A nurse is caring for a client in an acute care setting.
Complete the following sentence by using the list of options.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
The client is at risk for hypostatic pneumonia as evidenced by the client's immobility
Rationale
The combination of paraplegia (which leads to limited mobility) and symptoms such as productive cough, tachycardia, and confusion suggest a respiratory issue, likely hypostatic pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. When using crutches, the client should position both hands on the grips with the elbows slightly flexed for proper support and balance.
B. In the three-point gait, the crutches and the injured leg move together, followed by the uninjured leg. The stronger leg does not move first.
C. The client should not lean on the axillary crutch pads as it can cause nerve damage. Body weight should be supported through the hands and arms.
D. When going up stairs, the uninjured leg should move first, followed by the crutches and the affected leg.
Correct Answer is C
Explanation
A. Fidelity refers to being loyal, faithful, and keeping promises, which does not directly apply to this situation.
B. Autonomy refers to respecting a person's right to make their own decisions, which is not the focus here.
C. Beneficence refers to promoting the well-being of others, and in this situation, the nurse is demonstrating care by providing comfort to the grieving client.
D. Veracity refers to telling the truth, which is not the focus of the nurse's actions in this case.
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