A nurse is caring for a client who is immobile.
Which of the following interventions is appropriate to prevent contracture?
Align a trochanter wedge between the client’s legs.
Apply an orthotic to the client’s foot.
Place a towel roll under the client’s neck.
Position a pillow under the client’s knees.
The Correct Answer is B
An orthotic is a device that supports or corrects the function of a body part. In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients. Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.
Choice A is wrong because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.
Choice C is wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.
Choice D is wrong because a pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis.
Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.
Contracture can limit the range of motion and function of the affected body part. Contracture can be caused by inactivity, scarring, or diseases that affect the muscles or nerves. Prevention of contractures requires early diagnosis and initiation of physical medicine approaches such as passive range of motion exercises and splinting before contractures are present or while contractures are mild.
An orthotic is a device that supports or corrects the function of a body part. In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients. Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.
Choice A is wrong because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.
Choice C is wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.
Choice D is wrong because a pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis.
Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.
Contracture can limit the range of motion and function of the affected body part. Contracture can be caused by inactivity, scarring, or diseases that affect the muscles or nerves. Prevention of contractures requires early diagnosis and initiation of physical medicine approaches such as passive range of motion exercises and splinting before contractures are present or while contractures are mild.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because placing a wedge under one of the hips can help prevent compression of the inferior vena cava by the uterus, which can compromise placental blood flow and cause fetal hypoxia. Placing a wedge under the hip can also help reduce the risk of maternal hypotension, which can also affect fetal oxygenation.
Choice A is wrong because inserting a pillow under the client’s knees can increase the risk of thromboembolism, which is a potential complication of cesarean birth.
Choice B is wrong because positioning the client in reverse Trendelenburg can increase the risk of maternal aspiration, which is another potential complication of cesarean birth.
Choice C is wrong because assisting the client into the lithotomy position can also compress the inferior vena cava and reduce placental blood flow. The lithotomy position is also not necessary for cesarean birth, as the baby is delivered through an incision in the abdomen and uterus.
Correct Answer is B
Explanation
This is because rubella is a highly contagious viral infection that can cause serious harm to the developing fetus if the pregnant person gets infected. Rubella can cause congenital rubella syndrome, which can result in hearing and vision loss, heart defects and other serious conditions in newborns.
Choice A is wrong because aspirin should not be given to children or adolescents with viral infections, as it can cause Reye’s syndrome, a rare but potentially fatal condition that affects the liver and brain.
Choice C is wrong because rubella does not require airborne precautions, which are used for diseases that can spread through very small droplets that can remain in the air for long periods of time, such as tuberculosis or measles. Rubella spreads through direct contact with saliva or mucus of an infected person, or through respiratory droplets from coughing or sneezing.
Therefore, standard and droplet precautions are sufficient to prevent transmission. Choice D is wrong because Koplik spots are a characteristic sign of measles, not rubella.
Koplik spots are small white spots that appear on the inside of the cheeks before the measles rash develops. Rubella causes a pink or red rash that usually starts on the face and moves down the body.
Normal ranges for rubella antibody tests are:
- IgM: Negative or less than 0.9 IU/mL
- IgG: Negative or less than 10 IU/mL
A positive IgM result indicates a recent or current infection, while a positive IgG result indicates a past infection or immunity from vaccination.
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