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 A

Explanation

A. Isometric exercises involve contracting or tensing muscles without actually moving the joint. Instructing the client to tighten muscle groups for a short period and then relax is the correct approach for isometric exercises. This action helps activate and strengthen specific muscle groups without moving the joints.
B. Moving the client's limbs through their complete range of motion is known as passive range of motion exercises. These exercises are important for maintaining joint flexibility but are not isometric.
C. Asking the client to move her arms and legs while applying slight resistance is known as resisted range of motion exercises. These exercises involve active movement against resistance and are not considered isometric.
D. Having the client move each limb independently through its complete range of motion is known as active range of motion exercises. These exercises involve voluntary
movement of each joint through its full range of motion and is not isometric.

A. Irrigate the wound with an antiseptic prior to obtaining the specimen. B. Include intact skin at the wound edges in the culture. C. Swab an area of skin away from the wound to identify the usual flora. D. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

Correct Answer is D

Explanation

A. Irrigating the wound with an antiseptic prior to obtaining the specimen can introduce substances that may interfere with the accuracy of the culture results. Sterile saline is the preferred solution for wound irrigation.
B. Intact skin at the wound edges should not be included in the culture. The specimen should be obtained directly from the wound bed or drainage.
C. Swabbing an area of skin away from the wound to identify the usual flora is not appropriate for obtaining a wound drainage specimen. The culture should be taken directly from the wound site.
D. Before obtaining a wound-drainage specimen for culture, it is important to cleanse the wound with a sterile solution, such as 0.9% sodium chloride saline irrigation. This helps remove debris and contaminants from the wound site, providing a more accurate specimen for culture.

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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

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Correct Answer is A

Explanation

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Correct Answer is D

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