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 D
Explanation
A. Placing the nurse's feet close together side by side to have a good center of gravity:
While maintaining a good center of gravity is important, in a falling situation, it's crucial to prioritize the client's safety over the nurse's stability. This option doesn’t address the prevention of the client’s fall.
B. Rocking the nurse's pelvis out and trying to hold the patient up to prevent falling:
Attempting to hold the patient up during a fall may put both the nurse and the client at risk of injury.
C. Grasping the gait belt and pushing the client’s body backward away from the nurse's body:
Pushing the client backward could cause the client to lose balance and fall in an uncontrolled manner.
D. Using the patient's gait belt to gently slide the client down the nurse's body to the floor:
This is the recommended action as it allows for a controlled descent to the floor, minimizing the impact of the fall and reducing the risk of injury to both the client and the nurse.
Correct Answer is C
Explanation
A. 30 degrees:
This angle does not meet the criteria for a High Fowler's position, which requires a more upright position.
B. 15 to 20 degrees:
This angle is lower than what is generally considered as High Fowler's position. High Fowler's is a more upright position.
C. 90 degrees:
High Fowler's position involves elevating the head of the bed to 90 degrees. This position is often used for better lung expansion and respiratory function.
D. 45-60 degrees:
While this range is higher than a semi-Fowler's position, it is not as upright as the 90-degree elevation in a High Fowler's position.
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