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.
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Related Questions
Correct Answer is C
Explanation
A. Documenting the findings is also important, but it should be noted as Mongolian blue spots rather than vernix caseosa.
B. Reporting the parents to the department of children and families would be inappropriate, as Mongolian blue spots are not a sign of abuse or neglect
C. Mongolian blue spots, also known as congenital dermal melanocytosis, are benign skin markings that are usually present at birth or appear shortly after. They are more common in individuals with darker skin tones and are not indicative of any disease or disorder.
D. While it is always prudent to notify the healthcare provider of any findings, in the case of Mongolian blue spots, no immediate medical intervention is necessary.
Correct Answer is B
Explanation
A. Clubbing is a sign of chronic hypoxia, not acute hypoxemia.
B. Cyanosis, a bluish discoloration of the skin and mucous membranes, is an indicator of acute hypoxemia.
C. Palpating for decreased tactile fremitus is related to fluid or air in the lungs, not specifically hypoxemia.
D. Auscultation for adventitious breath sounds can reveal respiratory issues but does not directly confirm hypoxemia.
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