Author Question: An older woman has left-sided paralysis from a thrombus formation in the cerebral vasculature. ... (Read 46 times)

Frost2351 · **on:** Jul 11, 2018

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.

Question 2

An older man who had a gastric resection states that he wants to ambulate but the osteoarthritis (OA) in his knees causes too much pain. Which intervention should the nurse implement to in-crease the amount of walking this man can perform?

a. Encourage the patient to keep his leg ele-vated.
b. Instruct him to rest until the pain disap-pears.
c. Suggest taking pain medication before walking.
d. Collaborate with the health care provider to make a walker available.

jasonq · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

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.

Answer to Question 2

C
The nurse suggests taking the pain medication before walking to provide relief during the time when the pain occurs. In addition, if the patient premedicates, then the analgesic effect is likely to last long enough to benefit the patient for any pain after walking. Elevating leg will provide comfort and decrease in edema after exercise; however inactivity may exacerbate the pain. Inac-tivity tends to exacerbate the pain of OA. Instead, the nurse recommends a balance of rest and exercise. A walker is not indicated and will not alleviate any pain in the knees; it is intended to provide stability for ambulation.