A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

Place a pillow under the client's knees when changing positions.

Use a sheet when repositioning the client onto his side.

Apply an immobilizing collar on the client prior to movement.

Instruct the client to keep his arms at his side when altering positions.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Place a pillow under the client's knees when changing positions: Elevating the knees with a pillow may be appropriate for comfort, but in a client with a thoracic spine injury, this can alter spinal alignment and increase the risk of further injury. Maintaining proper spinal alignment during all movements is more important than knee elevation.

B. Use a sheet when repositioning the client onto his side: Using a sheet for logrolling or turning helps maintain spinal alignment and allows multiple caregivers to move the client safely as a unit. This technique minimizes rotation or flexion of the spine, which is critical in preventing further spinal cord injury in clients with thoracic spine trauma.

C. Apply an immobilizing collar on the client prior to movement: Cervical collars are used for cervical spine injuries, not thoracic spine injuries. Applying a collar would not stabilize the thoracic spine and could give a false sense of security while performing repositioning.

D. Instruct the client to keep his arms at his side when altering positions: The client may need to assist in turning if possible, and keeping the arms rigidly at the side is not necessary. Restricting arm movement does not ensure spinal safety and may limit the client’s ability to participate safely in repositioning.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"A"}

Explanation

Rationale for correct choices

• deep vein thrombosis (DVT): The client displays classic findings of DVT, including unilateral leg swelling, warmth, inflammation, and increased calf circumference. These findings, paired with a sedentary lifestyle and recent trauma to the leg, strongly indicate development of a thrombus in the affected extremity.

• Unequal leg circumference: The right calf measures 45.72 cm while the left measures 40.64 cm, showing significant unilateral swelling. A difference greater than 3 cm is strongly associated with DVT due to venous obstruction and impaired return, causing fluid accumulation and increased limb girth.

• Ultrasound results: The duplex ultrasound shows loss of venous compressibility and a thrombus in the right leg. These findings are diagnostic for DVT, confirming venous obstruction and establishing the cause of the client’s symptoms and leg swelling.

Rationale for incorrect choices

• undiagnosed fracture: A fracture would typically produce severe pain, deformity, or inability to bear weight, none of which are strongly present. The ultrasound confirms thrombosis, and the symptoms align more with venous obstruction than bone injury.

• cellulitis of a leg bone: Cellulitis usually presents with diffuse skin redness, warmth, and often fever. Although the leg is warm and inflamed, the presence of a venous thrombus on ultrasound and significant calf size difference more accurately support DVT rather than an infectious process.

• Difficulty walking: Difficulty walking can occur from many causes, such as arthritis or recent injury, and is not specific enough to confirm DVT. Objective findings like limb circumference and ultrasound imaging better demonstrate the underlying condition.

A. Instruct the client to bend at the waist to put on slippers B. Keep the client's heels elevated while in bed C. Massage the clients affected leg three times daily D. Maintain slight adduction of the client's affected hip

Correct Answer is D

Explanation

Rationale:

A. Instruct the client to bend at the waist to put on slippers: Bending at the waist increases the risk of hip dislocation after total hip arthroplasty. Clients should avoid flexing the hip beyond 90 degrees and use adaptive equipment for dressing to maintain safety.

B. Keep the client's heels elevated while in bed: Elevating the heels is not routinely indicated and may cause hip or knee strain. Proper positioning focuses on maintaining hip alignment and preventing dislocation or pressure injuries rather than heel elevation.

C. Massage the client’s affected leg three times daily: Massaging the leg after hip surgery is contraindicated due to the risk of dislodging a deep vein thrombus (DVT). Gentle range-of-motion exercises are preferred, but direct massage should be avoided until clotting risk is ruled out.

D. Maintain slight abduction of the client’s affected hip: Keeping the hip in slight abduction with pillows or abduction devices helps prevent dislocation of the prosthetic joint. Proper positioning is essential for safe recovery following total hip arthroplasty.

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A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?

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Explanation

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