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

Answer and Explanation

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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Correct Answer is C

Explanation

A. "How long have you struggled with your weight?" While this may provide background information, it shifts the focus to the client's weight history rather than validating their current emotional experience and distress.
B. "Let's discuss some weight loss strategies that might work for you." This response prematurely shifts to problem-solving and weight management without first addressing the client’s emotional needs or acknowledging their feelings of embarrassment and vulnerability.
C. "It sounds like you're saying that you feel uncomfortable around others." This is a therapeutic, reflective response that validates the client’s feelings and encourages them to express more about their emotional experience, fostering trust and emotional support.
D. "Have you always felt uncomfortable being overweight?" This question may come across as judgmental and focuses too much on the client's body image history rather than their current emotional experience, potentially worsening feelings of shame.

A. Apply a transparent dressing to the wound. B. Irrigate the wound with sterile water. C. Apply direct pressure to the wound with thick dressing material. D. Tie a tourniquet around the leg distal to the wound.

Correct Answer is C

Explanation

A. Apply a transparent dressing to the wound. Transparent dressings are not appropriate for active bleeding as they are too thin and do not absorb blood or provide compression to control hemorrhage.
B. Irrigate the wound with sterile water. Wound irrigation is not a priority when a client is actively bleeding. Controlling the bleeding takes precedence over cleaning the wound.
C. Apply direct pressure to the wound with thick dressing material. Direct pressure is the first-line intervention to control external bleeding. Applying firm pressure with a thick dressing helps compress the blood vessels and minimize blood loss.
D. Tie a tourniquet around the leg distal to the wound. A tourniquet should be applied proximal (above) the wound if needed and only after direct pressure fails to control the bleeding. Applying it distal is ineffective and potentially harmful.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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