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 B

Explanation

This is because the retention port is a sterile site that can be accessed by a syringe to aspirate urine without contaminating the specimen or the closed drainage system. The retention port should be cleaned with an alcohol swab before inserting the syringe. The specimen should be transferred to a sterile container and labeled appropriately.
Choice A is wrong because unclamping the collection port below the bag would allow urine to flow out of the bag, which is not sterile and may contain bacteria or sediment.
Choice C is wrong because disconnecting the catheter from the collection tubing would break the closed drainage system and increase the risk of infection.
Choice D is wrong because using the balloon port to obtain the sterile specimen would deflate the balloon that holds the catheter in place and cause trauma to the bladder wall.
Normal ranges for urine characteristics vary depending on the type of analysis, but some general parameters are:
• Color: pale yellow to amber
• Clarity: clear or slightly cloudy
• Odor: faint aromatic
• pH: 4.5 to 8.0
• Specific gravity: 1.005 to 1.030
• Protein: <150 mg/24 hr
• Glucose: negative
• Ketones: negative
• Blood: negative
• Nitrites: negative
• Leukocyte esterase: negative
• Bacteria: <10,000 CFU/mL

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

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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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Explanation

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