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. Congruent communication occurs when verbal and nonverbal messages are consistent with each other. In the scenario, the nurse's direct eye contact, pleasant expression, and verbal statement ("The colostomy looks good") appear to be aligned and supportive of each other. This demonstrates congruence in communication, where both verbal and nonverbal cues are reinforcing a positive message to the client.

A. Introductory communication typically refers to the initial phase of interaction where the nurse establishes rapport, introduces themselves, and sets the tone for the interaction. This does not directly apply to the nurse's actions described in the scenario of changing a client's colostomy bag.

B. Noncongruent communication occurs when there is a mismatch between verbal and nonverbal messages. In this scenario, the nurse makes direct eye contact, has a pleasant expression, and verbally reassures the client that "the colostomy looks good." If these nonverbal cues (eye contact, pleasant expression) are not aligned with the verbal message (reassuring statement), it would be noncongruent communication. However, based on the scenario, it seems the nurse's nonverbal cues (eye contact, pleasant expression) support the verbal message, so this option is less likely.

C. Nonverbal communication includes gestures, facial expressions, eye contact, body language, and tone of voice. In the scenario described, the nurse demonstrates nonverbal communication by making direct eye contact and having a pleasant expression while interacting with the client. Nonverbal communication is an important aspect of nursing care as it conveys empathy, reassurance, and attentiveness to the client's needs.

A. ‘I know how you feel. I've lost people close to me too." B. "Your mother is still living to give you support." C. "You will never be the same. This will make you stronger" D. 1 am sad for you. I'll stay with you for a while if you need to talk."

Correct Answer is D

Explanation

D. It acknowledges the client's emotions by expressing empathy ("I am sad for you") and offering support ("I'll stay with you for a while if you need to talk"). This approach validates the client's grief, acknowledges the significance of their loss, and offers the opportunity for the client to express their feelings if they choose to do so.

A. This can inadvertently minimize the client's grief by suggesting that the nurse's losses are comparable or that the nurse understands the client's emotions completely.

B. It does not acknowledge or validate the client's current emotions and may overlook the complex feelings associated with losing a parent.

C. This response, although intended to provide encouragement, may not be therapeutic in the context of immediate grief. It suggests a future positive outcome from the loss without acknowledging the client's current emotional pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse makes direct eye contact and has a pleasant expression on her face when changing a client's colostomy bag. The nurse tells the client, "The colostomy looks good." What type of communication is the nurse demonstrating?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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