A nurse is caring for a patient who has herpes zoster and is inquiring about the use of complementary and alternative therapies.
Which of the following actions should the nurse take to reduce the patient’s risk of developing plantar flexion contractures?
Place a pillow under the patient’s knees.
Position a trochanter roll under each of the patient’s hips.
Advise the patient to wear rubber-soled slippers.
Apply an ankle-foot orthotic device to the patient’s feet.
The Correct Answer is D
Choice A rationale
Placing a pillow under the patient’s knees can actually increase the risk of plantar flexion contractures by keeping the foot in a flexed position.
Choice B rationale
Positioning a trochanter roll under each of the patient’s hips would not directly prevent plantar flexion contractures. Trochanter rolls are typically used to maintain alignment and prevent external rotation of the hip.
Choice C rationale
Advising the patient to wear rubber-soled slippers would not directly prevent plantar flexion contractures. While rubber-soled slippers can provide safety benefits such as preventing slips and falls, they do not have a direct impact on the prevention of contractures.
Choice D rationale
Applying an ankle-foot orthotic device to the patient’s feet can help maintain the foot in a neutral position, thereby reducing the risk of developing plantar flexion contractures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Pupil clarity is not typically used to assess an older adult client’s risk for falls. It is more relevant in neurological assessments.
Choice B rationale
The appearance of gait is a crucial factor in assessing an older adult client’s risk for falls. Abnormalities in gait can increase the risk of falls.
Choice C rationale
Visual fields are important in assessing an older adult client’s risk for falls. Impaired visual fields can increase the risk of falls.
Choice D rationale
Visual acuity is important in assessing an older adult client’s risk for falls. Poor visual acuity can increase the risk of falls.
Correct Answer is D
Explanation
Choice A rationale
While elevating the head of the bed to 30 degrees can be helpful in some procedures, it is not the most crucial step when inserting a nasogastric (NG) tube. The primary goal is to ensure the tube enters the esophagus and not the trachea.
Choice B rationale
If a patient begins to gag or choke during the procedure, it may indicate that the tube has entered the trachea instead of the esophagus. However, removing the NG tube immediately might not always be the best course of action. It’s important to first assess the situation, reposition the patient, and attempt to advance the tube while the patient swallows.
Choice C rationale
Applying suction to the NG tube prior to insertion is not a standard practice. Suction is typically applied after the NG tube has been properly placed and secured, to remove gastric contents for therapeutic (decompression) or diagnostic (analysis) purposes.
Choice D rationale
Encouraging the patient to take sips of water can facilitate the insertion of the NG tube into the esophagus. Swallowing helps guide the tube down into the esophagus instead of the trachea.
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