A nurse is caring for a client who is immobile.
Which of the following interventions is appropriate to prevent contracture?

Align a trochanter wedge between the client’s legs.

Apply an orthotic to the client’s foot.

Place a towel roll under the client’s neck.

Position a pillow under the client’s knees.

Answer and Explanation

The Correct Answer is B

An orthotic is a device that supports or corrects the function of a body part. In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients. Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.

Choice A is wrong because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.

Choice C is wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.

Choice D is wrong because a pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis.

Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.

Contracture can limit the range of motion and function of the affected body part. Contracture can be caused by inactivity, scarring, or diseases that affect the muscles or nerves. Prevention of contractures requires early diagnosis and initiation of physical medicine approaches such as passive range of motion exercises and splinting before contractures are present or while contractures are mild.

Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A client who is ambulatory and receiving oxygen should be evacuated first during a fire because they are at risk of fire and explosion from the oxygen source. The nurse should instruct the staff to turn off the oxygen supply, remove the oxygen device from the client, and assist them to walk out of the building using the nearest exit.
Choice B is wrong because a client who uses a wheelchair and is confused is not in immediate danger from the fire. They can be evacuated using a swing carry or an extremity carry by two staff members after the clients who are more vulnerable are evacuated.
Choice C is wrong because a client who is bedridden and wears a hearing aid is not in immediate danger from the fire. They can be evacuated using a cradle drop by one staff member after the clients who are more vulnerable are evacuated.
Choice D is wrong because a client who has a fracture and is in balance suspension traction is not in immediate danger from the fire. They can be evacuated using a special device such as a sked or a sled by two or more staff members after the clients who are more vulnerable are evacuated.

A. Posting swallowing precautions at the head of the client’s bed. B. Noting changes in the treatment plan in the client’s medical record. C. Having interdisciplinary team meetings for the client on a regular basis. D. Recording the client’s progress in the nurses’ notes. E. Recording the client’s progress in the nurses’ notes.

Correct Answer is C

Explanation

Having interdisciplinary team meetings for the client on a regular basis.

This action best promotes communication among staff caring for the client because it allows for consistent and coordinated care planning, information sharing, and goal setting for the client who has expressive aphasia and right hemiparesis following a stroke.

Choice A is wrong because posting swallowing precautions at the head of the client’s bed does not promote communication among staff, but rather informs them of the client’s risk of aspiration due to dysphagia, which is a common complication of stroke.

Choice B is wrong because noting changes in the treatment plan in the client’s medical record is a standard practice that does not necessarily enhance communication among staff, but rather documents the client’s progress and interventions.

Choice D is wrong because recording the client’s progress in the nurses’ notes is also a standard practice that does not necessarily enhance communication among staff, but rather provides a summary of the client’s status and care.

Expressive aphasia is an acquired language disorder that affects the ability to produce spoken or written language, while right hemiparesis is a weakness or partial paralysis of the right side of the body.

Both of these conditions are caused by damage to the left hemisphere of the brain, which is responsible for language and motor control of the right side of the body. Stroke and traumatic brain injury are common causes of left hemisphere damage

View Question and Answer

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

A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?

Correct Answer is C

Explanation

A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?

A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?

A nurse is caring for a postoperative client following a perineal prostatectomy. Exhibits For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Potential Order:.

A nurse is assessing a client who is taking haloperidol and is experiencing pseudo-parkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?

A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use?

A nurse is caring for a school-age child who is 2 hr postoperative following cardiac catheterization. The nurse observes blood on the child’s dressing. Which of the following actions should the nurse take?

A nurse is reporting a client’s laboratory tests to the provider to obtain a prescription for the client’s daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

A nurse is caring for a client who is immobile.
Which of the following interventions is appropriate to prevent contracture?