A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

Flex the client's feet using pillows.

Support the client's feet with foot boots.

Place a hand roll under the client's heels.

Remove ankle-foot orthotic devices at bedtime.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: "Support the client's feet with foot boots."

Choice A rationale:

Flexing the client's feet using pillows might not be sufficient to prevent foot drop. Foot drop is a condition where the client is unable to dorsiflex their foot, and using pillows alone may not provide adequate support to prevent this condition.

Choice B rationale:

Supporting the client's feet with foot boots is the most appropriate intervention to prevent foot drop due to immobility. Foot boots are specifically designed to hold the foot in a dorsiflexed position, preventing the calf muscles from tightening and causing foot drop.

Choice C rationale:

Placing a hand roll under the client's heels might offer some relief, but it's not the most effective intervention for preventing foot drop. Hand rolls are generally used to prevent footdrop by keeping the ankles in a neutral position, rather than solely supporting the heels.

Choice D rationale:

Removing ankle-foot orthotic devices at bedtime is not recommended if the client is at risk for developing foot drop. Ankle-foot orthotic devices are designed to provide continuous support to the feet and prevent muscle contractures. Removing them at bedtime could compromise the effectiveness of the intervention.

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Correct Answer is C

Explanation

The correct answer is choice C. "I will remove all stuffed animals from my baby's crib."

Choice A rationale:

"I will place my baby on her side to sleep." Placing a baby on their side to sleep is not recommended as it increases the risk of sudden infant death syndrome (SIDS). The back sleep position is the safest for infants to reduce the risk of SIDS.

Choice B rationale:

"I should avoid giving my baby a pacifier." Using a pacifier during sleep actually has a protective effect against SIDS. It's recommended to offer a pacifier at naptime and bedtime after breastfeeding is well-established.

Choice C rationale:

"I will remove all stuffed animals from my baby's crib." This is the correct answer as it demonstrates an understanding of safe sleep practices. Soft bedding, including stuffed animals, can pose a suffocation hazard for infants. A clear and uncluttered crib is recommended for safe sleep.

Choice D rationale:

"I will cover my baby with a light blanket when she is sleeping." The use of blankets, even lightweight ones, in an infant's sleep environment is associated with an increased risk of SIDS. It's advised to keep the crib free from blankets, pillows, and other loose items.

A. Sit beside the client. B. Speak slowly and loudly to the client. C. Dim the lights in the client's room. D. Choose a private room for the interview.

Correct Answer is D

Explanation

The correct answer is choice D: Choose a private room for the interview.

Choice D rationale:

Opting for a private room for the interview is essential when interacting with a client who uses a hearing aid. This choice helps minimize background noise and distractions, ensuring effective communication between the nurse and the client. Adequate lighting and minimizing auditory interference are crucial for clients with hearing difficulties.

Choice A rationale:

Sitting beside the client is a considerate approach, but it may not directly address the hearing aid user's needs. The focus should be on creating an optimal environment for communication, which includes minimizing auditory and visual obstacles.

Choice B rationale:

Speaking slowly and loudly to the client is not the most appropriate approach. While speaking clearly and facing the client is recommended, speaking loudly may distort sounds and hinder understanding for clients with hearing aids.

Choice C rationale:

Dimming the lights in the client's room is not necessary for addressing the needs of a client with a hearing aid. Adequate lighting is important for lip-reading and effective communication, especially for clients who rely on visual cues.

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A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

Nursing Test Bank

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