A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Sheepskin heel pad

Footboard

Trochanter roll

Abduction pillow

Answer and Explanation

The Correct Answer is B

A.   A sheepskin heel pad is primarily used for pressure ulcer prevention, not for preventing plantar flexion contractures.
B.   A footboard helps maintain the feet in a dorsiflexed position, preventing plantar flexion contractures in clients with impaired mobility. This device provides support and alignment to the lower extremities.
C.   A trochanter roll is used to prevent external rotation of the hips and to maintain proper alignment. It is not specifically designed to prevent plantar flexion contractures.
D.   An abduction pillow is used to maintain hip alignment and prevent hip adduction. It is not designed to address plantar flexion contractures.

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Correct Answer is B

Explanation

A - Using a stiff toothbrush is not appropriate for oral care in immobile clients, as it can irritate or damage the gums and oral tissues. A soft-bristled toothbrush is recommended to ensure gentle cleaning.

B - Turning the client on his side is the correct action to prevent aspiration. This position allows fluids and saliva to drain from the mouth, reducing the risk of aspiration, which is critical for immobile clients.

C - Using the thumb and index finger to keep the client’s mouth open can lead to accidental injury. Instead, a padded tongue blade should be used to maintain the client’s mouth open safely during oral care.

D - Applying petroleum jelly to the lips should be avoided, as it is oil-based and can increase the risk of aspiration if inhaled. A water-based lubricant or lip balm should be used instead.

A. False imprisonment B. Invasion of privacy C. Assault D. Battery

Correct Answer is A

Explanation

A. False imprisonment occurs when a person is intentionally confined or restrained against their will, and they have not given consent. In this scenario, if the nurse restrains the client against her will, it would be considered false imprisonment.
B. Invasion of privacy involves intruding into a person's private affairs, disclosing private information, or using their name or likeness without their consent. This option is not applicable in this scenario.
C. Assault is the intentional threat of causing harm to another person, which creates a reasonable fear of imminent harmful or offensive contact. It involves the apprehension of harm, but not the actual physical act.
D. Battery is the intentional harmful or offensive touching of another person without their consent. It involves the actual physical act of touching.

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A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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