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. Loosen the client's bed linens:

For support surfaces to be effective, there must be minimal layering in between the device and the person. A single sheet that can be kept dry and crease free is optimal. Loosening linens can help make the client more comfortable by reducing pressure and friction on the skin, but it does not directly address the client's acute pain from a pressure injury.

B. Provide bright lights in the client's room:

Bright lights may not be directly relevant to managing acute pain from a pressure injury. In fact, some clients may prefer a dimly lit environment when experiencing pain. Therefore, this option is not the most appropriate for pain management in this case.

C. Massage the client's sacrum:

Massaging the client's sacrum is not recommended when there is a pressure injury, as this could further damage the tissue and exacerbate the injury.

D. Offer to play music in the client's room:

Music therapy is a widely recognized nonpharmacological intervention for pain management. Listening to music can reduce the perception of pain by distracting the client, promoting relaxation, and triggering the release of endorphins. This approach is safe, inexpensive, and can be tailored to the client’s preferences.

A. I will walk three times per week." B. "I will take 250 milligrams of calcium once per day." C. I will decrease my intake of dairy products." D. I will avoid exposure to the sun.

Correct Answer is A

Explanation

A. "I will walk three times per week."

Weight-bearing exercises like walking help strengthen bones and reduce the risk of osteoporosis. Regular physical activity is a key component in maintaining bone health.

B. "I will take 250 milligrams of calcium once per day."

This amount of calcium is insufficient. The recommended daily intake for older adults is typically around 1,000 to 1,200 milligrams of calcium per day, divided into doses for better absorption.

C. "I will decrease my intake of dairy products."

Dairy products are rich sources of calcium and are beneficial for bone health. Decreasing their intake would not be advisable for reducing the risk of osteoporosis.

D. "I will avoid exposure to the sun."

Sun exposure helps the body produce vitamin D, which is essential for calcium absorption and bone health. Avoiding sun exposure could lead to a deficiency in vitamin D, increasing the risk of osteoporosis.

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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?

Nursing Test Bank

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