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

Weight-bearing activities to stimulate joint relaxation.

Exercises to strengthen flexor muscles.

Range of motion exercises to prevent worsening of contractures.

Frequent position changes to reverse the contractures.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Weight-bearing activities are not suitable for a patient with contractures, as they may worsen joint stiffness and discomfort. Engaging in weight-bearing activities could lead to further limitations in joint mobility and exacerbate the contractures.

Choice B rationale:

Exercises to strengthen flexor muscles might be beneficial in other contexts, but for a patient with contractures, the focus should be on improving joint mobility and preventing the contractures from worsening. Strengthening exercises do not directly address the issue of limited joint mobility caused by contractures.

Choice C rationale:

Range of motion exercises are essential for patients with contractures. These exercises involve moving joints through their full range of motion to maintain or improve joint flexibility. Regularly performing range of motion exercises prevents further tightening of muscles and joints, thereby preventing the worsening of contractures.

Choice D rationale:

Frequent position changes are important to prevent pressure ulcers and maintain overall comfort, but they do not specifically address the issue of contractures. While position changes are necessary, they are not the primary intervention for managing contractures.

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Correct Answer is D

Explanation

Choice A rationale:

Applying ankle restraints but leaving the wrists unrestrained is not a balanced approach. Restraints should only be used when necessary and should be applied correctly following the healthcare facility's policies and guidelines. Applying restraints to one part of the body while leaving another unrestrained can lead to injuries and is not a safe practice.

Choice B rationale:

Tying a double knot that is difficult to undo can be dangerous in emergency situations. Restraints should allow for quick release in case of emergencies, ensuring patient safety. Difficult-to-undo knots can delay the removal of restraints, leading to potential harm to the patient.

Choice C rationale:

Tying a slip knot to the side rails of the bed is unsafe and against restraint protocols. Slip knots can tighten when pulled, increasing the risk of injury to the patient. Restraints should be applied to designated areas and never tied to movable parts of the bed or other objects in the room.

Choice D rationale:

Checking on the patient frequently is the most appropriate action when a patient is in restraints. Regular monitoring ensures the patient's safety and well-being, assesses their comfort, and allows for prompt response to any signs of distress or discomfort. Frequent checks also help in preventing complications associated with immobilization, such as pressure ulcers and impaired circulation.

A. Decreased respiratory rate due to lungs becoming stronger. B. Increased urinary output due to enhanced bladder muscle tone. C. Atrophy of leg muscles due to immobility. D. Frequent bowel movement due to increased peristalsis.

Correct Answer is C

Explanation

Choice C rationale:

When a patient has been bedridden for an extended period, such as two weeks, the nurse expects to find atrophy of leg muscles due to immobility. Lack of physical activity leads to muscle wasting, which can result in decreased muscle mass and strength. This condition is reversible with proper rehabilitation and exercise.

Choice A rationale:

Decreased respiratory rate due to stronger lungs is not a typical effect of immobility. Immobility can lead to decreased lung expansion and increased risk of respiratory complications, such as pneumonia.

Choice B rationale:

Increased urinary output due to enhanced bladder muscle tone is not a direct effect of immobility. Immobility can affect urinary elimination, but it is more likely to cause urinary retention due to decreased mobility and inability to reach the bathroom independently.

Choice D rationale:

Frequent bowel movements due to increased peristalsis are not expected with immobility. Immobility often leads to slowed peristalsis, which can result in constipation rather than frequent bowel movements.

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

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