The nurse designs care for the immobilized patient to help combat the major dangers of immobilization, which include: Select all that apply.
Loss of calcium from bone matrix
Stasis of respiratory secretions
Increased cardiac workload
Decreased circulation from pressure
Increased mental activity
Correct Answer : A,B,C,D
A. Loss of calcium from bone matrix
Immobility causes bone demineralization, increasing the risk for osteoporosis and fractures.
B. Stasis of respiratory secretions
Lack of movement decreases chest expansion, leading to retained secretions and risk of pneumonia or atelectasis.
C. Increased cardiac workload
Immobilization leads to venous stasis and reduced venous return, increasing cardiac workload and risk of thromboembolism.
D. Decreased circulation from pressure
Prolonged pressure leads to reduced perfusion, increasing risk for pressure ulcers.
E. Increased mental activity
Immobilization often results in decreased mental stimulation, potentially leading to depression or confusion, especially in older adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Move body parts rapidly through the movements.
Rapid movement can cause injury and discomfort. Movements should be slow and smooth.
B. Support extremities above and below joints.
Supporting both above and below the joint ensures joint stability and prevents strain or injury during passive ROM.
C. Stretch the body part just beyond the existing range of motion.
Passive ROM should stay within the current range. Forcing motion can cause pain or injury.
D. Continue moving body parts if muscle spasticity occurs.
If spasticity occurs, movement should stop. Forcing motion through spasms can increase injury risk.
Correct Answer is B
Explanation
A. "Keep your head straight and turn it as far as possible to either side."
This is rotation, not hyperextension.
B. "Move your head from the upright position back as far as you can."
This describes hyperextension, which is the movement of the head beyond the neutral upright position.
C. "Move your head so that your chin rests on your chest."
This is flexion, not hyperextension.
D. "Move your head laterally towards your right and left shoulder."
This describes lateral flexion, not hyperextension.
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