{"id":142430,"date":"2024-09-22T05:25:33","date_gmt":"2024-09-22T05:25:33","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=142430"},"modified":"2024-09-22T05:25:35","modified_gmt":"2024-09-22T05:25:35","slug":"a-nurse-is-planning-care-for-a-client-who-is-immobile","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2024\/09\/22\/a-nurse-is-planning-care-for-a-client-who-is-immobile\/","title":{"rendered":"A nurse is planning care for a client who is immobile."},"content":{"rendered":"\n<p>A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?<\/p>\n\n\n\n<p>A.<br>Use trochanter rolls beside the client&#8217;s legs.<\/p>\n\n\n\n<p>B.<br>Logroll the client every 4 hr.<\/p>\n\n\n\n<p>C.<br>Place the client&#8217;s arms at their side when turning them.<\/p>\n\n\n\n<p>D.<br>Cross the client&#8217;s ankles when lying supine.<\/p>\n\n\n\n<p><strong><mark style=\"background-color:rgba(0, 0, 0, 0)\" class=\"has-inline-color has-ast-global-color-6-color\">The Correct answer and Explanation is:<\/mark><\/strong><\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Correct Answer: A. <strong>Use trochanter rolls beside the client&#8217;s legs.<\/strong><\/h3>\n\n\n\n<p>Trochanter rolls are an important tool in managing immobility. They help maintain the proper alignment of a client&#8217;s legs, especially when lying in bed for extended periods. When a client is immobile, there is a high risk of developing complications such as contractures, misalignment of joints, and pressure injuries. Using trochanter rolls placed beside the legs helps prevent external rotation of the hips, which can lead to muscle strain and hip joint deformity. Proper positioning not only maintains body alignment but also prevents discomfort and long-term musculoskeletal issues.<\/p>\n\n\n\n<h4 class=\"wp-block-heading\">Explanation:<\/h4>\n\n\n\n<p><strong>Immobility-related complications<\/strong>: Clients who are immobile are at risk for a range of complications, including pressure ulcers, contractures, muscle atrophy, joint deformities, deep vein thrombosis (DVT), and respiratory issues. Therefore, it is essential for nurses to carefully plan interventions that minimize these risks.<\/p>\n\n\n\n<p><strong>Trochanter rolls<\/strong>: Trochanter rolls are cylindrical devices, often made from rolled-up towels or foam, placed from the client&#8217;s hips to just above the knees. Their primary function is to keep the hips and legs in a neutral position and prevent the external rotation of the legs, which can occur when a client is lying supine for long periods. Preventing external rotation is important for maintaining proper joint alignment and reducing the risk of deformities, such as hip contractures, that can result from prolonged immobility.<\/p>\n\n\n\n<p><strong>Other incorrect options<\/strong>:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>B. Logroll the client every 4 hr<\/strong>: While logrolling is an important technique used to maintain spinal alignment, especially for clients with spinal cord injuries, it is not appropriate for general immobility care. Additionally, turning and repositioning should be done every 2 hours, not every 4 hours, to prevent pressure ulcers.<\/li>\n\n\n\n<li><strong>C. Place the client&#8217;s arms at their side when turning them<\/strong>: This could impair the range of motion and lead to shoulder joint immobility. Proper arm positioning, with support to prevent contractures, is essential during turning.<\/li>\n\n\n\n<li><strong>D. Cross the client&#8217;s ankles when lying supine<\/strong>: This could increase pressure on the skin and lead to pressure injuries. Instead, legs should be positioned in alignment, with padding as necessary to prevent pressure sores.<\/li>\n<\/ul>\n\n\n\n<p>In conclusion, using trochanter rolls (Option A) is essential for maintaining proper leg alignment and preventing complications in immobile clients.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care? A.Use trochanter rolls beside the client&#8217;s legs. B.Logroll the client every 4 hr. C.Place the client&#8217;s arms at their side when turning them. D.Cross the client&#8217;s ankles when lying supine. [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-142430","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/142430","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=142430"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/142430\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=142430"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=142430"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=142430"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}