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.
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The Correct Answer is B
The correct answer is choice B. Applying an orthotic to the client’s foot.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceb. Instruct the client to notify the provider if diarrhea develops.
Choice A rationale:
Infusing penicillin G over 10 minutes is not recommended as it may cause adverse reactions.The infusion rate should be based on the specific guidelines for the medication and patient condition.
Choice B rationale:
Diarrhea can be a sign of a serious side effect called Clostridium difficile-associated diarrhea, which can occur with antibiotic use.It is important for the client to notify the provider if this symptom develops.
Choice C rationale:
Penicillin G should be stored according to the manufacturer’s instructions, which typically do not include refrigeration after reconstitution.Incorrect storage can affect the medication’s efficacy.
Choice D rationale:
Checking for a sulfa allergy is not relevant for penicillin G administration.Sulfa allergies are related to sulfonamide antibiotics, not penicillins.
Correct Answer is B
Explanation
The correct answer is choice B. Determine the client’s knowledge about diaphragm use. This is the first action the nurse should take because it allows the nurse to assess the client’s readiness to learn, identify any knowledge gaps, and tailor the teaching to the client’s needs.
Some of the other choices are wrong because:
- Choice A. Supervise return demonstration of diaphragm use.
This is not the first action the nurse should take because it assumes that the client already knows how to use the diaphragm correctly and safely. The nurse should first teach the client how to insert, remove, and care for the diaphragm before asking for a return demonstration.
- Choice C. Document the client’s level of understanding about potential adverse effects.
This is not the first action the nurse should take because it is part of the evaluation phase of teaching, not the assessment phase. The nurse should first determine what the client knows and needs to know about diaphragm use and its possible risks and benefits.
- Choice D. Teach the client how to insert the diaphragm.
This is not the first action the nurse should take because it is part of the implementation phase of teaching, not the assessment phase. The nurse should first assess the client’s knowledge, motivation, and preferences before providing instruction on how to use the diaphragm.
A contraceptive diaphragm is a birth control device that prevents sperm from entering the uterus.
It is a small, soft silicone or rubber cup with a flexible rim that covers the cervix.
It is inserted into the vagina with spermicide before sex and is held in place by the pelvic muscles. It is a reusable type of contraception that women can use to avoid getting pregnant.
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