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A nurse is collecting data from a client who has had paraplegia for several years. Which of the following physiologic changes due to immobility should the nurse consider when evaluating this client's overall status? (Select all that apply.)

Muscle atrophy

Venous pooling

Urinary stasis

Increased depth of respirations

Increased metabolic rate

Answer and Explanation

Correct Answer : A,B,C

A. Muscle atrophy

Lack of movement leads to wasting of muscle tissue over time, a common consequence of immobility.

B. Venous pooling

Immobility causes reduced venous return, leading to venous stasis or pooling, increasing the risk of DVT.

C. Urinary stasis

Lying flat for extended periods contributes to bladder emptying issues, increasing risk for UTIs and renal calculi.

D. Increased depth of respirations

Immobility leads to shallow breathing and reduced lung expansion, not deeper respirations.

E. Increased metabolic rate

Immobility generally results in a decreased metabolic rate due to lower energy needs.

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Correct Answer is C

Explanation

A. Develops fatigue when assisting with morning hygiene care

Fatigue during hygiene suggests low endurance; not ready to ambulate safely.

B. Needs assistance raising her legs to put on socks

Needing assistance for simple tasks shows weakness and poor muscle control.

C. Performs active range-of-motion (ROM) exercises of all extremities

Performing full active ROM exercises indicates good muscle strength and coordination, suggesting readiness to attempt ambulation.

D. Demonstrates mild dyspnea when eating breakfast

Dyspnea with minimal activity (eating) indicates limited cardiopulmonary reserve-not yet fit to ambulate.

A. Place the stockings on the client after the client ambulated to the restroom B. Ensure the client's toes are visible after placing the stockings on the client C. Measure the client's calf circumference and leg length from heel to knee. D. After applying the stockings, place two fingers between the client's leg and stocking to check the fit.

Correct Answer is C

Explanation

A. Place the stockings on the client after the client ambulated to the restroom.

Stockings should be applied before the client gets out of bed in the morning to prevent venous stasis and swelling.

B. Ensure the client's toes are visible after placing the stockings on the client.

Visible toes allow for monitoring of circulation, color, and temperature, which helps detect complications like restricted blood flow.

C. Measure the client's calf circumference and leg length from heel to knee.

Although the stocking should not constrict the toes, having them visible is not the primary indication of a proper fit. The focus is on ensuring proper compression around the calf and knee areas.

D. After applying the stockings, place two fingers between the client's leg and stocking to check the fit.

Unlike anti-embolism devices like TED hose, these stockings are meant to be snug to ensure adequate compression. The two-finger rule is more applicable to items like restraints, not compression stockings.

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A nurse is collecting data from a client who has had paraplegia for several years. Which of the following physiologic changes due to immobility should the nurse consider when evaluating this client's overall status? (Select all that apply.)

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