A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?

Use trochanter rolls beside the client's legs.

Logroll the client every 4 hr.

Place the client's arms at their side when turning them.

Cross the client's ankles when lying supine.

Answer and Explanation

The Correct Answer is A

A. Use trochanter rolls beside the client's legs:

Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.

B. Logroll the client every 4 hr:

Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.

C. Place the client's arms at their side when turning them:

Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.

D. Cross the client's ankles when lying supine:

Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.

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Correct Answer is A

Explanation

A. Metabolic syndrome:

Metabolic syndrome is a cluster of conditions that increase the risk of cardiovascular disease, diabetes, and stroke. These conditions include elevated blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Individuals with metabolic syndrome are at an increased risk of developing cardiovascular disease.

B. Family history of alcohol use disorder:

While a family history of alcohol use disorder may contribute to various health issues, it is not a direct risk factor for cardiovascular disease. However, excessive alcohol consumption itself can contribute to cardiovascular problems.

C. Hypotension:

Hypotension, or low blood pressure, is generally not considered a risk factor for cardiovascular disease. In fact, low blood pressure is often associated with a reduced risk of certain cardiovascular events.

D. Participation in competitive sports:

Participation in competitive sports, in general, is not a risk factor for cardiovascular disease. In fact, regular physical activity is often recommended for cardiovascular health. However, the specific type and intensity of sports activities, as w

A. Exercise 1 hr before bedtime. B. Drink a cup of hot cocoa before bedtime. C. Eat a light carbohydrate snack before bedtime.. D. Take a 30-min nap daily.

Correct Answer is C

Explanation

A. Exercise 1 hr before bedtime:

While regular exercise is beneficial for overall health, exercising close to bedtime may actually interfere with sleep. It is better to exercise earlier in the day

B. Drink a cup of hot cocoa before bedtime:

While a warm beverage like hot cocoa may be soothing for some individuals, it contains caffeine, which can interfere with sleep. Caffeine consumption, especially close to bedtime, is generally discouraged for those experiencing insomnia.

C. Eat a light carbohydrate snack before bedtime: can help promote sleep. Carbohydrates increase the availability of tryptophan, an amino acid that contributes to the production of serotonin (a neurotransmitter associated with relaxation and sleep).However, the snack should be light and not too heavy to avoid discomfort or indigestion during sleep

D. Take a 30-min nap daily:

Taking a 30-minute nap daily may not be the most effective intervention for insomnia. Napping during the day can interfere with nighttime sleep, especially if it's taken too close to bedtime. Short naps earlier in the day are generally recommended if needed.

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