A nurse is contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

Promote independence in activities of daily living for the client.

Provide relief from pain and discomfort for the client.

Maintain immobilization and alignment for the client.

Provide optimal nutrition and hydration for the client.

Answer and Explanation

The Correct Answer is C

When contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture, the highest priority nursing intervention to assist in meeting this outcome is to maintain immobilization and alignment for the client. This helps to ensure that the bones are in the correct position to heal properly and can prevent complications such as malunion or nonunion.

a. Promoting independence in activities of daily living for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.
b. Providing relief from pain and discomfort for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.
d. Providing optimal nutrition and hydration for the client is important, but it is not the highest priority intervention for achieving functional healing of a fracture.

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Correct Answer is D

Explanation

a. Decorticate posturing is marked by the flexion of the arms, with the hands clenched into fists and the legs extended and internally rotated.
b. External rotation of the lower extremities is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight.

c.Pronation of the hands is characteristic of decerebrate posturing, where the arms are extended and pronated.

d. In decorticate posturing, the lower extremities typically exhibit plantar flexion. Additionally, the upper extremities show flexion of the arms, wrists, and fingers with adduction of the arms.

A. Position the lower extremities so that they are touching B. Ensure that the client's heels are touching the bed. C. Prevent hip ﬂexion of the aﬀected extremity. D. Instruct the client to avoid movement of the aﬀected leg.

Correct Answer is C

Explanation

When contributing to the plan of care for a client who is postoperative following a total hip arthroplasty, the nurse should include information on preventing hip ﬂexion of the aﬀected extremity. This can help prevent dislocation of the new hip joint and promote healing.

a. Positioning the lower extremities so that they are touching is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the lower extremities should be determined by the surgeon's instructions and the client's comfort.
b. Ensuring that the client's heels are touching the bed is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the heels should be determined by the surgeon's instructions and the client's comfort.

d. Instructing the client to avoid movement of the aﬀected leg is not necessary for a client who is postoperative following a total hip arthroplasty. The client will need to begin moving and exercising the aﬀected leg as part of their rehabilitation and recovery.

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A nurse is contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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