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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Touching the patient’s face with a cotton ball is not part of the Romberg test. This action is more commonly associated with tests of facial sensation.

Choice B rationale

Applying a vibrating tuning fork to the patient’s forehead is not part of the Romberg test. This action is more commonly associated with tests of vibratory sensation.

Choice C rationale

Having the patient stand with their arms at their sides and their feet together is the correct method for conducting a Romberg test.

Choice D rationale

Performing direct percussion over the area of the kidneys is not part of the Romberg test. This action is more commonly associated with tests of kidney function or the presence of kidney disease.

A. Initiate a cardiac enzyme panel B. Start intravenous fluid therapy C. Provide pain relief medication D. Obtain an electrocardiogram (ECG) E. Perform a comprehensive physical assessment

Correct Answer is D

Explanation

Choice A rationale: Initiating a cardiac enzyme panel can help determine if the client has had a heart attack. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first. An ECG can provide immediate information, while a cardiac enzyme panel takes longer to return results.

Choice B rationale: Starting intravenous fluid therapy may be necessary depending on the client’s hydration status and overall condition. However, it is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.

Choice C rationale: Providing pain relief medication may be necessary if the client is in pain. However, the client’s primary complaint is chest tightness and difficulty breathing, not pain. Therefore, addressing the potential cardiac issue is the priority.

Choice D rationale: The client’s symptoms of sudden shortness of breath, chest tightness, and anxiety, along with her history of hypertension and diabetes, are concerning for a possible cardiac event. An electrocardiogram (ECG) can provide immediate information about the heart’s electrical activity and help identify if the client is experiencing a heart attack or other cardiac event. This should be the first action taken to quickly identify the cause of the client’s symptoms and initiate appropriate treatment.

Choice E rationale: Performing a comprehensive physical assessment is an important part of nursing care. However, in this situation, the client’s symptoms indicate a need for immediate intervention to address her potential cardiac issue.

Choice F rationale: Monitoring the client’s blood glucose levels is important given her history of diabetes. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting a Romberg test as part of a patient’s physical assessment. Which of the following methods should the nurse employ?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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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?