An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?
Stiffness in the lower extremities
A reddened area over the sacrum
Difficulty hearing some types of sounds
Difficulty moving the upper extremities
The Correct Answer is B
A. Stiffness in the lower extremities can occur due to lack of movement and muscle disuse. Prolonged immobility leads to muscle atrophy and contractures, causing stiffness and reduced range of motion. This is a common complication seen in clients who are bedridden or have limited mobility.
B. A reddened area over the sacrum indicates a potential pressure injury or pressure ulcer. Immobility increases the risk of pressure ulcers due to prolonged pressure on bony prominences, such as the sacrum. Regular repositioning and pressure relief strategies are essential to prevent skin breakdown in immobile clients.
C. Difficulty hearing certain types of sounds is not typically associated with immobility. It may be related to age-related changes in hearing or other auditory issues but is not a direct complication of immobility.
D. Difficulty moving the upper extremities can occur due to muscle weakness or disuse atrophy, which can result from immobility. However, it is less common compared to stiffness and difficulty in the lower extremities because upper extremities are often more frequently moved or exercised even in bedridden clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
For this scenario, the volume to be infused is 100 mL, the drop factor is 60 gtt/mL, and the time is 60 minutes.
Plugging in the numbers: (100 mL × 60 gtt/mL) / 60 min = 6000 gtt / 60 min = 100 gtt/min.
Therefore, the nurse should set the IV flow rate to deliver 100 drops per minute.
Correct Answer is ["2"]
Explanation
To administer a dose of 10 mg of olanzapine using 5 mg tablets, the nurse would need to give two (2) tablets
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