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A nurse is caring for a client who had a right-sided ischemic stroke that left him paralyzed on one side of the body. The nurse recognizes that skin breakdown and contractures from disuse are common complications. Which of the following would the nurse do to prevent these?

Explanation

• Assisting the client with toileting, elevating the clients left arm and repositioning the client every two hours are the correct answers

• The patient is repositioned as frequently as possible (at least every two hours) and is encouraged to move independently in bed to prevent complications of immobility such as pneumonia and constipation. Pressure on any part of the body for too long impedes circulation

• The affected arm is elevated to promote venous return and reduce edema

• Many clients will have difficulty in using the restroom and will often need assistance.  A nurse should assist with toileting at least every 2 hours and check the perineal area for skin breakdown

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