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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 A

Explanation

Rationale:

A. Instruct the client to lie supine with his knees flexed: Flexing the knees reduces tension on the abdominal wall and helps prevent further protrusion of abdominal contents. This position is critical for stabilizing the evisceration while awaiting surgical intervention.

B. Cover the wound with a dry sterile dressing: Using a dry dressing can cause the exposed organs to dry out and adhere to the material, increasing the risk of tissue damage. A moist sterile dressing is needed to protect and preserve the protruding tissues.

C. Position the client in semi-Fowler's position: Elevating the head of the bed increases intra-abdominal pressure and can worsen evisceration. This position should be avoided to prevent strain on the open surgical site.

D. Cover the wound with a transparent dressing: Transparent dressings are not suitable for eviscerations because they do not provide adequate moisture or protection for exposed organs. A sterile saline-moistened dressing is required to maintain tissue integrity.

A. "You should appoint a family member as your health care surrogate." B. "Once you have completed a living will, it cannot be changed." C. "You will need an attorney to appoint a health care surrogate." D. "Your health care surrogate will make decisions on your behalf if you are unable."

Correct Answer is D

Explanation

Rationale:

A. "You should appoint a family member as your health care surrogate.": While clients may choose a family member, they are not required to do so. The decision is personal, and clients can appoint anyone they trust, regardless of relation, to serve as their health care surrogate.

B. "Once you have completed a living will, it cannot be changed.": A living will can be revised or revoked at any time by the client as long as they remain mentally competent. Clients retain the right to alter their advance directives based on changes in preferences or health status.

C. "You will need an attorney to appoint a health care surrogate.": Appointing a health care surrogate does not require an attorney. Most states allow individuals to complete this process using standardized forms and witnesses, without the need for legal representation.

D. "Your health care surrogate will make decisions on your behalf if you are unable.": A health care surrogate is authorized to make medical decisions when the client is no longer capable of doing so. This ensures that the client’s preferences are respected even if they become incapacitated.

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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

A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client about advanced directives. Which of the following information should the nurse include?

Correct Answer is D

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.