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    Ati rn adult medical surgical 2023 proctored exam

    A nurse is planning care for a client who has had a recent cerebrovascular accident (CVA). Which of the following actions should the nurse include in the plan of care to decrease the client's risk for footdrop?

    Explanation & Rationale

    Rationale: A. Apply a sequential compression device: A sequential compression device (SCD) is used to prevent deep vein thrombosis (DVT), not foot drop. It does not provide the necessary support for preventing foot drop, which results from muscle weakness or paralysis after a CVA. B. Use padded splints: Padded splints help maintain the foot in a neutral position, which is essential in preventing foot drop. Foot drop occurs due to weakness of the dorsiflexor muscles, and splints can prevent the foot from falling into an abnormal position, reducing the risk of deformities. C. Elevate the extremity above the heart: Elevating the extremity above the heart is typically done to reduce edema, not to prevent foot drop. While elevating the limb can help with swelling, it does not address the muscle weakness that causes foot drop in post-CVA patients. D. Reposition the client every 2 hr: Repositioning the client every 2 hours is important for preventing pressure ulcers and promoting circulation. However, it is does not prevent foot drop, which requires targeted interventions such as splints or exercises to maintain proper foot positioning.

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