A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?
Flex the client's feet using pillows.
Support the client's feet with foot boots.
Place a hand roll under the client's heels.
Remove ankle-foot orthotic devices at bedtime.
The Correct Answer is B
The correct answer is choice B: "Support the client's feet with foot boots."
Choice A rationale:
Flexing the client's feet using pillows might not be sufficient to prevent foot drop. Foot drop is a condition where the client is unable to dorsiflex their foot, and using pillows alone may not provide adequate support to prevent this condition.
Choice B rationale:
Supporting the client's feet with foot boots is the most appropriate intervention to prevent foot drop due to immobility. Foot boots are specifically designed to hold the foot in a dorsiflexed position, preventing the calf muscles from tightening and causing foot drop.
Choice C rationale:
Placing a hand roll under the client's heels might offer some relief, but it's not the most effective intervention for preventing foot drop. Hand rolls are generally used to prevent footdrop by keeping the ankles in a neutral position, rather than solely supporting the heels.
Choice D rationale:
Removing ankle-foot orthotic devices at bedtime is not recommended if the client is at risk for developing foot drop. Ankle-foot orthotic devices are designed to provide continuous support to the feet and prevent muscle contractures. Removing them at bedtime could compromise the effectiveness of the intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. "Tighten your stomach muscles.” This is because when turning an immobile client in bed, it’s important to use proper body mechanics to prevent injury. Tightening the stomach muscles helps to stabilize the core, which supports the spine and can help prevent back strain.
Choice A rationale:
"Keep your feet close together” is wrong because having a wide base of support with the feet apart provides better balance and stability when turning a client in bed.
Choice C rationale:
"Straighten your knees” is wrong because you should keep your knees slightly bent to maintain balance and allow for a smooth transfer of weight as you turn the client.
Choice D rationale:
"Bend at your waist” is wrong because bending at the waist increases the risk of a back injury. It’s important to bend the knees and keep the back straight when leaning over to turn a client.
Correct Answer is C
Explanation
The correct answer is choice C. Pallor with scaly skin.
Choice A rationale:
"Heart rate 89/min." Heart rate within the range of 60-100 beats per minute is generally considered normal for adults at rest. This value doesn't specifically indicate malnourishment.
Choice B rationale:
"Pink mucous membranes." Pink mucous membranes indicate adequate oxygenation and hydration but don't necessarily reflect nutritional status or malnourishment.
Choice C rationale:
"Pallor with scaly skin." Pallor (pale skin) along with scaly skin can be indicative of malnourishment. Malnourished individuals may not receive adequate n
Choice D rationale:
"Body mass index 23." A body mass index (BMI) of 23 falls within the normal range (18.5-24.9), so it doesn't necessarily indicate malnourishment. However, BMI alone may not fully capture malnourishment, as it doesn't consider other factors like muscle mass and specific nutrient deficiencies.
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