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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The correct answer is choicec. Release of personal belongings form.

Choice A rationale:

Completion of an incident report is not typically part of postmortem care documentation unless there was an unusual or unexpected event surrounding the death.

Choice B rationale:

While the name of the nurse certifying the client’s death is important, it is usually documented separately in the death certificate or other official records, not necessarily in the postmortem care documentation.

Choice C rationale:

The release of personal belongings form is crucial as it ensures that the client’s belongings are properly accounted for and handed over to the appropriate person, providing a clear record of what was released and to whom.

Choice D rationale:

Documenting one client identifier at the time of death is important, but it is not specific to postmortem care documentation. Identifiers are generally used throughout the client’s medical record to ensure accuracy and consistency.

A. "Stand with your feet together and your arms at your sides.” B. "After I place the tuning fork, tell me when you no longer hear the sound.” C. "I'm going to stroke the lateral side of the bottom of your foot.” D. "Touch each fingertip as quickly as possible with your thumb.”

Correct Answer is A

Explanation

The correct answer is choice A: "Stand with your feet together and your arms at your sides."

Choice A rationale:

This statement is correct. The nurse should instruct the client to stand with their feet together and their arms at their sides for a Romberg test. This position helps to assess the client's ability to maintain balance with minimal sensory input, evaluating their proprioception and vestibular function.

Choice B rationale:

The instruction about the tuning fork is unrelated to the Romberg test. The tuning fork is commonly used to assess hearing and vibratory sensations, not balance.

Choice C rationale:

This statement is unrelated to the Romberg test. Mentioning the lateral side of the foot suggests a neurological examination related to assessing reflexes, such as the Babinski reflex.

Choice D rationale:

This instruction pertains to a different test known as the "finger-to-nose" test, which is used to assess coordination, not balance.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?

Correct Answer is C

Explanation

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client?

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed?

A nurse is preparing to administer medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which of the following entities?

A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures?

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?