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A home care nurse is assisting with the care of a client.

Exhibits
The nurse is planning to focus data collection based on the general findings. Select 5 complications the client is at risk for.

Urinary stasis

Calcium resorption

Contractures

Hypocalcemia

Hypertension

Diarrhea

Pressure ulcer

Atelectasis

Answer and Explanation

Correct Answer : A,B,C,G,H

Rationale:
• Urinary stasis: Immobility slows bladder emptying and ureteral flow, increasing residual urine. This promotes bacterial growth and risk of urinary tract infection. MS clients with decreased mobility are especially vulnerable.

• Calcium resorption: Bone demineralization occurs during prolonged immobility. Without weight-bearing, calcium is released from bone into the bloodstream, raising serum calcium and weakening bones.

• Contractures: Lack of movement leads to shortening and stiffening of muscles and joints. Over time, joints lose flexibility, especially if the client remains curled in one position.

• Hypocalcemia: The client is more likely to develop hypercalcemia due to calcium resorption from bones. There's no evidence of low calcium symptoms like tetany or numbness.

• Hypertension: The client's vital signs are within normal range. Immobility may reduce cardiac output over time, but it does not typically cause high blood pressure.

• Diarrhea: Immobility usually causes constipation due to slowed peristalsis. There's no report of active GI symptoms or triggers for diarrhea in this case.

• Pressure ulcer: Continuous pressure on one area reduces capillary blood flow. This leads to tissue ischemia and skin breakdown, especially over bony prominences like the hip and shoulder.

• Atelectasis: Lying on one side restricts lung expansion, and refusal to change positions impairs ventilation. This can cause alveolar collapse and decreased oxygen exchange.

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

Explanation

Rationale:

A. Plan a time at the end of the shift to document nursing interventions: Delaying documentation until the end of the shift risks forgetting important details and compromises accuracy. Best practice is to document interventions and observations as close to the time of care as possible to ensure timely, complete records.

B. Delegate collection of vital signs to the assistive personnel on the team: Delegating routine tasks like vital sign collection allows the nurse to focus on complex responsibilities requiring clinical judgment. This supports time efficiency while ensuring client care needs are still met promptly.

C. Make a priority to-do list at the beginning of the shift: Creating a task list based on client acuity and scheduled interventions helps the nurse remain focused and organized. Prioritizing tasks early supports decision-making and improves workflow throughout the shift.

D. Keep track of how long it takes to complete certain tasks: Monitoring time spent on different tasks helps identify inefficiencies and allows the nurse to adjust workflow. This self-awareness supports better time management in future shifts.

E. Complete activities with one client before moving to another client: Focusing on one client at a time may lead to inefficiencies and delayed care for other clients. Nurses should cluster care and prioritize based on client needs, rather than adhering rigidly to completing all care for one client before moving on.

A. Deep palpation B. Light palpation C. Auscultation D. Inspection

Correct Answer is D,C,B,A

Explanation

Rationale:

D. Inspection: This is always the first step in any physical assessment. The nurse observes the abdomen for contour, symmetry, skin condition, and any visible movements or abnormalities.

C. Auscultation: Performed before palpation to avoid altering bowel sounds. Listening to bowel and vascular sounds provides key information about gastrointestinal activity and blood flow.

B. Light palpation: Conducted next to assess for tenderness, guarding, and superficial masses. This helps ensure client comfort and provides a baseline before deeper pressure is applied.

A. Deep palpation: Done last to evaluate organ size, deep masses, or tenderness. It can stimulate peristalsis or discomfort, so it follows the less invasive steps to minimize changes to assessment findings.

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A home care nurse is assisting with the care of a client. Exhibits The nurse is planning to focus data collection based on the general findings. Select 5 complications the client is at risk for.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is D,C,B,A

Explanation

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A home care nurse is assisting with the care of a client.

Exhibits
The nurse is planning to focus data collection based on the general findings. Select 5 complications the client is at risk for.