extremities to maintain joint mobility.Cevap

Cevap

The correct interventions are positioning the client upright with the chin tucked during meals, supporting the affected arm with pillows, and performing passive range-of-motion exercises.
Providing basic care for a client with stroke-related deficits focuses on safety, maintaining physical function, and promoting comfort. Upright positioning with a chin tuck is essential for safe swallowing and aspiration prevention. Supporting the hemiplegic arm prevents painful shoulder subluxation. Finally, passive range-of-motion exercises maintain joint mobility and prevent contractures in the paralyzed limbs.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has a right-sided CVA resulting in left-sided hemiplegia and dysphagia.
Identifying the specific physical and neurological deficits determines the necessary basic care and comfort interventions.
2
Evaluate the proposed interventions for dysphagia management.
Upright positioning with a chin tuck is required to prevent aspiration; delegating initial assessment and utilizing supine positioning post-meals are unsafe and contraindicated.
Dysphagia significantly increases aspiration risk, dictating safe feeding practices, RN-led assessments, and appropriate positioning.
3
Evaluate the proposed interventions for hemiplegia and immobility.
Supporting the affected arm and performing passive ROM are correct; immediate application of restraints without alternatives is inappropriate.
Immobile limbs require physical support and consistent movement to prevent contractures, avoid subluxation, and promote overall comfort.

Anahtar Kavram

Basic care and comfort for a client with hemiplegia and dysphagia involves strict airway protection during and after feeding, joint mobility maintenance, and safe delegation practices.
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Basic Care and Comfort

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