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 B
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. Correct. Positioning a pillow under the client's knees helps maintain the knee joint in a slightly flexed position, which can prevent contractures in the knee joint.
C. Incorrect. Applying an orthotic to the client's foot might be used to prevent foot drop but does not address contracture prevention in other areas of the body.
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 D
Explanation
A. Incorrect. Activities like jogging can increase intraocular pressure and should be avoided for a longer period after surgery.
B. Incorrect. Bending at the waist can increase intraocular pressure and should be avoided.
C. Incorrect. Lifting objects, especially those heavier than 10 pounds, can increase intraocular pressure and should be avoided.
D. Correct. After surgical repair of a detached retina, clients should avoid activities that might increase intraocular pressure, like heavy lifting or bending at the waist. Activities that do not strain the eye, like sewing, can typically be resumed earlier.
Correct Answer is ["C","D","G"]
Explanation
Based on the provided information, the nurse should include the following statements in the client's teaching:
C. "Wear loose-fitting clothing": This is because the specific gravity of the urine is slightly elevated (1.022), which may indicate mild dehydration. Loose-fitting clothing can help promote comfort and ventilation, especially in cases of dehydration.
D. "Wear flat or low-heeled shoes": There is no specific indication related to the urine dipstick results, but it is generally good advice for maintaining proper foot health and preventing strain on the feet and ankles.
G. "You should avoid fried foods": There are no specific indications related to the urine dipstick results, but a healthy diet is always beneficial for overall well-being. Avoiding fried foods can be a part of a balanced diet and promote better health.
The following statements should not be included in the client's teaching based on the provided urine dipstick results:
A. "Try using an abdominal support belt": There is no indication related to the urine dipstick results that suggests the need for an abdominal support belt.
B. "Take hot showers to help relieve itching": Itching is not mentioned in the urine dipstick results, so there is no specific indication to recommend hot showers for this purpose.
E. "You can douche twice weekly": Douche is not related to urine dipstick results, and douching is generally not recommended as it can disrupt the natural balance of vaginal flora and may cause more harm than good.
F. "Eat two large meals a day": There is no indication related to the urine dipstick results that suggests a specific meal plan, and eating two large meals a day may not be suitable for everyone's dietary needs.
It's important for the nurse to provide teaching based on the client's specific needs and health conditions. In this case, the nurse can focus on maintaining hydration (based on the specific gravity result) and promoting a balanced diet and healthy lifestyle. Always individualize teaching based on the client's health status and any specific concerns they may have.
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