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A 46-year-old male was injured in an industrial accident and has suffered a fractured left leg and left wrist. His wrist is treated with a cast and the leg is placed in skeletal traction. Because of immobilization of his leg, the patient is at risk for (Select all that apply.)

venous thrombosis.

pressure injury.

foot drop.

generalized edema.

constipation.

Answer and Explanation

Correct Answer : A,B,C,E

A. Venous thrombosis.

Immobility increases the risk of deep vein thrombosis (DVT) due to venous stasis in the lower extremities.

B. Pressure injury.

Prolonged immobility and pressure on bony prominences elevate the risk of skin breakdown and ulcers.

C. Foot drop.

Prolonged immobilization without proper foot support can cause plantar flexion contractures, known as foot drop.

D. Generalized edema.

While localized edema near the injury is expected, generalized edema is not typically associated with traction.

E. Constipation.

Decreased physical activity and possible pain medications (like opioids) contribute to constipation in immobilized patients.

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Correct Answer is ["A","B","C"]

Explanation

A. Muscle atrophy

Lack of movement leads to wasting of muscle tissue over time, a common consequence of immobility.

B. Venous pooling

Immobility causes reduced venous return, leading to venous stasis or pooling, increasing the risk of DVT.

C. Urinary stasis

Lying flat for extended periods contributes to bladder emptying issues, increasing risk for UTIs and renal calculi.

D. Increased depth of respirations

Immobility leads to shallow breathing and reduced lung expansion, not deeper respirations.

E. Increased metabolic rate

Immobility generally results in a decreased metabolic rate due to lower energy needs.

A. extend one leg and allow the client to slide down the leg to the floor. B. move both feet together when the client begins to fall C. wrap both arms around the client's arm and shoulders D. protect the client's extremities while lowering them to the floor.

Correct Answer is A

Explanation

A. Extend one leg and allow the client to slide down the leg to the floor.

It helps to control the fall, protects the client from injury, and allows the nurse to safely guide the client to the floor without using excessive force.

B. Move both feet together when the client begins to fall.

Keeping the feet together reduces stability and increases the risk of both the client and nurse falling.

C. Wrap both arms around the client's arm and shoulders.

This could cause injury to the client’s upper body and doesn't provide support for a safe fall.

D. Protect the client's extremities while lowering them to the floor.

While protecting extremities is important, the nurse’s primary action should be to use proper body mechanics (like extending one leg) to safely lower the client.

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A 46-year-old male was injured in an industrial accident and has suffered a fractured left leg and left wrist. His wrist is treated with a cast and the leg is placed in skeletal traction. Because of immobilization of his leg, the patient is at risk for (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","C"]

Explanation

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Correct Answer is A

Explanation

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