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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
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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.
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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.
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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.
Correct Answer is C
Explanation
Banana slices are soft, easy to chew, and can be picked up by the toddler’s fingers, which promotes independence in eating. According to the CDC, foods that toddlers should avoid include:
- Added sugars and no-calorie sweeteners, such as sugar-sweetened and diet drinks
- High-salt foods, such as canned foods, processed meats, frozen dinners, fast food, and junk food
- Unpasteurized juice, milk, yogurt, or cheese
- Foods that may cause choking, such as hard or crunchy foods, sticky foods, stringy cheese, and foods that are not cut up into small pieces
Choice A is wrong because popcorn is a choking hazard for toddlers.
It is hard, crunchy, and can get stuck in the airway. The NHS advises not to give whole nuts and peanuts to children under 5 years old.
Choice B is wrong because grapes are also a choking hazard for toddlers.
They are round, slippery, and can block the airway. The NHS recommends cutting grapes into quarters before giving them to young children.
Choice D is wrong because hot dogs are high in salt and can cause choking if not cut up into small pieces. The Extension warns against giving hot dogs to young toddlers.
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