During the acute CVA phase, a risk for falls related to paralysis is present.Which intervention best protects the patient from injury?

Question

Quizplus · Accepted Answer

Keeping the side rails up can prevent the patient from accidentally rolling out of bed and falling, providing added safety during the acute phase of a CVA. However, it is important to ensure that the side rails do not hinder the patient's ability to move and reposition themselves, as immobility can lead to other complications such as pressure ulcers. Keeping the bed in a high position may also increase the risk of falls, and assessing vision deficits and monitoring the condition are important components of nursing care, but do not directly address the risk of falls due to paralysis.

During the Acute CVA Phase, a Risk for Falls Related