A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select All that Apply.)
Contractures
Diarrhea
Polyuria
Atelectasis
Pressure ulcers
Correct Answer : A,D,E
Choice A rationale: Contractures are a common complication of immobility due to the shortening of muscles and connective tissues.
Choice B rationale: Diarrhea is not typically associated with complications of immobility.
Choice C rationale: Polyuria is not typically associated with complications of immobility.
Choice D rationale: Atelectasis, the collapse of lung tissue, can occur in immobile clients due to reduced lung expansion and ventilation.
Choice E rationale: Pressure ulcers are a significant risk in immobile clients due to prolonged pressure on specific areas of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale: The skin helps regulate body temperature by sweating and dilation or constriction of blood vessels.
Choice B rationale: The skin acts as a barrier, protecting the body from external threats such as pathogens and physical injury.
Choice C rationale: The skin is rich in sensory receptors, allowing for the perception of touch, pressure, pain, and temperature.
Choice D rationale: The skin plays a role in the production of vitamin D when exposed to sunlight.
Choice E rationale: Vitamin C production is not a function of the skin; vitamin C is obtained through diet.
Correct Answer is ["A","B"]
Explanation
Choice A rationale: Bearing the weight of the body on the hands is not the correct technique for using crutches. The weight should be borne on the arms, not the hands.
Choice B rationale: Using crutches that belonged to someone else may not be appropriate as they need to be properly fitted for the individual. Additionally, old crutches may be worn or damaged.
Choice C rationale: This statement is appropriate and does not indicate a need for additional teaching. Keeping spare crutch tips is a good practice, as crutch tips can wear down over time and may need replacement. This demonstrates the client's understanding of the need for maintenance and preparedness.
Choice D rationale: This statement is appropriate and indicates a good understanding of crutch care. Regular inspection of crutches is important to ensure their safety and effectiveness. It allows the client to identify any signs of wear or damage early on and take necessary actions, such as replacing worn-out parts, to prevent accidents or injuries.
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