The nurse is caring for a client who is admitted to the hospital following a cerebrovascular accident (CVA). Which of the following is a nursing intervention that should be implemented during this acute phase of CVA?
A) Position the client on the affected side.
B) Avoid placing the unresponsive person on the back.
C) Lower the head of the bed.
D) Turn the person at least once every 4 hours.
B
Feedback:
The nurse should avoid placing the unresponsive person on the back, because the tongue may fall back and occlude the airway; secretions may accumulate in the back of the throat. The nurse should position the unresponsive person on the unaffected side to keep the airway open and prevent aspiration, and elevate the head of the bed to reduce the chance of increased intracranial pressure. The nurse should also turn the person often, at least once every 2 hours, keeping the body in proper alignment.
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