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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 D

Explanation

A. Turn their foot and leg away from their other leg

This movement is called external rotation, not hyperextension.

B. Move their leg forward and up

This action is flexion of the hip.

C. Move their leg medially toward their other leg

This describes adduction, moving the limb toward the body's midline.

D. Move their leg behind their body

Hyperextension of the hip involves moving the leg backward beyond the normal range of extension.

A. Ask the client if she has been out of bed today. B. Ask the client to push her legs and feet against the nurse's palms. C. Check the client's pedal pulses and feet for edema. D. Ask the client how strong she feels today.

Correct Answer is B

Explanation

A. Ask the client if she has been out of bed today:

This gives some insight into activity level but doesn't objectively measure strength.

B. Ask the client to push her legs and feet against the nurse's palms:

This provides a direct, physical assessment of the client's lower extremity strength, which is essential before ambulation.

C. Check the client's pedal pulses and feet for edema:

These assessments are related to circulation, not muscular strength.

D. Ask the client how strong she feels today:

This is subjective and may not reflect actual muscle strength or ability to ambulate safely.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?

Correct Answer is D

Explanation

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Correct Answer is B

Explanation

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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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