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?

The correct answer is choice A. Use warm water when bathing the client.

Choice A rationale:

Using warm water when bathing helps maintain skin integrity by ensuring the skin is clean without causing excessive dryness or irritation. Warm water is gentle on the skin and helps in maintaining its natural moisture balance.

Choice B rationale:

Placing a donut-shaped cushion in the client’s chair is not recommended as it can cause pressure points and restrict blood flow, potentially leading to pressure ulcers.

Choice C rationale:

Massaging reddened areas over bony prominences is not advisable because it can cause further damage to already compromised skin and increase the risk of pressure ulcers.

Choice D rationale:

Maintaining the client in high-Fowler’s position for extended periods can increase pressure on the sacral area, leading to pressure ulcers. It is important to regularly reposition the client to alleviate pressure.

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.