Nokea
The nurse is planning a staff development conference regarding contractures. Which of the following information should the nurse include? Select all that apply.
- A. Range-of-motion exercises of the extremities help prevent contractures.
- B. Splinting the extremities may increase the risk of contractures.
- C. Too many pillows under the head may cause a neck flexion contracture.
- D. Using multiple staff members to reposition a client may prevent a contracture.
- E. Contractures after a hip arthroplasty can be prevented with an abduction pillow.
Correct Answer: A, C, E
Rationale: Range-of-motion exercises maintain joint flexibility and help prevent contractures. Too many pillows under the head can cause the neck to remain flexed, increasing the risk of a flexion contracture. An abduction pillow keeps the legs properly aligned and prevents adduction contractures after hip surgery.
You may also like to solve these questions
The nurse educates a client about the application of a plaster cast to a fractured radius. Which of the following statements by the client would require follow-up?
- A. If my arm feels itchy, I can use a hair dryer on the cool setting for relief.'
- B. I can reduce my arm's swelling by elevating it with a pillow.'
- C. I should be okay to shower with my cast.'
- D. It will be normal for me to feel heat after the cast is applied.'
Correct Answer: C
Rationale: Showering with a plaster cast risks wetting it, leading to breakdown or infection, requiring follow-up. Cool air for itching, elevation for swelling, and initial heat from cast setting are appropriate.
The nurse is caring for a client who is bedbound. Which intervention should the nurse implement to reduce this client's risk of developing contractures?
- A. Apply sequential compression devices to the lower extremities
- B. Perform passive range of motion exercises
- C. Obtain a specialty low-air loss mattress
- D. Turn the client every two hours
Correct Answer: B
Rationale: Passive range of motion exercises maintain joint mobility and prevent contractures in bedbound clients. Compression devices prevent clots, mattresses reduce pressure ulcers, and turning aids skin but not primarily joints.
The nurse is assessing a client with Paget's disease. Which of the following would be an expected finding?
- A. Bone deformities
- B. Berry aneurysm
- C. Heberden's nodes
- D. Janeway lesions
Correct Answer: A
Rationale: Paget's disease causes excessive bone remodeling, leading to deformities like bowing or enlargement. Berry aneurysms, Heberden's nodes, and Janeway lesions are unrelated to this condition.
The nurse is caring for a client who sustained a fractured tibia and fibula and has a cast applied to the extremity. Which of the following findings would indicate the client has developed compartment syndrome?
- A. The development of petechiae over the chest
- B. A new onset of dyspnea and chest pain
- C. Severe pain that is unrelieved by an opioid analgesic
- D. Localized bone pain with a fever
Correct Answer: C
Rationale: Severe, unrelieved pain is a hallmark of compartment syndrome, caused by increased pressure within a muscle compartment compromising circulation and nerve function. Petechiae and dyspnea suggest fat embolism, and bone pain with fever may indicate infection.
The nurse is discharging a client following knee arthroplasty. Which of the following information should the nurse include in discharge teaching?
- A. After this procedure, you will use a wheelchair to get around.'
- B. You will need to resume your prescribed anticoagulants.'
- C. Placing a pillow under your knee will help with the pain.'
- D. You may ice the site for one hour at a time.'
Correct Answer: B
Rationale: Resuming prescribed anticoagulants is crucial to prevent deep vein thrombosis after knee arthroplasty. A wheelchair may not be necessary, pillows under the knee can cause flexion contractures, and icing for one hour at a time risks skin damage; 15-20 minutes is safer.