A nurse is caring for a comatose patient and applies a hand and wrist roll in each hand of the patient to keep the thumb slightly adducted and correct position to the fingers. What is the primary purpose of this action?
To prevent contractions in the hand.
To prevent skin breakdown.
To prevent decrease perfusion in the lower extremities.
To prevent pooling of blood in the hand.
The Correct Answer is A
A. To prevent contractions in the hand:
The use of hand and wrist rolls helps prevent contractures, which are permanent shortening of muscles or joints. This is particularly important in comatose patients or those with limited mobility to maintain proper hand positioning and prevent deformities.
B. To prevent skin breakdown:
While proper positioning can contribute to preventing skin breakdown, the primary purpose of hand and wrist rolls, in this context, is to address the risk of contractures rather than skin breakdown.
C. To prevent decreased perfusion in the lower extremities:
The action described is specifically related to the hands and wrists, not the lower extremities. It is not designed to prevent decreased perfusion in the lower extremities.
D. To prevent pooling of blood in the hand:
While maintaining proper hand positioning may contribute to optimal circulation, the primary purpose is to prevent contractures rather than addressing blood pooling.
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Related Questions
Correct Answer is C
Explanation
A. Droplet isolation:
Droplet isolation is used for diseases spread by respiratory droplets that are larger than those in airborne transmission. Examples include influenza and bacterial meningitis.
B. Enhanced contact isolation:
Enhanced contact precautions are implemented for patients known or suspected to be infected with pathogens that require additional control measures beyond standard precautions. This may include multi-drug resistant organisms.
C. Airborne isolation:
Airborne isolation is specifically used for diseases that are transmitted through small airborne particles that can remain suspended in the air for an extended period. Tuberculosis is one such example. The use of N95 respirators and negative pressure rooms is common for airborne precautions.
D. Neutropenic isolation:
Neutropenic precautions are implemented for patients with compromised immune systems, particularly those with low neutrophil counts. It involves measures to protect the patient from potential infections.
Correct Answer is D
Explanation
A. Systolic pressure:
The first sound heard during blood pressure measurement corresponds to the systolic pressure, the pressure in the arteries when the heart is contracting.
B. Pulse pressure:
Pulse pressure is the numerical difference between the systolic and diastolic pressures but is not specifically represented by a sound in blood pressure measurement.
C. Auscultatory gap:
An auscultatory gap is a temporary disappearance of sounds during blood pressure measurement, typically occurring between the systolic and diastolic pressures. It is not directly associated with the second sound.
D. Diastolic pressure:
The second sound heard corresponds to the closure of the aortic valve, marking the beginning of diastole. This sound represents the diastolic pressure, which is the pressure in the arteries when the heart is at rest.
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