A nurse is caring for a client who had a spinal cord injury and has paraplegia. The client is alert and oriented.
The client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities are performed once each day.
On Day 5, the client’s feet are warm, pedal pulses are 2+ bilaterally, plantar flexion contractures are noted bilaterally, and the left heel has a 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, with skin intact.
Which findings require intervention by the nurse?
Passive range-of-motion exercises to lower extremities performed once each day
Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact
Plantar flexion contractures noted bilaterally
Pedal pulses 2+ bilaterally
Correct Answer : A,B,C
The correct answers are Choices A, B, and C.
Choice A rationale: Passive range-of-motion exercises should be performed more frequently than once each day to maintain joint mobility, prevent contractures, and stimulate circulation. Performing them only once daily is inadequate for a client with paraplegia who is immobile.
Choice B rationale: Nonblanchable erythema is a sign of a stage 1 pressure ulcer, indicating that the skin is at risk of further breakdown and infection. Immediate intervention is required to prevent progression to more severe pressure injuries.
Choice C rationale: Plantar flexion contractures can lead to significant long-term disability and complications, such as difficulty in ambulation and pain. These contractures require intervention through more frequent range-of-motion exercises, splinting, or physical therapy to prevent worsening.
Choice D rationale: Pedal pulses that are 2+ bilaterally are within normal limits and indicate adequate peripheral circulation. This finding does not require intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C,A,D,B
Explanation
Choice A rationale
Injecting 5 units of air into the bottle of regular insulin is the second step in the procedure. This is done after injecting air into the NPH insulin bottle. The purpose of this step is to pressurize the vial, making it easier to withdraw the insulin.
Choice B rationale
Withdrawing the correct dose of NPH insulin from the bottle is the last step in the procedure. This is done after withdrawing the regular insulin to prevent contamination of the regular insulin with the NPH insulin.
Choice C rationale
Injecting 10 units of air into the bottle of NPH insulin is the first step in the procedure. This is done before injecting air into the regular insulin bottle. The purpose of this step is to pressurize the vial, making it easier to withdraw the insulin.
Choice D rationale
Withdrawing the correct dose of regular insulin from the bottle is the third step in the procedure. This is done after injecting air into the regular insulin bottle and before withdrawing the NPH insulin. The purpose of this step is to ensure that the correct dose of regular insulin is administered.
Correct Answer is C
Explanation
Choice A rationale
A lesion with uniform pigmentation is not typically a sign of skin malignancy. Most benign moles are uniform in color, including shades of tan, brown, and black.
Choice B rationale
The new appearance of petechiae, or small, pinpoint hemorrhages under the skin, is not typically associated with skin cancer. Petechiae can be a sign of a number of conditions, including certain infections, low platelet count, or certain medications.
Choice C rationale
A mole with an asymmetrical appearance is a potential indication of skin malignancy. Asymmetry, where one half of the mole does not match the other, is one of the ABCDEs (Asymmetry, Border irregularity, Color variation, Diameter greater than 6mm, and Evolving size, shape, or color) of melanoma detection.
Choice D rationale
The presence of a papule, a small, raised bump on the skin, is not necessarily indicative of skin cancer. Papules can be a sign of many different skin conditions, including acne, skin infections, or dermatitis.
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