A client who is at full-term gestation is in active labor and complains of a cramp in her leg.
Which intervention should the practical nurse (PN) implement?
Massage the calf and foot.
Extend the leg and flex the foot.
Check the pedal pulse in the affected leg.
Elevate the leg above the heart.
None
None
The Correct Answer is B
The correct answer is B. Extend the leg and flex the foot.
Choice A rationale:
Massaging the calf and foot is not recommended as it could potentially dislodge a blood clot if one is present, which can be dangerous.
Choice B rationale:
Extending the leg and flexing the foot helps to relieve the cramp by stretching the muscles involved. This is a safe and effective method to alleviate muscle cramps.
Choice C rationale:
Checking the pedal pulse in the affected leg is important for assessing circulation but does not directly address the immediate discomfort of the cramp.
Choice D rationale:
Elevating the leg above the heart is generally used to reduce swelling and improve circulation but is not specifically effective for relieving muscle cramps.
: 3
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Asking the client to describe the intensity of the eye pain using the numerical pain scale is not the most relevant action in this situation. The client's statement indicates a misconception about the purpose of pilocarpine eye drops, so addressing this misunderstanding should be the focus.
Choice B rationale:
Reminding the client that the action of the eye drops is to decrease internal eye pressure is the appropriate action. Pilocarpine eye drops are used to treat glaucoma by reducing intraocular pressure, not to anesthetize the eye.
Choice C rationale:
Documenting in the chart that the client understands the action and use of the eye drops might be necessary but should not be the first action taken. The priority is to correct the client's misunderstanding about the eye drops.
Choice D rationale:
Clarifying with the client that eye pain in glaucoma is uncommon, so drops are rarely needed, is not accurate. While eye pain might not be a common symptom of glaucoma, pilocarpine eye drops are specifically used to manage intraocular pressure and are not intended to address eye pain.
Correct Answer is D
Explanation
d. Escort the client to a calm and quiet place.
The PN should use a calm and firm approach to de-escalate the situation and remove the client from the stressful environment. This can help prevent further agitation and potential violence.
The other options are not correct because:
- Instructing a UAP to stay with the client may not be effective or safe, as the UAP may not have the skills or training to handle an agitated client.
- Notifying the client's healthcare provider is not a priority action, as it does not address the immediate safety of the client and others.
- Administering a PRN medication for agitation may be indicated, but it is not the first action. The PN should try non- pharmacological interventions first, unless there is an imminent risk of harm.
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