A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?

Use trochanter rolls beside the client's legs.

Logroll the client every 4 hr.

Place the client's arms at their side when turning them.

Cross the client's ankles when lying supine.

Answer and Explanation

The Correct Answer is A

A. Use trochanter rolls beside the client's legs:

Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.

B. Logroll the client every 4 hr:

Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.

C. Place the client's arms at their side when turning them:

Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.

D. Cross the client's ankles when lying supine:

Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.

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Correct Answer is C

Explanation

A. The client tucks their chin when they swallow:
This is a proper swallowing technique. Tucking the chin helps close off the airway during swallowing, reducing the risk of aspiration. It facilitates the safe passage of food or liquids into the esophagus
B. The client adjusts the head of their bed to 90°:
This action is appropriate. Keeping the head of the bed elevated to 30 to 45 degrees is recommended for clients with dysphagia as it helps prevent aspiration during swallowing.
C. The client drinks their thickened juice with a straw:
This action indicates a potential problem. The use of a straw with thickened liquids is generally not recommended for clients with dysphagia. Thickened liquids are used to slow down the flow of the liquid and reduce the risk of aspiration. Drinking thickened juice through a straw may compromise the effectiveness of thickening and increase the risk of aspiration.
D. The client takes frequent breaks while eating:
This action is also appropriate. Clients with dysphagia may need to take breaks between bites to ensure safe and effective swallowing. It allows the client to pace themselves and reduces the risk of aspiration.

A. "You shouldn't worry about the future so you can concentrate on getting well." B. "if you work hard on your physical therapy, you won't need to worry." C. "You're concerned about what will happen when you leave the hospital?" D. "Why are you concerned even though everyone is here to help you?"

Correct Answer is C

Explanation

A. "You shouldn't worry about the future so you can concentrate on getting well.":

This response dismisses the client's concerns and may make them feel invalidated. It implies that their worry is not justified and may hinder open communication about their feelings.

B. "If you work hard on your physical therapy, you won't need to worry.":

While encouragement and motivation are essential, this response may come across as minimizing the client's emotional concerns. It focuses solely on the physical aspect of recovery and does not address the broader emotional and psychological aspects of the client's worry about the future.

C. "You're concerned about what will happen when you leave the hospital?":

This response reflects active listening and empathy, acknowledging the client's expressed concern and inviting further discussion. It allows the client to express their feelings and concerns about the future, fostering a therapeutic nurse-client relationship.

D. "Why are you concerned even though everyone is here to help you?":

This response might be perceived as judgmental or dismissive of the client's feelings. It could make the client feel defensive and hesitant to share their concerns. It does not encourage open communication or exploration of the client's emotions.

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A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?

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