A nurse reviews an immobilized patient's laboratory results and discovers that his/her calcium lab values are abnormally high (Hypercalcemia). Which condition will the nurse monitor for most closely in this patient?
Thrombus formation
Pressure Ulcers
Renal stones
Hypostatic pneumonia
The Correct Answer is C
A) Thrombus formation:
While immobility increases the risk of thrombus formation due to stasis of blood in the veins, hypercalcemia is not directly linked to thrombus formation. However, immobility and hypercalcemia could contribute to increased clotting risk indirectly, but renal stones are a more direct concern in this situation.
B) Pressure ulcers:
Pressure ulcers are a common concern for immobilized patients due to prolonged pressure on bony prominences. However, hypercalcemia does not directly cause or increase the risk of pressure ulcers. While immobility is a risk factor for pressure ulcers, hypercalcemia is not the primary cause for concern in this case.
C) Renal stones:
Hypercalcemia (elevated calcium levels in the blood) can lead to the formation of renal stones (kidney stones), as excess calcium is often excreted in the urine, where it can crystallize and form stones. This is the most direct and significant concern for a patient with high calcium levels. Monitoring for renal stones would be the priority action for the nurse in this case.
D) Hypostatic pneumonia:
Hypostatic pneumonia occurs due to immobility, causing mucus accumulation in the lungs and subsequent infection. While immobility is a concern for pneumonia, it is not specifically linked to hypercalcemia. The nurse should be monitoring for pneumonia in any immobilized patient, but the more immediate risk related to hypercalcemia is renal stones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Return any fresh linen not used for a client to the linen supply: Fresh linen that has been placed on a client’s bed but not used should not be returned to the linen supply. This is to prevent cross-contamination. Once linen is brought into a patient’s room, it should be considered contaminated, even if it was not used, and should be discarded properly.
B) Tie linen bags securely at the top: This is the correct action. When disposing of soiled linens, tying the linen bag securely helps to prevent the spread of pathogens and minimizes the risk of contamination. It also keeps the environment clean and safe for both staff and patients.
C) Fill linen bags with as much soiled linen as possible: Linen bags should not be overfilled. Overfilling bags can make them difficult to handle and can increase the risk of exposure to contaminants. Bags should be filled to a safe and manageable level to ensure proper handling and safety when transporting soiled linens.
D) Use double bagging to remove soiled linen from the client's room: Double bagging is typically not necessary unless there is a significant risk of contamination, such as with highly infectious material. Standard practice is to use a single, securely tied bag. Double bagging can create unnecessary waste and complicate disposal procedures unless specifically indicated by the situation or facility protocols.
Correct Answer is C
Explanation
A) Health promotion model: The health promotion model focuses on enhancing well-being and preventing illness through behaviors that encourage healthy lifestyles. While this model involves teaching and empowering individuals to make healthy choices, it doesn’t specifically focus on an individual’s belief about the perceived risks and benefits, as in the case of smoking cessation. Therefore, this model is not the primary one being applied in this scenario.
B) Maslow's hierarchy of needs: Maslow's hierarchy of needs is a motivational theory that suggests people are driven by a series of hierarchical needs, ranging from basic physiological needs to self-actualization. While the model addresses human needs at different levels, it doesn’t directly explain why the nurse believes the smokers will quit after learning about the benefits of smoking cessation. This model does not focus on the health behaviors related to smoking cessation in particular.
C) Health belief model: The health belief model explains health behaviors based on an individual's perceptions of the severity of a health issue, the perceived benefits of taking action, and the perceived barriers to action. In this case, the nurse is preparing a class based on the assumption that smokers will quit once they realize the benefits of not smoking, which aligns with the key concepts of the health belief model. This model emphasizes the importance of perception in motivating individuals to change unhealthy behaviors.
D) Holistic health model: The holistic health model views the individual as a whole, considering physical, emotional, social, and spiritual aspects of health. While this model might inform a broader approach to health and wellness, it does not specifically focus on the educational process of changing health behaviors, such as quitting smoking. Therefore, it is not the most appropriate model for this scenario.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
