A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
Explanation & Rationale
Choice A reason: Discussing preferences for repositioning schedules is secondary to assessing physical ability in stroke clients, who may have hemiplegia. Evaluating ability ensures safety. Assuming preferences are priority risks unsafe repositioning, potentially causing falls, critical to avoid in ensuring safe mobility and care for stroke patients. Choice B reason: Evaluating the client’s ability to assist with repositioning is critical post-stroke to assess motor function, ensuring safe technique and preventing injury. This informs whether assistive devices or additional staff are needed, essential for reducing fall risk, promoting recovery, and tailoring care to the client’s physical capacity. Choice C reason: Repositioning without assistive devices is unsafe for stroke clients with potential weakness or paralysis, risking falls or strain. Evaluating ability is priority. Assuming no devices are needed risks injury, critical to prevent in ensuring safe handling, supporting recovery, and maintaining safety in stroke rehabilitation care. Choice D reason: Raising side rails ensures safety but is secondary to evaluating the client’s ability to assist, which guides repositioning technique. Assuming rails are the first step risks overlooking physical capacity, potentially leading to unsafe repositioning, critical to avoid in preventing falls and ensuring safe care for stroke clients.