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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 B

Explanation

A. Speeding the drying with a hair dryer:

This is not recommended as it can cause uneven drying and burns. Plaster casts must dry naturally.

B. Elevating the leg on one to two pillows:

Elevation promotes venous return and reduces swelling in the affected extremity.

C. Petaling the edges of the cast:

Petaling helps prevent skin breakdown from rough cast edges but does not affect edema.

D. Placing the patient in high Fowler's position:

This position benefits respiratory function but does not aid in reducing lower extremity edema.

A. "Keep your head straight and turn it as far as possible to either side." B. "Move your head from the upright position back as far as you can." C. "Move your head so that your chin rests on your chest." D. "Move your head laterally towards your right and left shoulder."

Correct Answer is B

Explanation

A. "Keep your head straight and turn it as far as possible to either side."

This is rotation, not hyperextension.

B. "Move your head from the upright position back as far as you can."

This describes hyperextension, which is the movement of the head beyond the neutral upright position.

C. "Move your head so that your chin rests on your chest."

This is flexion, not hyperextension.

D. "Move your head laterally towards your right and left shoulder."

This describes lateral flexion, not hyperextension.

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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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