Difficulty: Medium
Average Score: 82%
Simulated
The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.
Correct answer
A,C,D
Rationale
For a right-sided CVA, the left side is affected. Positioning to prevent shoulder adduction (A) supports the weak left arm to prevent contractures. Encouraging movement of the affected side (C) promotes neuroplasticity and recovery. Quadriceps exercises (D) strengthen the affected leg. Turning every shift (B) is too infrequent; every 2 hours is standard to prevent pressure ulcers. Instructing to hold fingers in a fist (E) risks contractures and is not therapeutic.