102. A client is in a rehabilitation unit 2 weeks after a right middle cerebral artery infarct. Which is the best activity plan?
102. A client is in a rehabilitation unit 2 weeks after a right middle cerebral artery infarct. Which is the best activity plan?
. Passive range of motion should be performed on the right arm and leg several times a day.
. The client should know how to get up from the right side of the bed.
. Maintain bed rest with all rails up until the client can lift both legs off the mattress.
. Immobilize joints on the left side of the body into a position of flexion contracture.
Test-Taking Tip
Right brain attack leads to left-sided weakness/paralysis. Nursing actions should focus on preventing problems of immobility.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Planning; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
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Answer 1 is incorrect because a stroke in the right brain would cause paralysis or weakness on the left side. It is not necessary to perform range of motion on the unaffected extremity. Answer 2 is correct because a stroke in the right brain would cause paralysis or weakness on the left side. Getting out of bed is easiest on the strong side. Answer 3 is incorrect because the client should be mobile as soon as possible. It is likely that only the left leg will be paralyzed or weak, and this may be a permanent condition. A client will need to learn mobility techniques despite the weakness. Answer 4 is incorrect because it is important to maintain range of motion for the joints on the affected side, rather than immobilize the left side.