A home care nurse is caring for a client who has advanced multiple.
sclerosis.
Nurses' Notes.
2 weeks ago:Today: The client reports depression is increasing as they are unable to. participate in activities they once enjoyed because of the.
advancing multiple sclerosis.
Even getting up to the wheelchair.
is "just too much" for them.
The home health aide reported client will not permit turning. position changes.
The client states, "I can only get comfortable.
curled on my left side.
I'm not moving.". Vital Signs.
Today:Temperature 36.8° C (98.2° F). Heart rate 80/min.
Respiratory rate 20/min.
BP 116/76 mm Hg. Client Education.
1 week ago:Educated the client about the importance of getting out of bed.
changing positions in bed.
Client stated, ""l try.". Select the 5 complications the client is at risk for.
Contractures.
Calcium resorption.
Hypocalcemia.
Diarrhea.
Urinary stasis.
Correct Answer : A,E
Choice A rationale:
Contractures are a risk for this client due to the lack of movement and constant positioning on one side. Contractures occur when the muscles, tendons, or ligaments shorten and tighten, limiting range of motion and flexibility. This can be a result of prolonged immobility or lack of use of the muscles.
Choice B rationale:
Calcium resorption is not a risk for this client. Calcium resorption refers to the process where bone tissue is broken down and calcium is released into the bloodstream. This process is not directly related to immobility or multiple sclerosis.
Choice C rationale:
Hypocalcemia, or low calcium levels in the blood, is also not a direct risk for this client. While immobility can lead to bone loss over time, it does not directly cause hypocalcemia.
Choice D rationale:
Diarrhea is not a risk for this client based on the information provided. Diarrhea can be a symptom of many conditions but there is no indication in the scenario that this client is at risk.
Choice E rationale:
Urinary stasis is a risk for this client due to their immobility. When a person is immobile, urine can pool in the bladder, creating an environment where bacteria can grow, potentially leading to urinary tract infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: b. “Tighten your muscles before relaxing them when using muscle relaxation techniques.”
Rationale for Choice B: Progressive Muscle Relaxation (PMR) is a well-established technique used in stress management and relaxation therapy. It involves systematically tensing and then relaxing specific muscle groups throughout the body. By tensing the muscles first, individuals can become more aware of the contrast between tension and relaxation, thereby enhancing the relaxation response. This heightened awareness helps individuals recognize and release muscular tension more effectively, leading to deeper relaxation and stress relief.
Rationale for Choice A: Choice A suggests talking to someone admired as the first step in using mindfulness techniques to relax. However, mindfulness practices typically involve cultivating awareness of the present moment without judgment. While seeking support from others may be beneficial for stress management, it is not a foundational aspect of mindfulness practice. Mindfulness often entails individual introspection and observation of one's thoughts, feelings, and bodily sensations.
Rationale for Choice C: Choice C recommends breathing in through the mouth and out through the nose during deep breathing exercises. While there are various breathing techniques utilized in stress management, the typical recommendation for deep breathing exercises is to inhale through the nose and exhale through the mouth. Nasal breathing helps regulate the flow of air, optimizes oxygen exchange, and activates the parasympathetic nervous system, promoting relaxation and stress reduction.
Rationale for Choice D: Choice D proposes imagining a stimulating situation when practicing guided imagery. However, guided imagery is a relaxation technique that involves creating vivid mental images of calming and tranquil scenes, such as a serene beach or peaceful forest. The purpose of guided imagery is to evoke positive emotions, reduce stress, and induce a state of deep relaxation. Imagining stimulating situations may have the opposite effect, potentially increasing arousal and tension rather than promoting relaxation.
In summary, while all choices may have some relevance to stress management, Choice B is the most appropriate as it aligns with the established technique of Progressive Muscle Relaxation. Choices A, C, and D deviate from widely recognized relaxation methods and are therefore considered incorrect in this context.
Correct Answer is A
Explanation
The correct answer is choice a. Maternal hypoglycemia.
Choice A rationale:
Maternal hypoglycemia can lead to decreased glucose availability for the fetus, which can result in fetal bradycardia due to reduced energy supply.
Choice B rationale:
Fetal anemia typically causes fetal tachycardia rather than bradycardia, as the fetus compensates for the lack of oxygen-carrying capacity by increasing the heart rate.
Choice C rationale:
Chorioamnionitis, an infection of the fetal membranes, usually causes fetal tachycardia due to the inflammatory response and fever.
Choice D rationale:
Maternal fever is more likely to cause fetal tachycardia rather than bradycardia, as the increased maternal temperature can lead to an increased fetal heart rate.
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