Author Question: The nurse is discussing joint mobility exercises with a client who experienced a stroke and now has ... (Read 65 times)

sdfghj · **on:** Jul 23, 2018

The nurse is discussing joint mobility exercises with a client who experienced a stroke and now has left-sided weakness.

Which of the following statements made by the client reflects the greatest insight regarding the best method for him to maintain mobility of the joints on his left side?
1. My wife knows how to do those exercises for the joints on my left side.
2. Physical therapy really exercises my left side when I go there every afternoon.
3. I'll remind the staff to exercise my left side when they come to help me with my bath and getting dressed.
4. I will do those passive range of motion exercises you taught me to my left side at least 3 times a day.

Question 2

The nurse caring for a 38-year-old female client with multiple fractures in the trauma intensive care unit knows that this client is at high risk for pulmonary complications such as atelectasis from her immobility.

One of the interventions that the nurse can do to help prevent this from occurring is to:
1. Keep the PaO2 level at or above 94
2. Instruct the client to deep breathe and cough every hour while awake
3. Turn the client every 2 hours
4. Keep the client on the ventilator as long as possible

covalentbond · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 4
If one extremity is paralyzed, teach the client to put each joint independently through its ROM.

Answer to Question 2

ANS: 2
In atelectasis, secretions block a bronchiole or a bronchus, and the distal lung tissue (alveoli) col-lapses as the existing air is absorbed, producing hypoventilation. The site of the blockage affects the severity of atelectasis. Sometimes an entire lung lobe or a whole lung collapses. At some point in the development of these complications, there is a proportional decline in the client's ability to cough productively. Turning the client is an excellent way to help prevent the accumulation of mucus in the dependent regions of the airways causing hypostatic pneumonia. Mucus is an excel-lent place for bacteria to grow. Keeping a client on a ventilator longer than necessary has the po-tential to cause multiple other complications and is not the best choice.