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

A. Incorrect. A residual of 65 mL may indicate delayed gastric emptying, but it alone does not directly correlate with an increased risk of aspiration unless it leads to significant overdistension or the client is unable to tolerate further feedings.

B. Incorrect. Sitting in high Fowler's position during feeding is actually a preventive measure against aspiration.

C. Correct. his factor increases the risk for aspiration. Clients with gastroesophageal reflux disease (GERD) are more prone to refluxing contents from the stomach into the esophagus, which can lead to aspiration, especially during or after feedings.

D. Incorrect. The osmolarity of the formula might affect tolerance but is not directly related to aspiration risk.

A. Place the client in seclusion when he exhibits signs of anxiety. B. Encourage the client to spend time in the dayroom. C. Encourage the client to take frequent rest periods. D. Withdraw the client's TV privileges if he does not attend group therapy.

Correct Answer is C

Explanation

A. Incorrect. Placing the client in seclusion is not an appropriate intervention for managing mania.
B. Incorrect. Encouraging the client to spend time in the dayroom may exacerbate symptoms of mania by providing more stimulation.
C. Correct. Encouraging the client to take frequent rest periods helps prevent overactivity and exhaustion, common in manic episodes.
D. Incorrect. Withdrawing privileges are not directly related to managing manic symptoms and may not be therapeutic.

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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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