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Zorluk: OrtaBasic Care and Comfort

An older adult client is receiving basic care on a medical-surgical unit following a cerebrovascular accident (CVA). The client exhibits right-sided hemiplegia and moderate dysphagia. Which of the following nursing interventions should be included in the client's daily care regimen? (Select all that apply.)

  1. Elevate the head of the bed to a high-Fowler's position during meals and for at least 30 minutes afterward.Cevap
  2. Stand on the client's right side and utilize a gait belt when assisting with ambulation.Cevap
  3. C
    Delegate the initial oral feeding session to the unlicensed assistive personnel (UAP).
  4. Position a pillow in the client's right axilla when resting in bed to prevent shoulder adduction.Cevap
  5. E
    Place the client in a flat, supine position immediately after oral hygiene to promote rest.
  6. F
    Manage new-onset urinary incontinence by applying absorbent briefs, assuming it is a normal age-related change.

Cevap

The correct interventions are to elevate the head of the bed during meals, stand on the client's right side during ambulation, and place a pillow in the right axilla to prevent contractures.
Clients with hemiplegia and dysphagia require specific basic care interventions to promote safety, mobility, and proper nutrition. High-Fowler's positioning during and after meals utilizes gravity to prevent aspiration. Standing on the affected side during ambulation provides necessary support and stability for the weakened limbs. Positioning a pillow in the axilla prevents adduction contractures that commonly develop in paralyzed shoulders.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has right-sided hemiplegia (weakness/paralysis on the right) and dysphagia (difficulty swallowing).
Identifying the specific physical deficits dictates the necessary basic care interventions for mobility, safety, and nutrition.
2
Evaluate interventions for dysphagia.
High-Fowler's positioning is required during and after meals to promote safe swallowing.
This positioning prevents aspiration, a major complication associated with dysphagia.
3
Evaluate interventions for hemiplegia.
The nurse must support the affected (right) side during ambulation and use pillows to prevent adduction contractures while the client is in bed.
Proper positioning and mobility support prevent musculoskeletal complications and ensure client safety.

Anahtar Kavram

Basic Care and Comfort for Stroke Survivors
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Konular

Basic Care and Comfort

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