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A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility?

Increased blood pressure

Decreased serum calcium levels

Swollen area on calf

Urinary frequency

Answer and Explanation

The Correct Answer is C

A. Immobility more commonly leads to orthostatic hypotension rather than increased blood pressure.

B. Immobility typically leads to increased calcium levels due to bone demineralization.

C. A swollen area on the calf may indicate a deep vein thrombosis (DVT), a serious complication of immobility.

D. Urinary stasis and retention, rather than frequency, are common complications of immobility.

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Correct Answer is C

Explanation

A. Exclude nutritional supplements from the list of medications the client reports: Incorrect. Nutritional supplements are medications and should be included in the medication reconciliation process.

B. Encourage the client to make his own list after he returns to his home: Incorrect. The nurse should be responsible for gathering the complete medication history upon admission, not relying on the client’s list from home.

C. Compare new prescriptions with the list of medications the client reports: This is the correct step in medication reconciliation. The nurse needs to ensure that new medications are compatible with the client's current medications and review any changes.

D. Include any adverse effects of the medications the client might develop: Incorrect. Adverse effects are not part of the medication reconciliation process; the focus is on identifying all current medications, including prescriptions, over-the-counter drugs, and supplements.

A. Client reports auditory hallucinations B. Inability to carry out a simple task C. Moves quickly from one idea to the next D. Client expresses illusions of grandeur

Correct Answer is B

Explanation

A. Auditory hallucinations are more commonly associated with psychosis rather than a depressive episode.

B. Inability to carry out simple tasks is a hallmark of a depressive episode due to low energy, poor concentration, and feelings of hopelessness.

C. Moving quickly from one idea to the next (flight of ideas) is characteristic of a manic episode, not a depressive episode.

D. Illusions of grandeur occur during manic episodes, not depressive episodes.

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A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility?

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A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility?