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.
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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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Headache is a common adverse effect of disulfiram when alcohol is consumed. It is part of the adverse reaction created by the drug to deter individuals from drinking. While headache is a known symptom, tinnitus is a more specific and distinctive adverse effect associated with disulfiram use.
Choice B rationale:
Hypertension is not a common adverse effect of disulfiram. Disulfiram does not directly impact blood pressure. Its primary action is to cause an adverse reaction when alcohol is consumed.
Choice C rationale:
Tinnitus (ringing in the ears) is a known adverse effect of disulfiram when alcohol is ingested. Disulfiram inhibits the breakdown of acetaldehyde, leading to an accumulation of this toxic substance in the body. Tinnitus is one of the symptoms of this toxic reaction and is a significant concern in individuals taking disulfiram for alcohol use disorder.
Choice D rationale:
Insomnia is not a common adverse effect of disulfiram. Disulfiram works by creating an unpleasant reaction when alcohol is consumed, which deters individuals from drinking. This reaction does not typically manifest as insomnia.
Correct Answer is C
Explanation
The correct answer is a. Moving both crutches with the stronger leg forward first.
Rationale for Choice C:
- Proper positioning of the hands on the grips and keeping the elbows slightly flexed helps ensure stability and control while using the crutches.
Rationale for Other Choices:
a.In a three-point gait, the client moves both crutches and the affected leg together, followed by the unaffected leg. The stronger leg does not move forward first.
b. Stepping with the affected leg first when going up stairs: This action is incorrect for the three-point gait. When ascending stairs, the client should move the stronger leg up first, followed by the crutches and the affected leg.
d. Supporting his body weight while leaning on the axillary crutch pads: This action is also correct for general crutch use, but it does not specifically address the weight-bearing restrictions and movement pattern of the three-point gait.
Additional Information:
- Practice and supervision:It's essential for the client to practice the three-point gait under the supervision of a healthcare professional to ensure proper technique and safety.
- Gradual progression:The client should gradually increase their distance and duration of crutch use as their strength and coordination improve.
- Pain management:Adequate pain management is crucial to allow the client to participate in rehabilitation and regain mobility.
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