A nurse is caring for a hospitalized client at risk for complications of immobility. Which of the following interventions should the nurse include to prevent complications?

Instruct the client to wear a hospital gown every day, even when out of bed.

Have the client remain in bed for self-care activities.

Encourage the client to sit in the chair for all meals.

Elevate the head of the bed to 30° to 45° for medication administration.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Instruct the client to wear a hospital gown every day, even when out of bed

This intervention does not directly address the prevention of complications related to immobility. Wearing a hospital gown may be necessary for medical reasons, but it does not promote mobility or prevent complications such as pressure ulcers, muscle atrophy, or deep vein thrombosis (DVT). Encouraging the client to wear regular clothes when out of bed might actually promote a sense of normalcy and encourage more movement.

Choice B Reason: Have the client remain in bed for self-care activities

Keeping the client in bed for self-care activities is counterproductive in preventing complications of immobility. Prolonged bed rest can lead to muscle atrophy, decreased joint mobility, and increased risk of pressure ulcers and DVT. Encouraging the client to get out of bed and perform self-care activities while standing or sitting can help maintain muscle strength and joint flexibility.

Choice C Reason: Encourage the client to sit in the chair for all meals

Encouraging the client to sit in a chair for meals is an effective intervention to prevent complications of immobility. Sitting up helps improve digestion and respiratory function and reduces the risk of pressure ulcers by changing the pressure points on the body. It also promotes muscle activity and circulation, which are crucial in preventing DVT and maintaining overall physical health.

Choice D Reason: Elevate the head of the bed to 30° to 45° for medication administration

While elevating the head of the bed can be beneficial for certain medical conditions and for medication administration, it does not significantly contribute to preventing complications of immobility. This position can help with respiratory function and prevent aspiration during medication administration, but it does not promote overall mobility or prevent muscle atrophy and pressure ulcers.

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Correct Answer is ["B","D","E"]

Explanation

Choice A Reason: Production of potassium

The musculoskeletal system does not produce potassium. Potassium is an essential mineral that is obtained through the diet and is crucial for various bodily functions, including muscle contraction and nerve function. The musculoskeletal system, however, is not involved in its production.

Choice B Reason: Maintains the body’s form and shape

One of the primary functions of the musculoskeletal system is to maintain the body’s form and shape. The skeletal system provides the framework that supports the body and gives it structure. Muscles attached to the bones help maintain posture and allow for movement, contributing to the overall form and shape of the body.

Choice C Reason: Provides reflexive responses to injuries

While the musculoskeletal system is involved in movement and support, reflexive responses to injuries are primarily mediated by the nervous system3. Reflex actions are automatic responses to stimuli that involve the spinal cord and peripheral nerves, not the musculoskeletal system directly.

Choice D Reason: Formation of blood cells through red or yellow marrow

The formation of blood cells, known as hematopoiesis, occurs in the bone marrow, which is part of the skeletal system. Red bone marrow is responsible for producing red blood cells, white blood cells, and platelets. Yellow bone marrow, primarily composed of fat cells, can also convert to red marrow if necessary to increase blood cell production.

Choice E Reason: Protection of soft organs

The musculoskeletal system plays a crucial role in protecting soft organs. For example, the rib cage protects the heart and lungs, the skull encases the brain, and the vertebrae shield the spinal cord. This protective function is vital for preventing injury to these essential organs.

A. WBC Count 22,000/mm³ B. Hgb 15 g/dL C. Creatine kinase 75 units/L D. Platelet count 200,000/mm³

Correct Answer is A

Explanation

Choice A Reason: WBC Count 22,000/mm³

A white blood cell (WBC) count of 22,000/mm³ is significantly higher than the normal range, which is typically between 4,000 and 11,000/mm³. An elevated WBC count, known as leukocytosis, often indicates the presence of an infection as the body produces more white blood cells to fight off pathogens. This elevated count can also be seen in other conditions such as inflammation, stress, or bone marrow disorders, but it is a strong indicator of infection.

Choice B Reason: Hgb 15 g/dL

Hemoglobin (Hgb) levels of 15 g/dL fall within the normal range for adults, which is generally 13.8 to 17.2 g/dL for males and 12.1 to 15.1 g/dL for females. Normal hemoglobin levels indicate that the blood’s oxygen-carrying capacity is adequate and do not specifically point to an infection.

Choice C Reason: Creatine kinase 75 units/L

Creatine kinase (CK) levels of 75 units/L are within the normal range, which is typically 24 to 204 U/L. CK is an enzyme found in the heart, brain, and skeletal muscle, and elevated levels can indicate muscle damage, myocardial infarction, or other conditions affecting these tissues. However, normal CK levels do not indicate the presence of an infection.

Choice D Reason: Platelet count 200,000/mm³

A platelet count of 200,000/mm³ is within the normal range, which is generally between 150,000 and 450,000 platelets per microliter of blood. Platelets are involved in blood clotting, and normal levels do not indicate an infection. Abnormal platelet counts can be associated with bleeding disorders or thrombosis, but a normal count does not suggest an infection.

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