Author Question: The nurse is admitting a patient who has been diagnosed as having had a stroke. The health care ... (Read 43 times)

saraeharris · **on:** Jul 22, 2018

The nurse is admitting a patient who has been diagnosed as having had a stroke. The health care provider writes orders for ROM as needed. What should the nurse do next?

a. Restrict patient's mobility as much as possible.
b. Realize the patient is unable to move extremities.
c. Move all the patient's extremities.
d. Further assess the patient.

Question 2

A nurse is assessing pressure points in a patient placed in the Sims' position. Which areas will the nurse observe?

a. Chin, elbow, hips
b. Ileum, clavicle, knees
c. Shoulder, anterior iliac spine, ankles
d. Occipital region of the head, coccyx, heels

yuyiding · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: D
Further assessment of the patient is needed to determine what the patient is able to perform. Some patients are able to move some joints actively, whereas the nurse passively moves others. With a weak patient, the nurse may have to support an extremity while the patient performs the movement. In general, exercises need to be as active as health and mobility allow.

Answer to Question 2

ANS: B
In the Sims' position pressure points include the ileum, humerus, clavicle, knees, and ankles. The lateral position pressure points include the ear, shoulder, anterior iliac spine, and ankles. The prone position pressure points include the chin, elbows, female breasts, hips, knees, and toes. Supine position pressure points include the occipital region of the head, vertebrae, coccyx, elbows, and heels.