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ANCC Medical-Surgical Nursing Exam Prep

Category - Medical-Surgical Nursing Practice Test

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Contractures are among the most serious long-term complications of severe burns. If a burn is located on the upper torso, which nursing measure would be least effective to help prevent contractures?
  1. Changing the location of the bed, the TV set, or both, daily
  2. Encouraging the client to chew gum and blow up balloons
  3. Avoiding the use of a pillow for sleep or placing the head in a position of hyperextension
  4. Helping the client to rest in the position of maximal comfort
Explanation
Answer - D - Helping the client to rest in the position of maximal comfort would be most effective to help prevent contractures. Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. Pain can immobilize a client as he seeks the position where he finds less pain and provides maximal comfort, but this approach can lead to contracture deformities and other complications.
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