When helping a patient with hemiparesis, the nurse should assist?

Appeared in: ISRO- 2016

Explanation

Patients with hemiparesis have one-sided weakness, making them unstable and likely to fall toward their affected side.
Positioning on the weak side allows the nurse to anticipate this instability, support the patient's trunk and hip, and prevent a fall.
This position provides the best leverage to control the patient's center of gravity if they lose their balance.
Using a gait belt while standing on the weak side is the standard safety procedure for ambulating patients with unilateral weakness.

Option B: Standing on the strong side leaves the weak, unstable side completely unguarded. The nurse cannot effectively intervene if the patient starts to fall toward their weak side.
Option C: Assisting from behind prevents the nurse from seeing if the patient's knee is about to buckle or if they show signs of dizziness. It also offers poor control for a sideways fall, which is common with hemiparesis.
Option D: Standing in front of the patient obstructs their path and forward movement. It provides very poor leverage to control a backward or sideways fall and can cause the patient to trip.

Clinical Relevance

Nursing practice connection: Use the key finding related to Safe patient ambulation for hemiparesis to guide bedside assessment, documentation, and the next nursing action.
Patient safety is the primary concern during ambulation. Always use a gait belt and stand on the weak side to prevent falls and associated injuries like fractures or head trauma.
Proper ambulation technique reduces the risk of musculoskeletal injury to the nurse by promoting the use of good body mechanics.
Documentation is key: always record the distance ambulated, the level of assistance required, the device used (e.g., cane, walker), and the patient's tolerance of the activity.

How to Approach the Question

First, identify the patient's condition from the stem: 'hemiparesis,' which means one-sided weakness.
Next, understand the task: 'assisting' with mobility.
Recall the fundamental safety principle for mobility assistance: protect the patient from their primary point of instability.
For a patient with one-sided weakness, the instability and risk of falling are greatest on that weak side.
Therefore, the nurse must position themselves on the weak side to provide effective support and prevent a fall.
Evaluate the options based on this principle. Standing on the weak side is the only option that directly addresses the patient's primary risk.

Concept Tested & Keywords

Concept Tested: Safe patient ambulation for hemiparesis
Stem keywords: hemiparesis, assist, nurse
Lead-in keywords: BEST, MOST RELEVANT CLUE
Clinical cues: Patient condition: Hemiparesis (one-sided weakness) implies a high risk of falls to one side.
Negative lead-in flag: false

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E6 Nursing Fundamentals Potter Perry 12e Part 4 p. 115-117

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 p. 68-70

Practise the full ISRO- 2016

Attempt every question from this paper in a timed mock, then review the full solution for each one.