A nurse is reviewing the medical records of four clients.

The nurse should identify that which of the following client findings requires follow-up care?

The correct answer is choice B. Applying an orthotic to the client’s foot.

An orthotic is a device that supports or corrects the function of a body part.

In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients.

Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.

Choice A is wrong because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.

Choice C is wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.

Choice D is wrong because a pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis.

Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.

Contracture can limit the range of motion and function of the affected body part. Contracture can be caused by inactivity, scarring, or diseases that affect the muscles or nerves. Prevention of contractures requires early diagnosis and initiation of physical medicine approaches such as passive range of motion exercises and splinting before contractures are present or while contractures are mild.

The correct answer is choice A. “I can give you information about respite care if you are interested.” Respite care is a service that provides short-term inpatient care for terminally-ill patients at a professional care facility, such as a hospital, hospice inpatient care facility, or nursing home. It is meant to relieve caregiver stress and offer them rest and time away from caregiving duties. Respite care is covered by Medicare for up to five consecutive days and no more than one respite period in a single billing period.

The nurse should offer this option to the son who is experiencing sleep deprivation due to caring for his mother.

Choice B is wrong because it suggests that the son should rely on medication to cope with his situation, which may not be appropriate or effective.

Sleeping pills may have side effects or interactions with other drugs, and they do not address the underlying cause of the son’s stress and fatigue.

Choice C is wrong because it does not acknowledge the son’s need for support or assistance.

It may sound like an empty compliment or a dismissal of the son’s concerns.

The nurse should express empathy and compassion, but also provide information and resources that can help the son.

Choice D is wrong because it does not offer any solution or guidance to the son.

It may also sound like a cliché or a generalization that does not reflect the son’s unique experience.

The nurse should avoid making assumptions or judgments about the son’s feelings or situation, and instead focus on his needs and preferences.