An older woman has left-sided paralysis from a thrombus formation in the cerebral vasculature
Rank the nursing goals of this woman's plan of care in order of importance, starting with the most important goal. (Select all that apply.)
A. Instruct her to call for help before moving.
B. Maintain her blood pressure below 120/80 mm Hg.
C. Reinforce occupational therapy for feeding.
D. Use range-of-motion exercises to prevent contractures.
B, A, D, C
Using Maslow's Hierarchy of Human Needs, the most important goal for this older woman is to control her blood pressure; hypertension and other factors contributed to the development of the thrombus. Thus to prevent further intimal damage to cerebral and other vessels, the nurse main-tains the blood pressure at or below the limit as determined by the health care provider. The second priority goal for the nurse is to maintain safety by instructing the older woman to call for help when moving, which will help prevent accidents and injuries. The next goal in importance is the prevention of contractures; joint flexibility is easier to maintain than it is to restore. In ad-dition, joint flexibility is important for adapting to her physical limitations as she learns to per-form activities of daily living. The last goal is using joint flexibility and muscle strength to learn self-feeding. The order of these goals is correct; each goal is dependent on the preceding goal for its success.
You might also like to view...
A patient underwent a retinal detachment repair. The nurse receives the following order from the patient's physician: Keep patient in upright sitting position, with head over the bed table, until first dressing change
What should the nurse do? A) Call the physician and tell him the order is an error and must be reviewed. B) Follow the order because this position will help keep the retinal repair intact. C) Instruct the patient to do this while awake but sleep lying flat on the unoperated side. D) Assume she should change the dressing at bedtime, then allow the patient to lie flat.
Within 4 hours after a cervical spinal injury, the client can discriminate light touch and position of the arms but cannot perform any motor function. What is the nurse's interpreta-tion of this finding?
A. The client is likely to have a full recovery from this injury. B. The spinal cord has experienced a complete injury. C. The spinal cord injury is posterior. D. The spinal cord injury is anterior.
The nurse provides teaching to the client preparing to self-administer PD at home. Which does the nurse include in client teaching to familiarize the client with terms used with PD?
1. Dwell time: time required for dialysate to infuse 2. Drain time: period when dialysate leaves the peritoneum 3. Waiting time: phase between each dialysis infusion cycle 4. Clearance time: time allotted for dialysate to remove toxins
The client recently diagnosed with tuberculosis asks the nurse why family members also will be treated. On what facts does the nurse base the response?
1. The medication for the family is preventative. 2. Smaller doses now will prevent side effects should they need the medication in larger doses later. 3. The medication will increase the family members' immune response. 4. The family members will get the disease, and treatment must begin early.