A nurse is assessing a client whose therapy has included bed rest for several weeks.
Which of the following findings should the nurse identify as the priority?
Loss of appetite
Left lower extremity tenderness
Increased heart rate during physical activity
Musculoskeletal weakness
The Correct Answer is B
A. While decreased appetite may be concerning, it is not typically considered a priority over potential complications related to immobility.
B. Left lower extremity tenderness could indicate deep vein thrombosis (DVT), a serious complication of prolonged bed rest that requires immediate attention to prevent pulmonary embolism.
C. Increased heart rate during physical activity may be expected after a period of bed rest and can be addressed with gradual reconditioning.
D. Musculoskeletal weakness is a common consequence of immobility and would be addressed as part of the client's rehabilitation but is not an immediate priority compared to potential complications like DVT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,E,C,B,A
Explanation
A. Deep palpation is the final step in an abdominal examination since it may elicit tenderness which may interfere with other aspects of examination.
B. This is the second last step just before deep palpation. It is used to detect any obvious masses or areas of tenderness.
C. Percussion is the third step in an abdominal examination where the nurse should percuss the client's abdomen systematically, tapping lightly on each area and noting the sound quality. It can be used to detect the presence of ascites which be stony dull on percussion.
D. Inspection is the first step where the nurse should inspect the contours of the client's abdomen using a penlight, looking for any abnormalities or distension.
E. Auscultation is the second step in an abdominal examination. The nurse should auscultate the client's abdomen using the diaphragm of the stethoscope, listening for bowel sounds in all four quadrants.
Correct Answer is D
Explanation
A. Although this client may have physical limitations, they are still engaging in social activities by going to the gym, indicating less likelihood of social isolation.
B. This client has regular social interactions with family members, suggesting they are not socially isolated.
C. Regular social gatherings with friends indicate social engagement and are not indicative of social isolation.
D. Restricting activities outside the home to only essential tasks like getting the mail due to pain or other reasons can indicate social isolation and limited social interactions.
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