A nurse is caring for a client who has impaired mobility from right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement?
Obtain a soft mattress for the client's bed.
Position soft pillows against the bottom of the feet.
Use a special boot to maintain dorsiflexion of the feet.
Cross the client's legs at the ankles.
The Correct Answer is C
A. Obtain a soft mattress for the client's bed: Soft mattresses do not provide the support needed to prevent pressure ulcers in immobilized clients.
B. Position soft pillows against the bottom of the feet: Pillows at the bottom of the feet may cause plantar flexion, leading to foot drop.
C. Use a special boot to maintain dorsiflexion of the feet: Boots or footboards help maintain neutral alignment and prevent foot drop, a common complication in paralyzed or immobile clients.
D. Cross the client's legs at the ankles: Crossing legs can impede circulation and increase the risk of pressure injury or deep vein thrombosis (DVT).
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Related Questions
Correct Answer is C
Explanation
A. Obtain a soft mattress for the client's bed: Soft mattresses do not provide the support needed to prevent pressure ulcers in immobilized clients.
B. Position soft pillows against the bottom of the feet: Pillows at the bottom of the feet may cause plantar flexion, leading to foot drop.
C. Use a special boot to maintain dorsiflexion of the feet: Boots or footboards help maintain neutral alignment and prevent foot drop, a common complication in paralyzed or immobile clients.
D. Cross the client's legs at the ankles: Crossing legs can impede circulation and increase the risk of pressure injury or deep vein thrombosis (DVT).
Correct Answer is C
Explanation
A. Walk in front of the client to guide her in moving the walker: The nurse should walk slightly behind and to the side of the client to provide support if needed.
B. Make sure that the upper bar of the walker is level with the client's waist: The walker should be adjusted so that the handgrips are at wrist level when arms are at the sides.
C. Check that the client moves the walker first: Proper walker use involves moving the walker first, then the weaker leg, followed by the stronger leg.
D. Have the client move one leg forward with the walker: The walker must be moved first before advancing the legs.
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