A nurse is planning care for a client who has had a recent cerebrovascular accident (CVA). Which of the following actions should the nurse include in the plan of care to decrease the client's risk for footdrop?
Elevate the extremity above the heart.
Use padded splints.
Reposition the client every 2 hr.
Apply a sequential compression device.
The Correct Answer is B
A. Elevate the extremity above the heart: Elevating the leg helps reduce edema but does not prevent footdrop, which is caused by weakness or paralysis of the ankle dorsiflexor muscles following a CVA. Elevation alone will not maintain proper ankle positioning.
B. Use padded splints: Padded footboards or splints help maintain the ankle in a neutral position and prevent plantar flexion, which reduces the risk of footdrop. This intervention supports proper alignment and promotes functional positioning during recovery.
C. Reposition the client every 2 hr: Repositioning prevents pressure injuries and promotes circulation but does not specifically address the muscular imbalance that leads to footdrop. While important for overall care, it is not the primary intervention for this complication.
D. Apply a sequential compression device: Sequential compression devices are used to prevent venous thromboembolism, not footdrop. They promote blood flow in the lower extremities but do not maintain ankle dorsiflexion or prevent contractures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decrease intake of fresh fruits or vegetables: Clients receiving radiation therapy do not need to reduce intake of fresh fruits or vegetables, as these foods provide essential nutrients that support healing and overall health. Nutrition should be maintained to promote tissue repair and immune function.
B. Decrease time spent outdoors: Radiation therapy can make the skin more sensitive to sunlight, increasing the risk of burns or irritation. Clients should limit sun exposure, wear protective clothing, and use sunscreen to protect areas receiving radiation.
C. Limit engaging in sport activities that can cause bruising: While bleeding risk is more relevant to clients receiving chemotherapy that affects platelet counts, radiation therapy alone does not require limiting physical activities that may cause bruising. Normal exercise is generally encouraged as tolerated.
D. Limit socializing in large crowds: Radiation therapy does not directly suppress the immune system, so avoiding crowds is not necessary unless the client is also receiving immunosuppressive treatment.
Correct Answer is B
Explanation
A. Contact the client's power of attorney to sign the consent: Involving a power of attorney is not necessary if the client is competent and understands the procedure. The client has the legal right to consent, even if they are unable to read or write.
B. Allow the client to sign the consent with an X: A client who cannot write can legally indicate consent by marking an X on the consent form, as long as they demonstrate understanding of the procedure. This ensures the client’s autonomy and meets legal requirements for informed consent.
C. Notify the surgical team that the client is unable to sign the consent: Simply notifying the team does not address the legal requirement for documented consent. The nurse should facilitate a method for the client to provide valid consent, such as using an X.
D. Inform a family member of the need to sign the consent: Family members should only sign if the client is legally incapable of consenting. Since the client understands the procedure, their own consent is valid, and involving family unnecessarily could violate patient autonomy.
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