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?

Apply a sequential compression device.

Use padded splints.

Elevate the extremity above the heart.

Reposition the client every 2 hr.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Apply a sequential compression device: A sequential compression device (SCD) is used to prevent deep vein thrombosis (DVT), not foot drop. It does not provide the necessary support for preventing foot drop, which results from muscle weakness or paralysis after a CVA.

B. Use padded splints: Padded splints help maintain the foot in a neutral position, which is essential in preventing foot drop. Foot drop occurs due to weakness of the dorsiflexor muscles, and splints can prevent the foot from falling into an abnormal position, reducing the risk of deformities.

C. Elevate the extremity above the heart: Elevating the extremity above the heart is typically done to reduce edema, not to prevent foot drop. While elevating the limb can help with swelling, it does not address the muscle weakness that causes foot drop in post-CVA patients.

D. Reposition the client every 2 hr: Repositioning the client every 2 hours is important for preventing pressure ulcers and promoting circulation. However, it is does not prevent foot drop, which requires targeted interventions such as splints or exercises to maintain proper foot positioning.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Provide the client with high-protein meals: High-protein meals are important for tissue repair and healing, especially in clients at risk for pressure ulcers. Adequate nutrition, including protein, is essential to promote skin integrity and prevent further skin breakdown.

B. Gently massage the reddened areas: Massaging reddened areas can increase tissue damage and worsen skin breakdown. Instead of massaging, the nurse should relieve pressure on those areas to prevent further injury.

C. Place the client in a supine position: The supine position might increase pressure on the client's scapulae. It is better to reposition the client to relieve pressure from affected areas, ideally by turning them to their side or using pillows to offload pressure.

D. Use hot water when cleaning the client's skin: Hot water can dry and irritate the skin, worsening the condition. The nurse should use lukewarm water and gentle, non-irritating products to clean the skin and prevent further damage.

A. Tilt the client's head with the affected ear facing up. B. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal. C. Point the tip of the syringe toward the top of the ear canal. D. Use cool fluid for irrigation.

Correct Answer is C

Explanation

Rationale:

A. Tilt the client's head with the affected ear facing up: Tilting the head with the affected ear facing up is not recommended. The head should be tilted so the affected ear faces downward, allowing the irrigating fluid to drain out easily and reducing the risk of injury or discomfort.

B. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal: The syringe tip should not be inserted deeply into the ear canal. Inserting the tip too far can cause trauma to the ear canal or eardrum. The tip should be placed at the opening of the ear canal to allow for safe irrigation.

C. Point the tip of the syringe toward the top of the ear canal: The syringe should be aimed toward the top or posterior wall of the ear canal, not directly at the eardrum. This allows the fluid to flow along the ear canal and helps prevent injury to the eardrum while effectively flushing the ear.

D. Use cool fluid for irrigation: Cool fluid can cause dizziness or discomfort for the client. It is better to use warm, body-temperature fluid during ear irrigation to ensure the client remains comfortable and to avoid any adverse effects.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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