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 A

Explanation

A. Correct. The child should be instructed to blow into the peak expiratory flow meter as hard and quickly as possible to achieve maximal effort. This provides an accurate measure of peak expiratory flow, which is important in assessing asthma control.
B. Incorrect. The child's body position during testing does not typically affect the accuracy of peak expiratory flow measurements.
C. Incorrect. While recording the average of multiple readings over time is important, the child needs to understand how to perform a single accurate reading first.
D. Incorrect. The tongue is not usually involved in the use of a peak expiratory flow meter.
The child should place their lips tightly around the mouthpiece to create a seal while blowing forcefully into the device.

A. Sit on the bed next to the client. B. Sit in a chair next to the bed. C. Stand at the side of the bed. D. Stand at the foot of the bed.

Correct Answer is B

Explanation

A. Incorrect. Sitting on the bed next to the client may infringe on the client's personal space and comfort.
B. Correct. Sitting in a chair next to the bed at the client's eye level helps establish a more comfortable and empathetic interaction.
C. Incorrect. Standing at the side of the bed may be perceived as less engaging and could create a power dynamic.
D. Incorrect. Standing at the foot of the bed may be uncomfortable for the client and may impede effective communication.

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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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Correct Answer is A

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Correct Answer is B

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