A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident (stroke). In planning care for this client, the nurse implements which one of the following as an appropriate intervention?
1. Encourage an even gait when walking in place.
2. Assess the extremities for unilateral swelling and muscle atrophy.
3. Encourage holding the breath frequently to hyperinflate the client's lungs.
4. Teach the use of a two-point crutch technique for ambulation.
ANS: 2
Because edema moves to dependent body regions, assessment of the immobilized client should include the sacrum, legs, and feet. Unilateral increases in calf diameter can be an early indication of thrombosis. The client who has suffered a cerebrovascular accident with left-sided paralysis may not be capable of an even gait. To prevent stasis of pulmonary secretions, the client's posi-tion should be changed every 2 hours, and fluids should be increased to 2000 mL, if not contra-indicated. The client should deep breathe and cough every 1 to 2 hours to promote chest expan-sion. The client would most likely ambulate safely with a walker, or a cane. If crutches are used, the client should use a three-point support.
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