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
Abduction pillow
Sheepskin heel pad
Footboard
The Correct Answer is D
A. Trochanter roll. This device is used to prevent external rotation of the hips, especially in clients who are immobile or lying supine. It does not support the feet or ankles and does not prevent plantar flexion.
B. Abduction pillow. An abduction pillow is placed between the legs to maintain proper hip alignment, particularly after hip surgery. It is not designed to prevent foot drop or plantar flexion contractures.
C. Sheepskin heel pad. This provides skin protection and pressure relief to prevent pressure ulcers on the heels. While useful for comfort and skin integrity, it does not keep the foot in a neutral position to prevent contractures.
D. Footboard. A footboard is placed at the foot of the bed to help maintain the foot in dorsiflexion, thereby preventing plantar flexion contractures (also known as foot drop). It supports proper alignment and is the most appropriate device for this purpose in clients with limited mobility.
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Related Questions
Correct Answer is C
Explanation
A. Hyperthyroidism. This condition is not a contraindication to the use of combination oral contraceptives. Women with hyperthyroidism can generally use hormonal contraceptives safely under medical supervision.
B. Hypocalcemia. Low calcium levels are not linked to increased risk with combination oral contraceptives and do not contraindicate their use.
C. Thrombophlebitis. This condition involves inflammation and clot formation in the veins, and is a major contraindication to combination oral contraceptives. These medications increase the risk of blood clots, making them unsafe for clients with current or prior thromboembolic disorders.
D. Diverticulosis. This gastrointestinal condition is not affected by hormone levels and is not a contraindication to combination oral contraceptive use.
Correct Answer is A
Explanation
A. "The estimated blood loss was 250 milliliters." This is a relevant clinical detail that directly impacts the client’s postoperative care. It provides important information for ongoing assessment of fluid status, potential for anemia, and need for interventions.
B. "The client was intubated without complications." While important during surgery, this is less relevant in the postoperative period unless the intubation caused complications or the client remains intubated. It does not guide current nursing care.
C. "There was a total of 10 sponges used during the procedure." Sponge counts are part of surgical safety and accountability, but they are not typically necessary in nursing hand-off unless a retained item is suspected.
D. "The client is a member of the board of directors." This is not clinically relevant and could breach confidentiality or bias care. Hand-off reports should focus solely on the client’s medical condition and nursing care needs.
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