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 C

Explanation

Choice A Reason:

Removing the protective gown before removing gloves is incorrect. The correct procedure is to remove gloves first, followed by the gown, to prevent contamination from the gown to the hands.

Choice B Reason:

Using an electronic thermometer is not recommended for clients with Clostridium difficile. Disposable thermometers or dedicated equipment should be used to prevent cross-contamination.

Choice C Reason:

This is the correct answer. The protective gown should be removed before leaving the client’s room to prevent the spread of Clostridium difficile spores to other areas of the healthcare facility. Proper removal and disposal of PPE are crucial in infection control.

Choice D Reason:

Shaking bed linens is incorrect as it can aerosolize Clostridium difficile spores, increasing the risk of spreading the infection. Linens should be carefully handled and placed in a linen bag without shaking.

A. Pupillary dilation B. Persistent headache C. Presence of hand tremors D. Difficulty waking E. Foot drop

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

Explanation

Choice A Reason: Pupillary dilation

Pupillary dilation can be a sign of increased intracranial pressure or brain injury, which are potential complications following a motor vehicle accident with a loss of consciousness. Assessing for changes in pupil size and reactivity is crucial in identifying neurological impairments that may require immediate intervention.

Choice B Reason: Persistent headache

A persistent headache is a common symptom following a traumatic brain injury (TBI) or concussion. It can indicate ongoing issues such as intracranial bleeding or increased intracranial pressure. Monitoring the severity and duration of the headache is important for determining the need for further medical evaluation and treatment.

Choice C Reason: Presence of hand tremors

Hand tremors are not typically associated with acute brain injuries resulting from a motor vehicle accident. They are more commonly linked to conditions such as Parkinson’s disease, essential tremor, or other neurological disorders. While tremors should be noted, they are not a primary concern in the context of post-accident assessment.

Choice D Reason: Difficulty waking

Difficulty waking, or altered level of consciousness, is a significant indicator of potential brain injury or increased intracranial pressure. It is essential to monitor the client’s level of consciousness closely, as changes can signal worsening neurological status and the need for urgent medical intervention.

Choice E Reason: Foot drop

Foot drop is a condition characterized by difficulty lifting the front part of the foot, often due to nerve damage or muscle weakness. While it can occur in the context of neurological injury, it is not a primary manifestation to assess for immediately following a motor vehicle accident with a loss of consciousness. The focus should be on more acute signs of brain injury.

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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?

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