A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures?

Trochanter roll

Footboard

Sheepskin heel pad

Abduction pillow

Answer and Explanation

The Correct Answer is B

Rationale:

A. Trochanter roll: A trochanter roll is used to prevent external rotation of the hips in clients who are immobile. It does not support the feet or ankles and therefore does not prevent plantar flexion contractures.

B. Footboard: A footboard helps maintain the foot in a dorsiflexed, neutral position by providing firm support against the soles. This prevents foot drop, a common plantar flexion contracture in clients with limited mobility.

C. Sheepskin heel pad: Sheepskin heel pads protect the heels from pressure ulcers by reducing friction and shear but do not maintain ankle alignment or prevent plantar flexion of the feet.

D. Abduction pillow: An abduction pillow is placed between the legs to maintain hip alignment after procedures like hip replacement. It offers no support to the feet and does not prevent plantar flexion.

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Correct Answer is A

Explanation

Rationale:

A. Ask the client if they would prefer a translator who is the same gender: Offering a professional interpreter of the same gender, when possible, shows cultural sensitivity and promotes client comfort and openness, especially for intimate or personal health discussions.

B. Use a website with a ".com" URL to translate for the client: Websites, especially commercial ones, may be inaccurate or unreliable for medical translation. Miscommunication through these tools can result in errors and compromise client safety.

C. Request a family member of the client to translate: Family members may unintentionally alter or filter information, leading to errors or withholding of critical health data. It also poses confidentiality concerns and is not considered a best practice.

D. Ask a nursing student who speaks the same language as the client to translate: Unless the student is a certified medical interpreter, this action is inappropriate. Medical interpretation requires training to ensure accurate, unbiased communication that upholds privacy and safety.

A. Nurses notes are used to create the critical pathway B. Critical pathways should reduce health care costs C. Critical pathways have an unlimited timeframe for completion. D. Nurses should discontinue the critical pathway if variances occur

Correct Answer is B

Explanation

Rationale:

A. Nurses notes are used to create the critical pathway: Critical pathways are developed from evidence-based clinical guidelines and best practices, not directly from nurses’ notes. While documentation may help track progress, it is not the foundation for pathway creation.

B. Critical pathways should reduce health care costs: Critical pathways standardize care for specific diagnoses, promoting timely interventions and reducing unnecessary treatments or delays. This efficiency helps lower healthcare costs while improving patient outcomes.

C. Critical pathways have an unlimited timeframe for completion: Each critical pathway includes a defined timeline with expected outcomes for each phase of care. This structure ensures care is efficient and progress is monitored closely to prevent delays or complications.

D. Nurses should discontinue the critical pathway if variances occur: Variances are deviations from the expected outcomes and are used to evaluate and adjust care. They do not justify discontinuing the entire pathway but rather indicate a need for reassessment or individualized modifications.

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A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take when communicating with the client?

Correct Answer is A

Explanation

A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse plan to include?

Correct Answer is B

Explanation

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