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

Place a towel roll under the client's neck.

Position a pillow under the client's knees.

Apply an orthotic to the client's foot.

Align a trochanter wedge between the client's legs.

Answer and Explanation

The Correct Answer is C

A. Incorrect. Placing a towel roll under the client's neck is a preventive measure to maintain proper cervical alignment, but it does not specifically address contracture prevention.

B. Incorrect. This can promote flexion of the knees, which may actually contribute to knee flexion contractures over time. While it might be comfortable for the client, it's not a preventive measure against contractures.

C. Correct. Orthotics can help maintain proper alignment of the foot and ankle, preventing foot drop and other related contractures. They are designed to support joints and muscles, minimizing the risk of stiffness and contracture formation.

D. Incorrect. Aligning a trochanter wedge between the client's legs might help prevent external rotation of the hips but does not specifically address contracture prevention.

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Correct Answer is C

Explanation

Choice A rationale:

Watery stool is not indicative of paralytic ileus. Paralytic ileus is a condition characterized by the inhibition of bowel peristalsis, leading to symptoms such as abdominal distention, constipation, and lack of bowel sounds.

Choice B rationale:

Dizziness is not a specific symptom of paralytic ileus. Dizziness can be caused by various factors and is not directly related to the gastrointestinal condition.

Choice C rationale:

Abdominal distention is the correct choice. Paralytic ileus often presents with abdominal distention due to the accumulation of gas and fluids in the intestines. This distention can cause discomfort and a visible increase in the size of the abdomen.

Choice D rationale:

Oliguria, a decreased urine output, is not a typical symptom of paralytic ileus. It is more indicative of kidney-related issues or dehydration rather than gastrointestinal problems.

A. A client who is scheduled for a procedure in 1 hr B. A client who received a pain medication 30 min ago for postoperative pain C. A client who has 100 mL of fluid remaining in his IV bag D. A client who was just given a glass of orange juice for a low blood glucose level

Correct Answer is D

Explanation

A. A client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.

A client who received a pain medication 30 min ago for postoperative pain may not need immediate assessment, unless there are signs of increased pain or other complications. The nurse can document the medication administration and observe the client’s response.
A client who has 100 mL of fluid remaining in his IV bag may not need immediate assessment, unless there are signs of fluid overload or electrolyte imbalance. The nurse can monitor the client’s fluid intake and output, weight, blood pressure, pulse, temperature, and laboratory values.
A client who was just given a glass of orange juice for a low blood glucose level need immediate assessment to reassess for persistent hypoglycemia

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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