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 A
Explanation
A. Screen the child's visitors for active infections. Neutropenia places the child at high risk for infection due to a severely weakened immune system. Screening visitors for signs of illness is essential to minimize exposure to infectious agents.
B. Prepare the child for a platelet transfusion. Platelet transfusions are used to treat thrombocytopenia, not neutropenia. While leukemia may cause both conditions, neutropenia specifically increases infection risk, not bleeding risk.
C. Monitor the child for indications of active bleeding. While bleeding is a concern in leukemia, it is more directly linked to low platelet levels. The priority intervention for neutropenia is infection prevention, not bleeding control.
D. Initiate a low-protein diet for the child. A low-protein diet is not appropriate for a child with leukemia. These children need adequate protein for healing, immune support, and maintaining strength during treatment.
Correct Answer is A
Explanation
A. The stoma appears dark purple in color. This is a priority finding, as it may indicate impaired circulation or necrosis of the stoma tissue. A healthy stoma should appear pink or red and moist. A dark purple or black color requires immediate evaluation.
B. The colostomy has had no output. While it is important to monitor output, it is not unusual for a new colostomy to have minimal or no output in the first 24–48 hours post-op as bowel function returns.
C. The client refuses to look at the colostomy. This is a psychosocial concern and may indicate body image issues or denial, but it is not the most urgent issue in the immediate postoperative period.
D. The client reports a pain level of 6 on a scale from 0 to 10. Pain management is important, but a pain level of 6, while needing intervention, does not take priority over a potential vascular compromise of the stoma.
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