When helping a stroke patient nurse should assist?

NHM UP Staff Nurse - 2017

Medical Surgical Nursing

Medium

Appeared in: NHM UP Staff Nurse - 2017

Explanation

A stroke patient typically has hemiparesis (one-sided weakness), which creates instability and a high risk of falls.
The nurse's primary role during assistance is to support the patient's area of weakness.
By standing on the weak side, the nurse can physically brace the patient's knee and hip, preventing the leg from buckling during weight-bearing activities like standing or walking.
This position allows the nurse to act as an external support, anticipating and correcting loss of balance effectively.

Option B: The patient's strong side is, by definition, capable of bearing weight and maintaining stability. Providing support here is redundant and neglects the vulnerable weak side.
Option C: Standing in front of the patient blocks their path of movement, can cause them to lean backward, and puts the nurse in an unstable position to control a fall.
Option D: This position offers poor control over the patient's weak side. The nurse cannot see or react quickly to the patient's knee buckling and cannot prevent a forward or sideways fall.

Clinical Relevance

Nursing practice connection: Use the key finding related to Safe patient handling and transfer techniques for patients with hemiparesis or hemiplegia to guide bedside assessment, documentation, and the next nursing action.
Fall prevention is a critical patient safety goal in stroke rehabilitation. Incorrect assistance techniques are a leading cause of falls and subsequent injuries like fractures.
This principle is essential for patient and family education to ensure safe mobility at home after discharge.
What if? If the patient is learning to walk with a cane, the cane is held on the strong side to create a wide base of support, while the nurse continues to guard and assist on the weak side.

How to Approach the Question

First, identify the key patient condition: 'stroke'. This immediately signals a risk of one-sided weakness (hemiparesis) and instability.
Next, determine the goal of the nursing action: 'assist'. The goal is to provide support and ensure safety during movement.
Analyze the core problem: The patient's weak side is the source of instability and is most likely to give way.
Evaluate the options based on the principle of supporting the area of instability. The only position that allows the nurse to directly support the weak leg and hip is by standing on that side.
Eliminate other options by considering their safety risks: assisting on the strong side leaves the weak side vulnerable, while front or back positions offer poor control and can increase fall risk.

Concept Tested & Keywords

Concept Tested: Safe patient handling and transfer techniques for patients with hemiparesis or hemiplegia.
Stem keywords: stroke patient, assist, nurse
Lead-in keywords: should assist
Clinical cues: The diagnosis of 'stroke' implies a high risk of one-sided weakness and instability, making fall prevention the top priority.

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