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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Respiratory alkalosis.

Respiratory alkalosis is caused by hyperventilation, not by immobility. Deep breathing won't target this issue.

B. Atelectasis.

While deep breathing can help prevent atelectasis (lung collapse), the primary concern in immobilized patients is hypostatic pneumonia.

C. Hypostatic pneumonia.

Deep breathing promotes lung expansion and mobilizes secretions, helping prevent hypostatic pneumonia, which results from stasis of secretions due to immobility.

D. Low oxygen saturation.

While deep breathing may improve oxygen saturation, the primary goal is to prevent atelectasis and pneumonia.

A. speeding the drying with a hair dryer. B. elevating the leg on one to two pillows. C. petaling the edges of the cast. D. placing the patient in high Fowler's position.

Correct Answer is B

Explanation

A. Speeding the drying with a hair dryer:

This is not recommended as it can cause uneven drying and burns. Plaster casts must dry naturally.

B. Elevating the leg on one to two pillows:

Elevation promotes venous return and reduces swelling in the affected extremity.

C. Petaling the edges of the cast:

Petaling helps prevent skin breakdown from rough cast edges but does not affect edema.

D. Placing the patient in high Fowler's position:

This position benefits respiratory function but does not aid in reducing lower extremity edema.

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The nurse designs care for the immobilized patient to help combat the major dangers of immobilization, which include: Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse directs the immobilized patient in frequent deep breathing exercises during the day in order to combat

Correct Answer is C

Explanation

A patient has just had a leg cast applied with plaster of Paris. The nurse can best reduce the incidence of edema by:

Correct Answer is B

Explanation

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