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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

After moving clients to a safe location, the next action the nurse should take is to pull the fire alarm. This will alert others in the building to the presence of a fire and activate the building's fire suppression systems.

Options a, c, and d are not the next actions the nurse should take. Using an extinguisher to put out the fire may be appropriate if the nurse has been trained to do so and if it is safe to do so. Closing the doors to client rooms can help to contain the spread of smoke and fire, but it is not the next action the nurse should take. Turning oﬀ electrical equipment in the room may help to prevent further ignition sources, but it is not the next action the nurse should take.

A. Use a cuﬀ with a width that is about 60% of the client's arm circumference. B. Apply the cuﬀ above the client's antecubital fossa. C. Have the client sit with his arm resting above the level of his heart. D. Release the pressure on the client's arm 5 to 6 mm per second.

Correct Answer is A

Explanation

When checking a client's blood pressure, the nurse should use a cuﬀ with a width that is about 60% of the client's arm circumference. This will help to ensure that the cuﬀ fits properly and provides an accurate reading.

Options b, c, and d are not correct. The cuﬀ should be applied over the client's brachial artery, which is located in the antecubital fossa. The client should sit with their arm resting at the level of their heart, not above it. The pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is A

Explanation

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