Neurological Disorders Q 4

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The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?

  

     A. The assistant places a gait belt around the client’s waist prior to ambulating.

     B. The assistant places the client on the back with the client’s head to the side.

     C. The assistant places her hand under the client’s right axilla to help him/her move up in bed.

     D. The assistant praises the client for attempting to perform ADL’s independently.

    

    

Correct Answer: C. The assistant places her hand under the client’s right axilla to help him/her move up in bed.

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This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client and nurse safety. Avoid pulling the affected arm. Place a hand behind the scapula when moving the upper extremity instead of pulling from the arm; Utilize a lift sheet during bed repositioning. When the patient is sitting provide the arm with a firm support surface

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Option A: Provide instructions on transfer techniques utilizing the stronger extremity to move the weaker extremity. For example, to move the affected leg in bed or when changing from a lying to a sitting position, slide the unaffected foot under the

affected ankle to lift, support, and bring the affected leg along in the desired movement.

Option B: Assist the patient with head control, and position based on specific dysfunction. Counteracts hyperextension, aiding in prevention of aspiration and enhancing ability to swallow. Optimal positioning can facilitate intake and reduce risk of aspiration head back for decreased posterior propulsion of tongue, head turned to weak side for unilateral pharyngeal paralysis, lying down on either side for reduced pharyngeal contraction.

Option D: Avoid doing things for the patient that the patient can do for self, but provide assistance as necessary. To maintain self-esteem and promote recovery, it is important for the patient to do as much as possible for self. These patients may become fearful and independent, although assistance is helpful in preventing frustration.

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