An older woman has left-sided paralysis from a thrombus formation in the cerebral vasculature.Rank the nursing goals of this woman's plan of care in order of importance,starting with the most important goal.

A)Instruct her to call for help before moving.
B)Maintain her blood pressure below 120/80 mm Hg.
C)Reinforce occupational therapy for feeding.
D)Use range-of-motion exercises to prevent contractures.
E)none of the above

Question

An older woman has left-sided paralysis from a thrombus formation in the cerebral vasculature.Rank the nursing goals of this woman's plan of care in order of importance,starting with the most important goal.

A)Instruct her to call for help before moving.
B)Maintain her blood pressure below 120/80 mm Hg.
C)Reinforce occupational therapy for feeding.
D)Use range-of-motion exercises to prevent contractures.
E)none of the above

Quizplus · Accepted Answer

Using Maslow's Hierarchy of Human Needs,the most important goal for this older woman is to control her blood pressure; hypertension and other factors contributed to the development of the thrombus.Thus to prevent further intimal damage to cerebral and other vessels,the nurse maintains the blood pressure at or below the limit as determined by the health care provider.The second priority goal for the nurse is to maintain safety by instructing the older woman to call for help when moving,which will help prevent accidents and injuries.The next goal in importance is the prevention of contractures; joint flexibility is easier to maintain than it is to restore.In addition,joint flexibility is important for adapting to her physical limitations as she learns to perform activities of daily living.The last goal is using joint flexibility and muscle strength to learn self-feeding.The order of these goals is correct; each goal is dependent on the preceding goal for its success.

An Older Woman Has Left-Sided Paralysis from a Thrombus Formation