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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
An hCG level of 30,000 IU/L is significantly elevated and may suggest a molar pregnancy, especially when values are higher than expected for gestational age. In a molar pregnancy (hydatidiform mole), trophoblastic tissue proliferates abnormally, producing excessive hCG. This level, in combination with normal hemoglobin and hematocrit, makes other causes like spontaneous or induced abortion less likely.
Key Takeaways:
- Extremely elevated hCG levels can indicate gestational trophoblastic disease (molar pregnancy).
- Molar pregnancy is a nonviable pregnancy characterized by abnormal trophoblast proliferation.
- Normal hemoglobin and hematocrit reduce the likelihood of current bleeding or miscarriage.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
Explanation
- Deep vein syndrome: This is not a recognized condition. The intended term may have been deep vein thrombosis (DVT), which is a valid orthopedic complication, but the clinical findings in this scenario point more urgently toward compartment syndrome and infection.
- Osteomyelitis: The client has an open fracture with drainage from the splint, a significantly elevated WBC count (28,000/mm³), and a high fever (38.9°C / 102°F). These findings suggest the development of a bone infection (osteomyelitis), especially in the context of recent surgery and internal fixation.
- Fat embolism syndrome: While fat embolism is a risk with long bone fractures, this client is not displaying key hallmark signs such as respiratory distress, petechiae, or altered mental status. The findings are more consistent with infection and circulatory compromise.
- Compartment syndrome: The client has classic signs including cool foot, numbness, inability to move toes, absent pulses, delayed capillary refill, and increased pain. These are hallmark signs of neurovascular compromise from compartment syndrome, a surgical emergency.
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