The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care?

Exercises to strengthen flexor muscles

Frequent position changes to reverse the contractures

Range-of-motion exercises to prevent worsening of contractures

Weight-bearing activities to stimulate joint relaxation

Answer and Explanation

The Correct Answer is C

C. Range-of-motion (ROM) exercises are essential in preventing contractures. These exercises aim to maintain or improve joint mobility by moving each joint through its full range of movement. They help stretch tight muscles and maintain flexibility, thereby preventing the progression of contractures.

A. While muscle strengthening exercises are beneficial for overall muscle health, in the context of contractures, the primary issue is the shortened and tight muscles. Strengthening exercises alone may not effectively address the contractures and could potentially exacerbate them.

B. Frequent repositioning is crucial to prevent and potentially reverse contractures. By changing the client's position regularly, pressure and stress on specific muscle groups are relieved, which can help prevent further tightening and promote flexibility. This intervention helps maintain joint mobility and prevents contractures from worsening.

D. Weight-bearing activities can be beneficial for joint health and bone density but may not directly address contractures. Contractures involve structural changes in the muscle-tendon unit rather than joint stiffness alone.

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Correct Answer is D

Explanation

D This action involves escalating the issue to a higher authority who can provide guidance and support. The nursing supervisor can assess the situation, provide advice on managing the critically ill client, and potentially reassign the nurse or provide additional resources.

A. This option does not address the immediate need to ensure the patient's safety and continuity of care. It's important to consider patient welfare and seek appropriate support before considering leaving the unit.

B. Discussing the client's care with another nurse could be a subsequent step, but it does not address the immediate need to ensure the nurse is qualified to provide the necessary care.

C. Proceeding without addressing the issue could jeopardize patient safety and is not ethically or professionally responsible. It's crucial to acknowledge limitations and seek appropriate assistance.

A. document the error. B. call the physician. C. notify the supervisor. D. assess the client.

Correct Answer is D

Explanation

D. Assessing the client is the nurse's first responsibility when a medication error is suspected. The nurse should promptly assess the client's condition to determine if any harm has occurred as a result of the error. This assessment includes vital signs, physical assessment, and evaluation of any signs or symptoms related to the medication error.

A. Documenting the medication error is important for accurate record-keeping and subsequent investigation. However, it should not be the nurse's first action. The priority should be to assess and address any potential harm to the client.

B. Calling the physician may be necessary depending on the severity of the error and the client's condition. However, it is not the first responsibility of the nurse in response to a suspected medication error. The nurse's primary concern should be the immediate assessment and management of the client's condition.

C. Notifying the supervisor or charge nurse is an important step to report the incident and seek guidance on next steps. Supervisors can assist in managing the situation, implementing corrective measures, and ensuring appropriate documentation and reporting procedures are followed. This is typically one of the first actions after ensuring the client's safety.

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The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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