Difficulty: Medium
Average Score: 67%
Simulated
Passage / Scenario
A nurse is caring for a client who had a spinal cord injury and has paraplegia. The client is alert and oriented.The client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities are performed once each day.On Day 5, the clientÔÇÖs feet are warm, pedal pulses are 2+ bilaterally, plantar flexion contractures are noted bilaterally, and the left heel has a 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, with skin intact.Which findings require intervention by the nurse?
Correct answer
A,B,C
Rationale
Correct Answer: A, B, C
Rationale:
A: Passive range-of-motion exercises to lower extremities performed once each day are important to prevent contractures and maintain joint mobility in immobile patients.
B: Left heel with nonblanchable erythema indicates a pressure injury or early sign of skin breakdown, requiring intervention to prevent further damage.
C: Plantar flexion contractures can lead to foot drop and impair mobility, so early intervention is necessary to prevent complications.
Summary:
D: Pedal pulses 2+ bilaterally indicate good circulation, which does not require immediate intervention.
E, F, G: Insufficient information provided to determine if these findings require immediate intervention.
Rationale:
A: Passive range-of-motion exercises to lower extremities performed once each day are important to prevent contractures and maintain joint mobility in immobile patients.
B: Left heel with nonblanchable erythema indicates a pressure injury or early sign of skin breakdown, requiring intervention to prevent further damage.
C: Plantar flexion contractures can lead to foot drop and impair mobility, so early intervention is necessary to prevent complications.
Summary:
D: Pedal pulses 2+ bilaterally indicate good circulation, which does not require immediate intervention.
E, F, G: Insufficient information provided to determine if these findings require immediate intervention.