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. "I should visually monitor the client continuously when in mechanical restraints." Continuous visual monitoring is required to ensure the client’s safety, monitor for distress or injury, and assess the ongoing need for restraints. This is a key safety standard in the use of mechanical restraints.
B. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." Skin integrity must be assessed much more frequently, typically every 15 to 30 minutes, to prevent injury or pressure-related complications while the client is restrained.
C. "I should expect the provider to evaluate the client within 4 hours of restraint application." For adults, a provider must evaluate the client within 1 hour of the initiation of mechanical restraints. A 4-hour delay does not meet safety or legal standards.
D. "I should ask the provider to write a prescription for mechanical restraints as needed." PRN (as-needed) prescriptions for restraints are not permitted. Each use must be justified, time-limited, and based on the client’s immediate behavior or condition.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.