A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?

Place a towel roll under the client's neck.

Position a pillow under the client's knees.

Apply an orthotic to the client's foot.

Align a trochanter wedge between the client's legs.

Answer and Explanation

The Correct Answer is C

A. Incorrect. Placing a towel roll under the client's neck is a preventive measure to maintain proper cervical alignment, but it does not specifically address contracture prevention.

B. Incorrect. This can promote flexion of the knees, which may actually contribute to knee flexion contractures over time. While it might be comfortable for the client, it's not a preventive measure against contractures.

C. Correct. Orthotics can help maintain proper alignment of the foot and ankle, preventing foot drop and other related contractures. They are designed to support joints and muscles, minimizing the risk of stiffness and contracture formation.

D. Incorrect. Aligning a trochanter wedge between the client's legs might help prevent external rotation of the hips but does not specifically address contracture prevention.

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Correct Answer is D

Explanation

A. Incorrect. Encouraging the client to lie down in a quiet room is not specifically related to addressing auditory hallucinations.
B. Incorrect. Referring to hallucinations as if they are real can reinforce the client's delusions or hallucinations.
C. Incorrect. Avoiding eye contact can be perceived as dismissive or uninterested.
D. Correct. Asking the client directly about their hallucinations helps assess their content and severity, which is essential for developing an effective plan of care.

A. Polyhydramnios B. Uterine tenderness C. Nausea D. Spotting

Correct Answer is D

Explanation

A. Incorrect. Polyhydramnios (excessive amniotic fluid) is not typically associated with placenta previa. It can be associated with conditions like fetal abnormalities or maternal diabetes.
B. Incorrect. Uterine tenderness might be present in conditions like uterine contractions, but it is not a primary finding in placenta previa.
C. Incorrect. Nausea is a common pregnancy symptom and is not directly related to placenta previa.
D. Correct. Spotting or painless vaginal bleeding is a hallmark sign of placenta previa, which occurs when the placenta covers part or all of the cervix. It can be life-threatening if severe bleeding occurs.

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A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?

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