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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Allow the patient to relax and then recheck the patient’s B/P in 5 minutes:

The initial elevated blood pressure reading could be influenced by the patient's anxiety about visiting the doctor. Allowing the patient to relax and rechecking the blood pressure after a few minutes may provide a more accurate reading.

B. Document the elevated blood pressure and notify the physician immediately:

It is premature to immediately notify the physician based on a single elevated blood pressure reading. Reassessing after the patient has had time to relax is a reasonable approach before taking further action.

C. Begin education related to hypertension (high blood pressure):

While patient education is important, addressing the patient's anxiety and obtaining accurate blood pressure readings should be the initial focus.

D. Schedule the patient for follow-up visits for measurement and monitoring of the patient’s blood pressure:

Scheduling follow-up visits may be necessary based on subsequent assessments, but the immediate concern is to recheck the blood pressure after allowing the patient to relax.

A. Pulse B. Temperature C. Blood Pressure D. Respirations

Correct Answer is C

Explanation

A. Pulse:

A pulse rate of 88 bpm is within the normal range. While it's important to monitor the pulse for changes, the reported pulse rate does not raise immediate concerns.

B. Temperature:

An oral temperature of 99.2 degrees Fahrenheit is within the normal range. While it's slightly elevated, it might be influenced by various factors, and isolated temperature readings are not as urgent as other vital signs.

C. Blood Pressure:

A blood pressure reading of 178/112 mm Hg is significantly elevated. High blood pressure is a major concern due to the potential risks it poses to the cardiovascular system, kidneys, and other organs. Immediate attention and further assessment are needed.

D. Respirations:

Respiratory rate of 18 bpm is within the normal range. While it's important to monitor respiratory rate, the reported rate does not raise immediate concerns.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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