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:

Encouraging the client to bear down is not an appropriate response to abdominal cramps during an enema. Bearing down can increase discomfort and does not address the underlying cause of the cramps.

Choice B Reason:

Stopping the enema and documenting that the client did not tolerate the procedure is not the best initial action. While it is important to document the client’s response, there are other steps that can be taken to alleviate the discomfort before stopping the procedure entirely.

Choice C Reason:

This is the correct answer. Lowering the height of the solution container will reduce the flow rate of the enema solution, which can help alleviate abdominal cramps. A slower flow rate is less likely to cause cramping and discomfort.

Choice D Reason:

Allowing the client to expel some fluid before continuing can help relieve discomfort, but it is not the most immediate or effective action. Adjusting the flow rate by lowering the height of the solution container is a more direct way to address the issue.

A. Crohn’s disease looks like what would appear to be a second-degree burn in the colon and rectum areas only. B. Crohn’s disease is characterized by a transmural granulomatous inflammation that can affect any part of the gastrointestinal tract. C. Crohn’s disease causes continuous inflammation of the mucosa and sub-mucosa of the colon and rectal linings. D. Crohn’s disease has the appearance of a patchwork quilt with some areas that are clear and some with sores.

Correct Answer is D

Explanation

Choice A Reason: Crohn’s disease looks like what would appear to be a second-degree burn in the colon and rectum areas only

This description is not accurate for Crohn’s disease. Crohn’s disease can affect any part of the gastrointestinal tract from the mouth to the anus, not just the colon and rectum. Additionally, describing it as a second-degree burn is misleading as it does not accurately represent the nature of the inflammation and ulceration seen in Crohn’s disease.

Choice B Reason: Crohn’s disease is characterized by a transmural granulomatous inflammation that can affect any part of the gastrointestinal tract

While this statement is medically accurate, it is not simplistic or non-medical. It uses technical terms like “transmural” and “granulomatous inflammation,” which may be difficult for a client to understand without a medical background. The goal is to provide a description that is easy to comprehend.

Choice C Reason: Crohn’s disease causes continuous inflammation of the mucosa and sub-mucosa of the colon and rectal linings

This description is more fitting for ulcerative colitis, another type of inflammatory bowel disease. Crohn’s disease is characterized by patchy areas of inflammation that can affect any part of the gastrointestinal tract, not just the colon and rectum. Therefore, this statement does not accurately describe Crohn’s disease.

Choice D Reason: Crohn’s disease has the appearance of a patchwork quilt with some areas that are clear and some with sores

This description is the most simplistic and non-medical. It effectively conveys the nature of Crohn’s disease, which involves patchy areas of inflammation interspersed with healthy tissue, resembling a patchwork quilt. This analogy helps clients visualize the condition without needing to understand complex medical terminology.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client’s discomfort?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has a new diagnosis of Crohn’s disease. Which of the following statements by the nurse provides the most simplistic and non-medical description of the disorder?

Correct Answer is D

Explanation

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