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 D

Explanation

A. "The higher the score, the higher the pressure injury risk.":The Braden Scale measures pressure injury risk, but a higher score indicates a lower risk of developing a pressure injury.

B. "The client's age is part of the measurement.":The client’s age is not a direct factor measured by the Braden Scale.

C. "Each element has a range from one to five points.":Each element in the Braden Scale is scored from 1 to 4 points. A score of 1 indicates the highest level of impairment for that element, while a score of 4 indicates the least impairment.

D. "The scale measures six elements.":

The Braden Scale evaluates six elements:Sensory perception,Moisture,Activity,Mobility,NutritionandFriction/shear. These elements are critical for assessing a client’s risk of developing pressure injuries.

A. "You need to understand that you have very little time left." B. "I will contact your provider to discuss your options." C. "Enjoy the time you have and do the things you want to do." D. "Hospice care is the best thing for you at this time."

Correct Answer is B

Explanation

A. "You need to understand that you have very little time left":

This response is blunt and may be emotionally distressing for the client. It is essential to communicate with sensitivity and respect the client's autonomy. This option does not explore the available treatment options, which is important in this situation.

B. "I will contact your provider to discuss your options":

This is the correct answer. It demonstrates the nurse's commitment to the client's wishes by taking proactive steps to explore treatment options. Involving the healthcare provider in the discussion allows for a more informed decision-making process and ensures that the client's preferences are considered in the overall care plan

C. "Enjoy the time you have and do the things you want to do":

This response may come across as dismissive and does not directly address the client's expressed desire for more treatment. It is important to acknowledge the client's wishes and explore available options before discussing end-of-life activities.

D. "Hospice care is the best thing for you at this time":

While hospice care is an important consideration for individuals with terminal illnesses, it may not align with the client's current preference for more treatment. Introducing hospice care at this point without discussing treatment options may be premature.

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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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