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","E"]

Explanation

A. Placenta previa: The client's symptoms do not specifically suggest placenta previa, which is characterized by painless vaginal bleeding, not back pain.
B. Disseminated intravascular coagulation: The client's symptoms and vital signs do not suggest disseminated intravascular coagulation, which is a serious condition characterized by excessive bleeding and clotting throughout the body.
C. Preeclampsia: The presence of uterine contractions, elevated blood pressure, and a potential increase in body temperature can indicate the risk of developing preeclampsia, a condition characterized by high blood pressure and signs of damage to other organ systems, often developing after the 20th week of pregnancy.
D. Sepsis: While the client has an elevated temperature, the symptoms provided do not strongly indicate sepsis. Other signs, such as rapid heart rate, low blood pressure, and changes in mental status, are usually associated with sepsis.
E. Preterm prelabour rupture of membranes (PROM): The client's report of lower back pain, pinkish vaginal discharge, and uterine contractions can raise concern for the risk of preterm prelabour rupture of membranes, where the amniotic sac ruptures before the onset of labor.
F. Seizures: The client's symptoms and information provided do not indicate a risk of seizures. Seizures can be associated with conditions like preeclampsia but are not directly indicated by the client's current assessment.

A. Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. B. Membranes intact. C. No uterine contractions noted. D. FHR baseline 138 E. minimal variability. F. No further reports of burning with urination. G. WBC 12.000/mm3 H. Platelet count 188,000/mm3 (150,000 to 400,000/mm3) I. Temperature 37.1° C (98.7° F) J. Blood pressure 120/78 mm Hg

Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge.

Membranes intact.

No uterine contractions noted.

FHR baseline 138, with minimal variability. No further reports of burning with urination.

Laboratory Results: WBC 12,000/mm3 (within the normal range of 5,000 to 10,000/mm3). Platelet count 188,000/mm3 (within the normal range of 150,000 to 400,000/mm3).

Vital Signs: Temperature 37.1°C (98.7°F), Blood pressure 120/78 mm Hg.

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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

Correct Answer is ["C","E"]

Explanation

Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

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