A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures?
Trochanter roll
Abduction pillow
Sheepskin heel pad
Footboard
The Correct Answer is D
A. Trochanter roll. This device is used to prevent external rotation of the hips, especially in clients who are immobile or lying supine. It does not support the feet or ankles and does not prevent plantar flexion.
B. Abduction pillow. An abduction pillow is placed between the legs to maintain proper hip alignment, particularly after hip surgery. It is not designed to prevent foot drop or plantar flexion contractures.
C. Sheepskin heel pad. This provides skin protection and pressure relief to prevent pressure ulcers on the heels. While useful for comfort and skin integrity, it does not keep the foot in a neutral position to prevent contractures.
D. Footboard. A footboard is placed at the foot of the bed to help maintain the foot in dorsiflexion, thereby preventing plantar flexion contractures (also known as foot drop). It supports proper alignment and is the most appropriate device for this purpose in clients with limited mobility.
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Related Questions
Correct Answer is C
Explanation
A. Refer the family to a chronic pain support group. While helpful, this is a later step in the care plan. The nurse must first assess the child's specific condition and patterns of pain.
B. Set up an appointment with the school nurse. This is a supportive measure but not the priority. The nurse must gather more information before involving school personnel.
C. Review the child's electronic pain diary. This is the first action because it allows the nurse to assess the frequency, triggers, severity, and duration of the migraines. Understanding the child's pain pattern is essential for effective treatment planning.
D. Request a change in medication from the provider. This may be necessary, but the nurse should first gather complete data on the child's symptoms and current response to treatment before suggesting changes to the medication regimen.
Correct Answer is B
Explanation
A. "You should not delegate this task because you have the capability to obtain clients' weights." The ability to perform a task does not mean it cannot be delegated. Delegation helps manage workload effectively as long as the task is appropriate for the role.
B. "You can delegate this task if the AP has been trained to use our scales." Weighing clients is a routine, noninvasive task that can be delegated to assistive personnel, provided they are trained and competent in using the equipment properly.
C. "You can delegate this task to an AP for new clients before performing a nursing assessment." Initial assessments require nursing judgment and should not be delegated. Data collection like weight should occur after the nurse completes the first assessment.
D. "You should not delegate this task because it requires nursing judgment." Weighing a client does not require clinical judgment and is considered appropriate for delegation to trained assistive personnel under supervision.
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