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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This response acknowledges the patient's concern directly. It demonstrates empathy by indicating that the nurse understands the client's feelings of apprehension or anxiety about self-injection. By expressing understanding, the nurse shows empathy towards the client's emotional state.
B. This question shows concern for the patient's well-being and invites them to share their experiences. While it demonstrates a caring attitude, it focuses more on physical comfort rather than directly addressing the client's emotional concerns. While this question shows a caring attitude, it doesn't specifically convey empathy regarding the client's emotional state or concerns.
C. This question seeks to gather information about the client's symptoms. It shows clinical interest and concern for the client's physical condition, but it doesn't directly convey empathy towards their emotional state or concerns. This question is important for assessing the client's condition but does not demonstrate empathy towards their emotional experience or concerns.
D. This response seeks clarification on the client's request or statement. It shows willingness to understand the client's needs or preferences. While it shows attentiveness and willingness to assist, it doesn't directly convey empathy towards the client's emotional concerns or validate their feelings.
Correct Answer is B
Explanation
B. This response acknowledges the urgency of the situation and seeks clarification on the appropriate administration technique. It demonstrates readiness to follow through with the medical resident's directive while ensuring safe and effective administration.
A. This response reflects hesitation and a concern about administering a medication that the nurse did not prepare or is unfamiliar with. In a critical situation like a "code blue," timely administration of medications as directed by the medical team is crucial for patient outcomes.
C. Checking IV patency is important to ensure the medication can be administered properly. However, in a "code blue" situation where time is critical, this step might unnecessarily delay administration of the medication.
D. This response indicates willingness to follow the directive given by the medical resident. It also emphasizes the importance of documenting and obtaining proper orders after the immediate crisis has been addressed.
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