The nurse is writing the care plan for a cerebrovascular accident (CVA) patient who has partial left-sided paralysis and is experiencing ataxia. Which intervention is most beneficial for this pa-tient?
a. Encourage the patient to ambulate as much as possible when she feels the energy to do so.
b. Ensure the patient receives pureed foods and thickened liquids.
c. Place the patient's call light on the right side of the patient and remind her to call for assistance before getting up.
d. Encourage the patient to use a communi-cation board.
C
The patient with ataxia has experienced a loss of balance or poor coordination; therefore, placing the call light on this patient's right side and reminding her to call for help will best address her high risk for falling. Pureed foods and thickened liquids are necessary for the patient with dys-phagia, and a communication board would assist a patient with dysarthria or aphasia.
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The nurse counsels the immobilized patient in regard to prevention of muscle atrophy and contractures. What will the nurse be sure to include when counseling this patient?
a. The need for additional calcium b. The need for additional protein c. The need for some type of exercise d. The need for a special protective bed
The nurse executive at the local hospital began working there 20 years ago and has risen to the highest designation in nursing. This career style is known as:
a. Linear. b. Spiral. c. Steady state. d. Entrepreneurial/transient.
The client is being treated with enteral feeding. Before administering the feeding, the nurse plans to elevate the head of the client's bed _____ degrees
a. 90 b. 45 c. 30 d. 15
Bowel sounds are:
A. high pitched. B. air and fluid moving through the small intestine. C. irregular. D. All of the above.