Difficulty: Medium
Average Score: 93%
Simulated
An unconscious client has left-sided paralysis. Which intervention should the nurse implement to best prevent foot drop?
Correct answer
D
Rationale
Pressure exerted on the soles of the feet when placed firmly against the footboard can impair circulation and lead to skin breakdown. Pillows provide inadequate support to prevent plantar flexion (foot drop). Performing ROM daily helps to maintain muscle tone, but it is inadequate to prevent plantar flexion when the client is in bed. Applying a foot boot brace provides good support to prevent foot drop. Removing and reapplying it every two hours allows for pressure reduction and promotes circulation.