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

This is because the client is experiencing bradycardia, which is a slow heart rate of less than 60/min. Bradycardia can cause decreased cardiac output, which can lead to symptoms such as tremors, fainting, dizziness, chest pain, shortness of breath, and hypotension. Some causes of bradycardia are sinus node dysfunction, atrioventricular block, medication side effects, hypothyroidism, hypothermia, and increased vagal tone.

The nurse should anticipate administering atropine sulfate, which is an anticholinergic drug that blocks the action of the vagus nerve on the heart and increases the heart rate and conduction. Atropine sulfate is the first-line drug for symptomatic bradycardia and can be given intravenously or intramuscularly. The nurse should monitor the client's vital signs, cardiac rhythm, and response to the medication. The nurse should also prepare for other interventions, such as transcutaneous pacing or permanent pacemaker insertion, if atropine sulfate is ineffective or contraindicated.

A. Decrease time spent outdoors. B. Limit engaging in sport activities that can cause bruising. C. Decrease intake of fresh fruits or vegetables. D. Limit socializing in large crowds.

Correct Answer is B

Explanation

The nurse should instruct the clients to limit engaging in sport activities that can cause bruising, as radiation therapy can cause thrombocytopenia and increase the risk of bleeding. The nurse should also encourage the clients to increase their fluid intake, eat a balanced diet that includes fresh fruits and vegetables, and protect their skin from sun exposure. The nurse should not advise the clients to limit socializing in large crowds, unless they have a low white blood cell count and are at risk of infection.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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