Question 1
Wrong Answer When teaching family members to position a hemiplegic patient in a supine position, the nurse should emphasize that:
Your Answer:
Contractures cannot be avoided and should be expected to develop within as few as 2 weeks
Rationale:
Placing a small pillow under the affected side decreases the risk of pain, joint contractures, and subluxation. Pillows may be used between extremities for comfort. The affected arm should be placed away from the body with the elbow extended and the palm up. The family should be encouraged to turn and position the patient diligently as a way to avoid contractures.
Question 2
Wrong Answer When positioning a patient in the prone position, to decrease lumbar vertebrae hyperextension and strain on the patient’s lower back, the nurse should:
Your Answer:
Place a small pillow under the patient’s shoulders, between the shoulder blades
Rationale:
A small pillow under the patient’s abdomen decreases lumbar vertebrae hyperextension and strain on the lower back. The pillow also helps improve breathing by reducing mattress pressure on the diaphragm. Patients may be placed in a variety of positions, including Fowler, side-lying, prone, or supine, if appropriate for the patient and the patient’s condition. Placing the arms over the patient’s head does not decrease lumbar vertebrae hyperextension or strain on the lower back. A pillow under the shoulder blades does not decrease strain on the lower back.
Question 3
Wrong Answer The nurse should teach a family member to reposition a patient more frequently when:
Your Answer:
Mobility begins to improve
Rationale:
The family should be taught to reposition the patient more frequently if joint mobility becomes impaired or worsens, pressure areas begin to appear, or the patient complains of discomfort. As mobility increases, the need to reposition the patient does not increase. Repositioning should be more frequent when the patient is experiencing discomfort. Repositioning needs are not affected by the presence of a urinary catheter.
Question 4
Correct Answer The nurse places a patient’s feet in therapeutic boots or splints to:
Your Answer:
Maintain the feet in dorsiflexion
Rationale:
The nurse places the patient’s feet in therapeutic boots or splints to maintain the feet in dorsiflexion and prevent plantar flexion contractures. Boots and splints are not applied to prevent pressure ulcers, but if they are too tight or placed incorrectly, pressure ulcers may result. While the therapeutic boots may promote patient comfort that is not the purpose of the device nor are they used to prevent contractures of the knee joints.
Question 5
Wrong Answer The nurse caring for a 70-year-old patient correctly plans to reposition the patient:
Your Answer:
Every 4 hours
Rationale:
Repositioning is recommended every 2 hours for older adult patients. Every 4 hours, every 6 hours, and once a shift are not recommendations supported by research.