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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. This statement reflects a misconception about menopause and sexual health, indicating a need for education on safe sex practices.
B. This statement indicates the client is taking steps to address discomfort during sexual activity, which is appropriate.
C. This statement reflects body image concerns commonly experienced by older adults and may warrant further exploration but does not necessarily indicate a need for immediate intervention.
D. This statement indicates a normal interest in sexual activity and does not necessarily indicate a need for intervention.

A. "Disconnect the drainage tube if the catheter requires irrigation." B. "Keep the collection bag below bladder level." C. "Use a size 20 French catheter for catheterization." D. "Allow the drainage bag to fill completely before emptying

Correct Answer is B

Explanation

A. Disconnecting the drainage tube can introduce bacteria and increase the risk of infection.
B. Maintaining the collection bag below the level of the bladder prevents backflow of urine and reduces the risk of infection.
C. Catheter size selection is based on individual client factors and is not directly related to infection prevention.
D. Allowing the drainage bag to overfill increases the risk of backflow and infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

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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?