An older adult client has been admitted to a skilled nursing facility. Which of the following can be caused by physical restraints? (Select all that apply.)
Pressure ulcers
Death
Sepsis
Decreased circulation/perfusion to the extremities
Fractures
Correct Answer : A,B,D,E
Choice A: Pressure ulcers - Physical restraints can lead to immobility, which increases the risk of pressure ulcers due to prolonged pressure on the skin.
Choice B: Death - Restraints can cause fatal accidents. For example, a person might try to remove the restraint, fall, and suffer a fatal injury.
Choice C: Sepsis - While sepsis is a severe condition often caused by an infection, it's not a direct result of physical restraints. However, if a pressure ulcer (caused by restraints) becomes severely infected, it could potentially lead to sepsis.
Choice D: Decreased circulation/perfusion to the extremities - Restraints can restrict movement, leading to decreased blood flow to the extremities.
Choice E: Fractures - Struggling against restraints can lead to falls and subsequent fractures.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Set walking distance goals is not the best goal, as it is too specific and may not be appropriate for all older clients with diabetes. Walking distance may vary depending on the client's physical condition, comorbidities, and preferences.
Choice B reason: Stabilize the serum glucose is not the best goal, as it is too vague and does not reflect the client's involvement in their care. Serum glucose levels may fluctuate depending on various factors, such as diet, medication, stress, and infection.
Choice C reason: Plan for consistent exercise is not the best goal, as it is not comprehensive and does not address other aspects of diabetes management, such as nutrition, medication, and monitoring. Exercise is only one component of a holistic care plan for older clients with diabetes.
Choice D reason: Facilitate self-management is the best goal, as it encompasses all the elements of diabetes care and empowers the client to take charge of their health. Self-management involves educating the client about diabetes, providing support and resources, and encouraging adherence to the prescribed treatment regimen.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the best goal for planning nursing care for an older client with diabetes mellitus.
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because the zoster vaccine Shingrix can be given to individuals who have had a previous episode of Herpes Zoster (HZ), as long as they are not currently experiencing an acute outbreak. The vaccine can help prevent future recurrences of HZ, as well as reduce the risk of postherpetic neuralgia, a painful complication of HZ.
Choice B reason: This statement is correct because the zoster vaccine Shingrix is recommended for all individuals over age 50 that have no contraindications to the vaccine, such as a history of severe allergic reaction to any component of the vaccine, or a current severe immunodeficiency. The vaccine can help prevent HZ and its complications, which are more common and severe in older adults.
Choice C reason: This statement is incorrect because the zoster vaccine Shingrix can be given to individuals with a chronic cardiac or respiratory condition, as long as they are not immunocompromised. The vaccine is not a live vaccine, so it does not pose a risk of causing or worsening the underlying condition. The vaccine can help protect the individuals from HZ and its complications, which can exacerbate their condition or interfere with their treatment.
Choice D reason: This statement is incorrect because the zoster vaccine Shingrix does not always prevent an individual from developing Herpes Zoster. The vaccine has a high efficacy rate of about 90%, but it is not 100%. The vaccine can reduce the severity and duration of HZ, as well as the risk of postherpetic neuralgia, if it does occur.
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