A nurse is caring for a client who has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity?
Sequential compression device
Abduction splint.
Ankle-foot orthotic.
Continuous passive motion machine.
The Correct Answer is C
An ankle-foot orthotic can help prevent a plantar flexion contracture of the affected extremity in a client who has right-sided paralysis following a cerebrovascular accident. This device can help maintain the foot and ankle in a neutral position and prevent the development of a contracture.
a. A sequential compression device is used to prevent deep vein thrombosis and is not specifically designed to prevent contractures.
b. An abduction splint is used to maintain the hip in a neutral position and is not specifically designed to prevent contractures of the foot and ankle.
d. A continuous passive motion machine is used to promote joint mobility and is not specifically designed to prevent contractures of the foot and ankle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
If a nurse is caring for an older adult client who tells the nurse that they have smoked one pack of cigarettes every day for the last 60 years, the next action the nurse should take is to ask what the client knows about the effects of smoking. This will help the nurse assess the client's knowledge and understanding of the risks associated with smoking and provide an opportunity for education.
Option b is incorrect because working with the client to establish a quit date is important but not the next intervention.
Option c is incorrect because suggesting that the client use nicotine gum to facilitate quitting is important but not the next intervention.
Option d is incorrect because referring the client to a local smoking cessation program is important but not the next intervention.
Correct Answer is C
Explanation
The Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each element has a range of one to four points, with a total possible score of 23 points. The lower the score, the higher the risk for pressure injury.
Option a is incorrect because each element has a range from one to four points.
Option b is incorrect because the lower the score, the higher the pressure injury risk.
Option d is incorrect because the client's age is not part of the measurement.
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