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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Do not let the patient know you are counting their respirations:
This is not directly related to obtaining vital signs and is not a critical factor for a patient with a low platelet count.
B. Let the patient rest for 5 minutes before you measure their blood pressure:
Allowing the patient to rest for a few minutes before measuring blood pressure is a good practice but may not be as critical as other considerations in a patient with a low platelet count.
C. Do not measure the patient’s temperature rectally:
Patients with low platelet counts are at an increased risk of bleeding. Rectal temperatures can be invasive and carry a risk of mucosal injury, making them less advisable in patients with bleeding risks.
D. Count the patient’s radial pulse for 30 seconds and multiply it by 2:
Counting the radial pulse is a suitable method for assessing heart rate in a patient at risk for bleeding. However, rectal temperature measurement should be avoided due to the risk of mucosal injury.
Correct Answer is A
Explanation
A. Increased, strong:
A pulse amplitude of +3 indicates an increased or strong pulse. This suggests a forceful and palpable pulse, potentially associated with conditions like fever, anemia, or increased cardiac output.
B. Diminished, weaker than expected:
This would typically be associated with a lower than normal pulse amplitude. It might suggest poor peripheral perfusion or decreased cardiac output.
C. Absent, unable to palpate:
If the pulse is absent or unable to be palpated, it could indicate severe conditions such as vascular occlusion or cardiac arrest.
D. Bounding:
A bounding pulse is one with a forceful and strong amplitude. It suggests a powerful expansion of the arterial wall, and it can be associated with conditions like fever, anemia, or increased cardiac output.
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