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    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

    A. Elevate the extremity above the heart: Elevating the leg helps reduce edema but does not prevent footdrop, which is caused by weakness or paralysis of the ankle dorsiflexor muscles following a CVA. Elevation alone will not maintain proper ankle positioning. B. Use padded splints: Padded footboards or splints help maintain the ankle in a neutral position and prevent plantar flexion, which reduces the risk of footdrop. This intervention supports proper alignment and promotes functional positioning during recovery. C. Reposition the client every 2 hr: Repositioning prevents pressure injuries and promotes circulation but does not specifically address the muscular imbalance that leads to footdrop. While important for overall care, it is not the primary intervention for this complication. D. Apply a sequential compression device: Sequential compression devices are used to prevent venous thromboembolism, not footdrop. They promote blood flow in the lower extremities but do not maintain ankle dorsiflexion or prevent contractures.

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