Question

Mr. Clark, a 77-year-old, was admitted with a CVA 3 days ago. This is the first time you have been assigned to care for the gentleman. You carry out an assessment of Mr. Clark’s mobility level and ability to participate in activities of daily living. You identify a nursing diagno- sis of Impaired Mobility related to Hemiplegia and Weakness. Select all the nursing interventions that would be appropriate for the nursing diagnosis. A. ___ Change Mr. Clark’s position every 2 hours, maintaining sound body alignment. B. ___ Use appropriate supportive devices to assist in maintaining correct positioning. C. ___ Teach client and his family correct positioning. D. ___ Prepare Mr. Clark for bed based on his usual bedtime patterns prior to the stroke.

Short answer

Appropriate nursing interventions for Mr. Clark's diagnosis of Impaired Mobility related to Hemiplegia and Weakness would likely include A, B, and C. These interventions focus on repositioning, using supportive devices, and educating on correct positioning.

Step-by-step solution

Understanding the Diagnosis

Read and understand the nursing diagnosis of 'Impaired Mobility related to Hemiplegia and Weakness'. Determine how this diagnosis would affect Mr. Clark's ability to change positions and move independently.

Analyzing Suitable Interventions

Review each proposed nursing intervention and decide whether it is appropriate in addressing the specific needs associated with the diagnosis of impaired mobility due to hemiplegia and weakness.

Selecting Appropriate Interventions

Choose the interventions that will help in maintaining good body alignment, prevent complications such as pressure sores or contractures, and educate the patient and family for continued care.

Key concepts

CVA (Cerebrovascular Accident)

A Cerebrovascular Accident (CVA), also commonly known as a stroke, occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. Brain cells begin to die in minutes. A stroke is a medical emergency, and prompt treatment is crucial. Early action can reduce brain damage and other complications.

The symptoms of a CVA can include sudden numbness or weakness in the face, arm, or leg, especially on one side of the body; confusion; trouble speaking or understanding speech; trouble seeing in one or both eyes; trouble walking; dizziness; or loss of balance or coordination.

There are two types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both require immediate medical attention, but the causes and treatments differ. Ischemic stroke is the more common type and is typically treated with medication that dissolves clots and prevents new ones from forming, while hemorrhagic stroke is usually treated by controlling the bleeding and reducing the pressure in the brain.

After a CVA, a patient may experience a range of complications, including impaired mobility, which often requires intensive rehabilitation and nursing care. Appropriate interventions aim to help patients regain as much function as possible and to prevent further complications.

Hemiplegia in Nursing Care

Hemiplegia refers to paralysis of one side of the body and is a common consequence of CVA. In nursing care, managing hemiplegia involves various interventions tailored to the patient's specific needs. The primary goal is to promote as much independence as possible and prevent secondary complications.

Nursing interventions for patients with hemiplegia include:

• Assessment of the patient’s ability to move and performing regular repositioning to prevent pressure ulcers.
• Using supportive devices such as braces or splints to maintain proper body alignment and prevent contractures.
• Education of patients and their families on proper positioning techniques to continue care at home.
• Working with physical and occupational therapists to develop a rehabilitation plan.
• Encouraging the patient to perform range-of-motion exercises to maintain joint flexibility and muscle strength.

Additionally, it is essential to consider the patient's psychological well-being, as the loss of mobility can lead to feelings of depression or helplessness. In the case of Mr. Clark, collaborating with an interdisciplinary team to address both the physical and emotional aspects of recovery is crucial for successful nursing care.

NCLEX-RN Examination Preparation

The National Council Licensure Examination for Registered Nurses (NCLEX-RN) is a crucial step for nursing students to become licensed practitioners. Preparation for the NCLEX-RN is multi-faceted, involving the understanding of a wide range of nursing concepts, including the care of patients with impaired mobility as seen in the example of Mr. Clark.

When preparing for the NCLEX-RN, students should focus on several key strategies:

• Reviewing nursing concepts thoroughly, with a focus on understanding rather than rote memorization.
• Practicing with a variety of sample questions and simulations that mimic the format of the actual exam.
• Time management during the test to ensure all questions are answered within the allotted time frame.
• Developing critical thinking and decision-making skills, which are essential for selecting the best interventions in patient scenarios.
• Studying resources recommended by the National Council of State Boards of Nursing (NCSBN).

To excel in questions about nursing interventions, such as those related to CVA and hemiplegia, understanding the rationale behind each intervention is necessary. Knowing why particular actions are taken in different situations underpins the effective care strategies that NCLEX-RN questions often explore. By combining theoretical knowledge with practical understanding, students can improve their chances of passing the NCLEX-RN and becoming skilled nursing professionals.