The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care?

Exercises to strengthen flexor muscles

Frequent position changes to reverse the contractures

Range-of-motion exercises to prevent worsening of contractures

Weight-bearing activities to stimulate joint relaxation

Answer and Explanation

The Correct Answer is C

C. Range-of-motion (ROM) exercises are essential in preventing contractures. These exercises aim to maintain or improve joint mobility by moving each joint through its full range of movement. They help stretch tight muscles and maintain flexibility, thereby preventing the progression of contractures.

A. While muscle strengthening exercises are beneficial for overall muscle health, in the context of contractures, the primary issue is the shortened and tight muscles. Strengthening exercises alone may not effectively address the contractures and could potentially exacerbate them.

B. Frequent repositioning is crucial to prevent and potentially reverse contractures. By changing the client's position regularly, pressure and stress on specific muscle groups are relieved, which can help prevent further tightening and promote flexibility. This intervention helps maintain joint mobility and prevents contractures from worsening.

D. Weight-bearing activities can be beneficial for joint health and bone density but may not directly address contractures. Contractures involve structural changes in the muscle-tendon unit rather than joint stiffness alone.

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Correct Answer is D

Explanation

D. When clients perceive that the knowledge or information being presented is beneficial to their health outcomes, they are more likely to be motivated to learn. Understanding how the knowledge can improve their health, manage their condition, or prevent complications provides intrinsic motivation to engage in learning activities.

A. While health literacy is important for understanding health information, having a high level of health literacy alone does not guarantee motivation to learn. Motivation to learn is more about personal engagement and perceived relevance of the information to one's own health and well-being.

B. While this may provide motivation for compliance with treatment plans or learning specific self-care tasks required for discharge, it does not necessarily translate to a strong motivation to learn beyond immediate needs related to discharge.

C. Formal education may contribute to overall cognitive abilities and learning skills, but it does not automatically translate into motivation to learn in a healthcare context. Motivation to learn is more about personal interest, perceived relevance, and understanding the benefits of acquiring new knowledge.

A. irregular wound borders B. distinct wound borders to plantar aspect of foot C. Patient reports 9 (0-10) scale to area D. minimal serous drainage E. +3 edema to the mid-calf

Correct Answer is ["A","E"]

Explanation

A. Venous ulcers often have irregular wound borders. This is due to the underlying venous hypertension and tissue breakdown, which can lead to irregular shapes of the ulcer.

E. Significant edema, particularly in the lower leg and ankle area (often graded as +2 or +3), is commonly associated with venous ulcers. Venous insufficiency leads to fluid accumulation in the tissues, resulting in edema.

B. This is less likely to be associated with a venous ulcer. Venous ulcers typically occur on the lower leg, particularly around the medial or lateral malleolus, rather than on the plantar aspect of the foot.

C. Severe pain, especially on a scale of 9 out of 10, is less typical of venous ulcers. Venous ulcers are usually associated with mild to moderate discomfort or pain, often described as aching or heaviness rather than severe pain.

D. Venous ulcers typically exhibit moderate to heavy serous drainage. This is due to the chronic inflammation and venous congestion that characterize venous insufficiency.

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The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care?

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Naxlex Comprehensive Predictor Exams

The nurse understands that motivation to learn is strongest when the client:

Correct Answer is D

Explanation

Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)

Correct Answer is ["A","E"]

Explanation

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