Examkin

Soru

Zorluk: OrtaAccident, Error, and Injury Prevention

A nurse is admitting a client who recently experienced a right-hemisphere stroke, resulting in left-sided hemiplegia and left homonymous hemianopsia. To mitigate the risk of accidental injury and falls, which intervention should the nurse prioritize in the client's care plan?

  1. A
    Keep all four side rails elevated at all times to prevent the client from accidentally rolling out of bed.
  2. B
    Delegate the initial evaluation of the client's swallowing ability to the assigned unlicensed assistive personnel.
  3. Position the call bell, water pitcher, and personal belongings consistently on the client's right side.Cevap
  4. D
    Implement contact precautions immediately due to the client's high likelihood of developing post-stroke incontinence.

Cevap

Positioning the call bell, water pitcher, and personal belongings consistently on the client's right side is the correct priority intervention.
For a client with a right-hemisphere stroke resulting in left-sided hemiplegia and left homonymous hemianopsia, the left side of the body is paralyzed and the left visual field is absent. Placing essential items on the unaffected right side ensures the client can see and reach them safely. If items are placed on the left side, the client may attempt to reach across their body, shift their center of gravity, and accidentally fall out of bed.

Adım Adım Çözüm

1
Analyze the client's neurological deficits based on the right-hemisphere stroke.
The client has left-sided hemiplegia (paralysis on the left side) and left homonymous hemianopsia (blindness in the left half of the visual field of both eyes).
Understanding the specific physical and sensory limitations is necessary to identify environmental hazards.
2
Evaluate how these deficits impact the client's safety and mobility in bed.
The client cannot clearly see objects placed on their left side and lacks the motor function to use their left arm to reach for them.
Reaching blindly across the body with the unaffected arm can alter the client's center of gravity, leading to accidental falls.
3
Select the intervention that best mitigates this specific injury risk.
Placing all essential items on the unaffected (right) side ensures they are within the client's visual field and functional reach.
This environmental modification directly prevents accidental falls and promotes safe independence.

Anahtar Kavram

Environmental modifications for clients with hemiplegia and homonymous hemianopsia to prevent accidental injuries.
Bu soruyu puanla

Konular

Accident, Error, and Injury Prevention

Bu konudan daha fazla soru