Author Question: The nurse is completing a care plan for a stroke patient who is at risk for impaired physical ... (Read 64 times)

notis · **on:** Jun 25, 2018

The nurse is completing a care plan for a stroke patient who is at risk for impaired physical mobility. Which interventions should the nurse include in the care plan? (Select all that apply.)

a. Assist the patient to stand.
b. Remind the patient to ambulate as much as possible.
c. Ensure that the call light is within reach.
d. Coach the patient in active range-of-motion (ROM).
e. Reinforce the use of a walker or cane.

Question 2

To help prevent aspiration while feeding a patient who has a right-sided paralysis, the nurse should implement which intervention(s)? (Select all that apply.)

a. Place the patient in high Fowler position.
b. Instruct the patient to tilt the head and neck forward.
c. Instruct the patient to drink liquids through a straw.
d. Place food in the left side of the mouth.
e. Avoid mixing foods with different tex-tures.

joneynes · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

A, C, D, E
Fall precautions important for this patient include helping the patient to stand, placing the call light within reach, coaching the patient in active ROM, and reinforcing the use of a walker or cane. Reminding the patient to ambulate as much as possible would potentially increase the risk of falls.

Answer to Question 2

A, B, D, E
To help prevent aspiration in this patient, the nurse should position the patient in high Fowler position, instruct the patient to tilt the head and neck forward, place food in the left side of the mouth, and avoid mixing foods with different textures. Drinking through a straw rather than sip-ping from a cup increases the risk for aspiration.