A nurse has placed a patient in restraints and obtained doctor's orders for the restraint.
Which action is appropriate for the nurse to conduct for a patient in restraints?

Choice A rationale:

Placing pillows under the patient's hips and knees before turning is a supportive measure but is not the nursing priority during the logrolling procedure. While it helps maintain proper body alignment, it is not the primary focus of the procedure.

Choice B rationale:

Turning the patient only to the right side and never to the left is incorrect. Patients should be turned gently and carefully to either side, depending on the situation and the patient's condition. Restricting the movement to only one side can cause discomfort and potential injury to the patient.

Choice C rationale:

Raising the head of the bed to at least 30 degrees before turning is a good practice to prevent aspiration and facilitate breathing. However, it is not the priority step when logrolling a patient. Proper body alignment and support are essential to prevent injuries during the procedure.

Choice D rationale:

The correct answer. Keeping the head, neck, back, hips, and legs in alignment with each other is the nursing priority when logrolling a patient. This technique ensures that the patient's spine is supported and prevents twisting or bending, reducing the risk of injury. It is crucial for the healthcare provider to coordinate the movement carefully to maintain proper alignment throughout the procedure.

Choice A rationale:

Assessing the strength of the lower extremities is one of the objectives of asking the patient to dorsiflex and plantarflex both feet against the nurse's hands. This action helps evaluate the muscle strength of the lower limbs, providing information about the patient's neuromuscular function.

Choice B rationale:

Assessing the patient's sense of balance is another objective of this action. Dorsiflexion and plantarflexion require coordination and balance. If the patient struggles to maintain balance while performing these movements, it could indicate issues with proprioception or neurological deficits.

Choice C rationale:

Assessing the presence of edema is not directly related to dorsiflexion and plantarflexion movements. Edema assessment typically involves inspecting and palpating specific areas of the body, such as the ankles, to check for swelling, discoloration, and pitting.

Choice D rationale:

Evaluating the range of motion of the ankle joint is a key aspect of asking the patient to dorsiflex and plantarflex both feet against the nurse's hands. This action allows the nurse to observe how far the patient can move their ankles, providing valuable information about joint flexibility and function.

Choice E rationale:

Assessing the status of the patient's skin turgor involves checking the skin's elasticity and hydration level, usually by pinching and observing how quickly the skin returns to its normal position. This assessment is unrelated to the dorsiflexion and plantarflexion movements and is not applicable in this context.