Which intervention should the nurse implement to prevent contractures in a patient who is immobile?
Encouraging frequent changes in position.
Applying heat packs to stiff joints.
Administering muscle relaxants.
Using soft restraints to immobilize the extremities.
The Correct Answer is A
Encouraging frequent changes in position helps prevent contractures by promoting joint mobility and preventing prolonged pressure on specific areas.
Incorrect choices:
b. Applying heat packs to stiff joints may provide temporary relief but does not address the underlying issue of immobility or prevent contractures.
c. Administering muscle relaxants is not the standard intervention for preventing contractures. The focus should be on promoting mobility and range of motion exercises.
d. Using soft restraints to immobilize the extremities is not an appropriate intervention for preventing contractures. Restraints should only be used when necessary and as a last resort, considering the patient's safety and autonomy.
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Related Questions
Correct Answer is A
Explanation
Encouraging frequent ambulation and leg exercises helps prevent venous stasis and promotes blood flow, reducing the risk of venous thromboembolism (VTE) in immobile patients.
Incorrect choices:
b. Administering sedatives can increase the risk of VTE by promoting immobility and reducing leg movement. It is not an appropriate preventive measure.
c. Applying cold compresses to the lower extremities does not directly prevent VTE. Warm compresses may be used to promote circulation, but prevention strategies primarily focus on mobilization and blood flow promotion.
d. Limiting fluid intake does not directly prevent VTE. Adequate hydration should be maintained to promote circulation and prevent complications such as dehydration and urinary tract infections.
Correct Answer is C
Explanation
Supporting bony prominences with pillows or foam pads helps distribute pressure and reduces the risk of pressure ulcers in patients with limited mobility.
Incorrect choices:
a. Placing the patient in a prone position for extended periods increases the risk of pressure ulcers, especially on the anterior aspects of the body.
b. Elevating the head of the bed to 90 degrees can lead to shearing forces and increase the risk of pressure ulcers.
d. Encouraging the patient to sit in a chair for long periods without adequate repositioning can also increase the risk of pressure ulcers.
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