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 C,D,A,B

Explanation

Rationale:

A. Close all nearby windows and doors: Containment helps prevent the spread of smoke and flames. Closing doors and windows minimizes oxygen supply to the fire and keeps it from moving into other areas.

B. Use the unit's fire extinguisher to attempt to put out the fire: The final step is to extinguish the fire, but only if it is safe to do so. The nurse should not attempt this before ensuring safety, alerting others, and containing the fire.

C. Transport the client to another area of the nursing unit: The first priority in a fire situation is rescue, removing anyone in immediate danger, especially vulnerable clients who cannot evacuate themselves.

D. Activate the facility's fire alarm system: Once the client is safe, the next step is to alarm the system to alert others in the facility and begin emergency response protocols.

A. Raise the head of the client's bed to a high-Fowler' B. Keep an abduction pillow between the client's legs C. Elevate the client's affected leg on a pillow when in bed. D. Position the client's knees slightly higher than the hips when up in a chair

Correct Answer is B

Explanation

Rationale:

A. Raise the head of the client's bed to a high-Fowler's: Placing the client in high-Fowler’s position increases hip flexion beyond 90 degrees, which raises the risk of dislocation following a hip arthroplasty. Proper positioning involves limited hip flexion.

B. Keep an abduction pillow between the client's legs: An abduction pillow maintains proper alignment by keeping the legs apart and preventing internal rotation or adduction of the hip, both of which increase the risk of dislocation after surgery.

C. Elevate the client's affected leg on a pillow when in bed: Elevating the affected leg on a pillow may cause external rotation or misalignment of the hip. Unless prescribed, this practice may inadvertently increase the risk of hip dislocation.

D. Position the client's knees slightly higher than the hips when up in a chair: Having the knees higher than the hips promotes hip flexion beyond 90 degrees, a common cause of prosthesis dislocation postoperatively. Proper chair height and posture help prevent this complication.

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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 enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is C,D,A,B

Explanation

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Correct Answer is B

Explanation

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