A nurse is monitoring a client for complications of immobility. Which of the following findings does the nurse identify as a complication of immobility?
(Select All that Apply.)

Hypertension

Diarrhea

Pressure injury

Contractures of extremities

Answer and Explanation

Correct Answer : C,D,E

A. Hypertension: Immobility more commonly leads to orthostatic hypotension, not hypertension.
B. Diarrhea: Immobility often causes constipation due to reduced peristalsis, not diarrhea.
C. Pressure injury: Prolonged pressure on bony prominences in immobile clients can cause skin breakdown and ulcers.
D. Contractures of extremities: Lack of movement leads to muscle shortening and joint contractures.
E. Crackles in the lungs: Crackles may indicate atelectasis or pneumonia, both of which are risks due to decreased lung expansion and secretion retention in immobile clients.

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Correct Answer is A

Explanation

A. Lower the head of the bed: This facilitates a horizontal transfer by making the bed and stretcher levels even, reducing strain during the move.
B. Place the bed in its lowest position: The bed should be adjusted to the same height as the stretcher for a smoother transfer.
C. Unlock the wheels on the bed: The wheels must be locked to prevent movement and injury.
D. Have two caregivers at the side of the bed: While help is needed, one caregiver on each side and possibly one at the head or foot is preferred depending on the client’s condition.

A. The client's ability to communicate B. The client's activity tolerance C. The client's current weight-bearing status D. The type of equipment the staff used to transfer the client in the past

Correct Answer is C

Explanation

A. The client's ability to communicate: Communication is important, but it is not the most critical factor in determining transfer method.
B. The client's activity tolerance: Activity tolerance affects length of mobility, but not necessarily the technique used for transfer.
C. The client’s current weight-bearing status: This determines whether the client needs full assistance, partial help, or assistive devices, and directly influences the transfer method and equipment used.
D. The type of equipment the staff used to transfer the client in the past: Past equipment may not match the client’s current condition.

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A nurse is monitoring a client for complications of immobility. Which of the following findings does the nurse identify as a complication of immobility? (Select All that Apply.)

Nursing Test Bank

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Explanation

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Correct Answer is C

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A nurse is monitoring a client for complications of immobility. Which of the following findings does the nurse identify as a complication of immobility?
(Select All that Apply.)