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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. This instruction is incorrect for a 24-hour urine collection. During a 24-hour urine collection, the client should urinate into a designated collection container at the start of the collection period and continue to collect all urine voided over the next 24 hours. The nurse should instruct the client to empty their bladder completely at the end of the 24-hour period into the same container used throughout the collection period. This ensures that all urine produced over the 24 hours is included in the specimen.
B. Discarding the first urine voided at the beginning of the collection period is a common instruction for some types of urine tests, such as for urinary catecholamines or specific timed collections. However, for a 24-hour urine collection, the client should start collecting urine from the very first void and include all subsequent urine produced over the next 24 hours.
C. This instruction is incorrect for a 24-hour urine collection. All urine produced during the 24-hour period should be saved in a single designated collection container. Using separate containers for each void would make it difficult to accurately measure the total volume of urine collected over the specified time frame.

D. Storing the urine collection container at room temperature is generally appropriate for a 24-hour urine collection. This helps maintain the stability of the urine sample and ensures accurate test results. Refrigeration may be required if specified by the healthcare provider for specific tests, but this should be clearly communicated to the client if necessary.

A. Butter B. Yogurt C. Pears D. Orange juice E. Cabbage

Correct Answer is ["B","D"]

Explanation

A. Butter is a dairy product, but it is not typically high in potassium. It is generally safe for clients following a low-potassium diet. Therefore, clients do not need to avoid butter specifically for its potassium content.
B. Yogurt, especially the varieties that are not low-fat or non-fat, can have a significant amount of potassium.
C Pears are generally considered low in potassium and are usually safe to include in a low-potassium diet.
D. Orange juice is a fruit juice and is naturally high in potassium. Clients should avoid or limit orange juice when following a low-potassium diet due to its potassium content.
E. Cabbage is a vegetable that is generally low in potassium. It is safe for clients following a low-potassium diet and does not need to be avoided for its potassium content.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is reinforcing teaching with a client who is to collect a 24-hr urine specimen. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is planning to reinforce teaching with a client about the need to follow a low-potassium diet. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

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