A nurse has been assigned four patients of which one of the patients is completely immobile. Which complication should the nurse expect as a result of immobility? (Select all that apply.)
Pressure ulcers
Contractures of the extremities
development of deep vein thrombosis
Crackles in the lungs
Polyuria
Diarrhea
Correct Answer : A,B,C,D
A. Immobile patients are at high risk for developing pressure ulcers due to prolonged pressure on the skin, leading to tissue breakdown.
B. Contractures of the extremities can occur as a result of muscle atrophy and lack of movement in immobilized patients.
C. Immobility increases the risk of venous stasis, leading to the development of deep vein thrombosis (DVT).
D. Crackles in the lungs may result from immobility due to fluid accumulation or atelectasis, particularly in patients who are not moving or changing position frequently.
E. Polyuria is not commonly associated with immobility.
F. Diarrhea is not commonly associated with immobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F","G"]
Explanation
The increase in axillary temperature to 100.5° F is significant and could indicate an infection or other inflammatory process. The heart rate has increased to 105/min, which, along with the reported symptoms of heat intolerance, nervousness, and irregular heartbeat during exercise, may suggest an endocrine disorder such as hyperthyroidism. The significant weight loss of 20 pounds in a month without changes in diet or physical activity is also concerning and warrants further investigation. The patient's history of having a bowel movement after every meal could be related to the reported diarrhea and should be explored further.
Correct Answer is C
Explanation
A. Stridor is a high-pitched sound typically heard in cases of airway obstruction.
B. Crackles are discontinuous sounds often associated with fluid in the alveoli.
C. Rhonchi are low-pitched, continuous sounds with a snoring quality, usually caused by secretions in the larger airways.
D. Wheezing is a high-pitched, continuous sound associated with narrowed airways.
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