A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?

Confusion

Blurred vision

Diarrhea

Polyuria

Answer and Explanation

The Correct Answer is A

Confusion can be a sign of delirium, which is a common complication of immobility in older adults due to sensory deprivation, sleep disturbance, medication side effects, or dehydration. The nurse should assess for other causes of confusion, such as infection or hypoxia, and implement interventions to prevent or treat delirium.

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Correct Answer is C

Explanation

The nurse should expect disequilibrium with movement if the client has impaired function of the vestibulocochlear nerve, as this nerve is responsible for hearing and balance. Deviation of the tongue from midline indicates impairment of the hypoglossal nerve (cranial nerve XII), loss of peripheral vision indicates impairment of the optic nerve (cranial nerve II), and inability to smell indicates impairment of the olfactory nerve (cranial nerve I).

A. Drink 3 L of fluids daily. B. Wipe the perineal area from front to back after urinating. C. Drink low-fructose cranberry juice. D. Take a warm bubble bath daily. E. Void every 6 hr during the day.

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

Explanation

Drinking plenty of fluids helps flush out bacteria from the urinary tract and prevent urinary stasis . Wiping from front to back prevents contamination of the urethra with fecal bacteria . Cranberry juice may prevent bacterial adherence to the bladder wall and lower the pH of urine, making it less favorable for bacterial growth . However, cranberry juice should be low in fructose because high-fructose corn syrup may increase bacterial growth . Bubble baths may irritate the urethra and increase the risk of infection . Voiding frequently (every 2 to 3 hours) prevents urinary stasis and bacterial growth .

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A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?

Correct Answer is C

Explanation

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

Explanation

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