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.

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Correct Answer is C

Explanation

This is because the nurse should provide honest and accurate information to the child about the reporting process and the possible outcomes, such as legal actions, investigations, or removal from the home.
This can help the child feel more prepared and less anxious about what will happen next. The nurse should also reassure the child that the abuse is not their fault and that they did the right thing by telling someone.

Choice A is wrong because reassuring the child that no one will be told about the abuse is unethical and illegal.
The nurse has a mandatory duty to report any suspected or confirmed cases of child abuse to the appropriate authorities, such as child protective services or law enforcement. Keeping the abuse a secret can also endanger the child’s safety and well-being, as well as prevent them from receiving the necessary medical and psychological care.

Choice B is wrong because ensuring that multiple nurses are present for the physical examination can increase the child’s fear, embarrassment, or discomfort.
The nurse should minimize the number of people involved in the examination and only include those who are essential for providing care or collecting evidence. The nurse should also explain to the child what will be done during the examination and obtain their consent before proceeding.

Choice D is wrong because using leading statements to obtain information from the child can influence their responses and affect the validity of their testimony.
The nurse should use open-ended questions and avoid suggesting or implying any details about the abuse. The nurse should also document the child’s statements verbatim and avoid interpreting or paraphrasing them.

A. “Would you like to speak to a spiritual advisor?” B. “Do you need a prescription for an antianxiety medication?” C. “Would you like to talk to a counselor about advance directives?” D. “Do you need information on hospice care?”

Correct Answer is A

Explanation

This statement shows respect for the client’s spirituality and offers support without imposing the nurse’s beliefs or values. Spirituality focuses on the significance and purpose of life and can help clients cope with depression and terminal illness.

Choice B is wrong because it implies that the client needs medication to deal with their feelings, which can be dismissive and insensitive.

Antianxiety medication may be appropriate for some clients, but it should not be the first option.

Choice C is wrong because it assumes that the client is ready to discuss advance directives, which may not be the case.

Advance directives are legal documents that specify the client’s wishes for end-of-life care, such as resuscitation, organ donation, or power of attorney.

The nurse should assess the client’s readiness and understanding before initiating this conversation.

Choice D is wrong because it suggests that the client is close to death and needs hospice care, which can be discouraging and frightening. Hospice care is an interdisciplinary team effort that provides palliative care for clients who have a terminal illness and a life expectancy of less than 6 months.

The nurse should explain the benefits of hospice care and obtain the client’s consent before making a referral.

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

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