A nurse is caring for a patient who has herpes zoster and is inquiring about the use of complementary and alternative therapies.
Which of the following actions should the nurse take to reduce the patient’s risk of developing plantar flexion contractures?
Place a pillow under the patient’s knees.
Position a trochanter roll under each of the patient’s hips.
Advise the patient to wear rubber-soled slippers.
Apply an ankle-foot orthotic device to the patient’s feet.
The Correct Answer is D
Choice A rationale
Placing a pillow under the patient’s knees can actually increase the risk of plantar flexion contractures by keeping the foot in a flexed position.
Choice B rationale
Positioning a trochanter roll under each of the patient’s hips would not directly prevent plantar flexion contractures. Trochanter rolls are typically used to maintain alignment and prevent external rotation of the hip.
Choice C rationale
Advising the patient to wear rubber-soled slippers would not directly prevent plantar flexion contractures. While rubber-soled slippers can provide safety benefits such as preventing slips and falls, they do not have a direct impact on the prevention of contractures.
Choice D rationale
Applying an ankle-foot orthotic device to the patient’s feet can help maintain the foot in a neutral position, thereby reducing the risk of developing plantar flexion contractures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8"]
Explanation
Step 1 is: Calculate the total units of heparin in the bag, which is 25,000 units.
Step 2 is: Divide the total units by the total volume to find the units per mL, which is (25,000 units ÷ 250 mL) = 100 units/mL.
Step 3 is: Divide the desired units per hour by the units per mL to find the mL/hr, which is (800 units/hr ÷ 100 units/mL) = 8 mL/hr. So, the infusion pump rate should be set at 8 mL/hr.
Correct Answer is C
Explanation
Choice A rationale
Tuberculosis is a serious infectious disease that affects the lungs. However, it does not typically cause lung hyperinflation.
Choice B rationale
Bronchitis is an inflammation of the bronchial tubes. While it can cause symptoms similar to those described, it does not typically cause lung hyperinflation or localized pneumonia in the left upper lobe.
Choice C rationale
Pneumonia is an infection that inflames the air sacs in one or both lungs. The client’s symptoms of a productive cough with thick yellow sputum, crackles in the left upper lobe, and decreased breath sounds at bases bilaterally are consistent with pneumonia. The chest x-ray showing left upper lobe pneumonia confirms this diagnosis.
Choice D rationale
Asthma is a condition in which a person’s airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe. While asthma can cause lung hyperinflation, it does not typically cause localized pneumonia in the left upper lobe.
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