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.
undefined
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 A
Explanation
The correct answer is choice A. Comparing the client’s current weight with preprocedure weight is the best way to evaluate the effectiveness of the paracentesis, which is a procedure to remove excess fluid from the abdominal cavity. The fluid buildup, or ascites, is a common complication of end-stage liver disease (ESLD), which is a condition in which the liver is severely damaged and cannot function adequately.
Choice B is wrong because examining for leakage at the site of the procedure is not a measure of effectiveness, but a potential complication that should be monitored and reported.
Choice C is wrong because checking the client’s serum albumin levels is not relevant to the paracentesis.
Albumin is a protein that helps maintain fluid balance in the body, but it is not affected by the removal of fluid from the abdomen.
Choice D is wrong because confirming that the client is able to urinate is not related to the paracentesis.
Urination is a function of the kidneys, not the liver, and it does not reflect the amount of fluid removed from the abdomen.
Correct Answer is A
Explanation
The correct answer is choice a. Maternal hypoglycemia.
Choice A rationale:
Maternal hypoglycemia can lead to fetal bradycardia, causing a sustained low fetal heart rate. Hypoglycemia in the mother can affect the fetus by reducing the availability of glucose, which is essential for fetal metabolism and heart function.
-
Choice B rationale:
Maternal fever is more commonly associated with fetal tachycardia rather than bradycardia. Fever in the mother can lead to an increased fetal heart rate, not a decreased one.
-
Choice C rationale:
Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, which can lead to fetal distress and tachycardia rather than bradycardia.
-
Choice D rationale:
Fetal anemia can also cause bradycardia, but in this scenario, maternal hypoglycemia is a more immediate concern as it directly affects the fetal heart rate by impacting the fetal metabolic processes.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.