The nurse is caring for a patient with impaired physical mobility. Which potential complications will the nurse monitor for in this pi(Select All that Apply.)

Foot drop

Increased socialization

Somnolence

Hypostatic pneumonia

Impaired skin intergrity

Answer and Explanation

Correct Answer : A,D,E

A) Foot drop: Foot drop is a common complication associated with impaired physical mobility. It occurs when the muscles responsible for lifting the front of the foot become weak or paralyzed, often due to prolonged immobility or neurological impairment. The nurse should monitor for this condition and implement preventive measures like using ankle-foot orthoses (AFOs) to support the foot in a neutral position and promote proper alignment.

B) Increased socialization: While it is important to encourage socialization and support mental health, increased socialization is not a complication associated with impaired mobility. In fact, patients with impaired mobility are more likely to experience social isolation, not increased socialization. Therefore, the nurse should focus on strategies to encourage social interaction to prevent feelings of loneliness and depression.

C) Somnolence: Somnolence, or excessive sleepiness, is not directly related to impaired physical mobility. While some patients with severe illness or conditions may experience somnolence, it is not a common complication of immobility. Instead, the nurse should focus on monitoring for complications like respiratory issues or skin breakdown.

D) Hypostatic pneumonia: Hypostatic pneumonia is a complication that can occur when a patient remains in a supine or immobile position for an extended period. The lack of movement and deep breathing can lead to pooled secretions in the lungs, which increases the risk of infection. The nurse should monitor for signs of respiratory distress and encourage frequent position changes, deep breathing, and coughing exercises to reduce the risk.

E) Impaired skin integrity: Impaired skin integrity is a major concern in patients with impaired mobility. Prolonged pressure on bony prominences due to immobility can lead to pressure ulcers (bedsores). The nurse should monitor the skin regularly, implement pressure-relieving devices, and reposition the patient frequently to prevent skin breakdown.

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Correct Answer is B

Explanation

A) When observed posteriorly, the hips and shoulders form an "S" pattern: This is not a normal finding. A normal alignment should have the shoulders and hips in a straight line when observed posteriorly. An "S" pattern could indicate issues such as scoliosis or other postural abnormalities that require further assessment.

B) When observed laterally, the spinal curves align in a reversed S pattern: This is the normal finding. The spine should form a reversed "S" curve when observed laterally. This curve includes a cervical curve (forward), a thoracic curve (backward), and a lumbar curve (forward). This curvature allows for optimal shock absorption and proper weight distribution during standing and movement.
C) The arms should be crossed over the chest or in the lap: This is not a normal finding for body alignment. Arms should be relaxed at the sides or slightly away from the body in a natural, neutral position. Crossing arms can indicate discomfort or tension, which may affect the patient’s posture.

D) The feet should be close together with toes pointed out: This is not the normal body alignment. Feet should be shoulder-width apart with toes pointing forward in a neutral position when standing. Toes pointed out may indicate abnormal posture or gait patterns, such as muscle imbalances or discomfort.

A. A patient with a stage IV pressure ulcer B. A patient with neck surgery C. A patient with hypostatic pneumonia D. A patient with a total knee replacement

Correct Answer is B

Explanation

A) A patient with a stage IV pressure ulcer: While logrolling is important for patients with pressure ulcers to prevent further skin damage and to ensure proper positioning, it is not the most common intervention for a patient with a stage IV pressure ulcer. For such patients, the primary focus is on wound care, pain management, and preventing further pressure on the affected area, rather than using logrolling as a primary method of movement.

B) A patient with neck surgery: Logrolling is most commonly used for patients with spinal injuries or those who have had neck surgery. The goal is to maintain the alignment of the spine during movement to avoid causing further injury or strain. This technique helps prevent flexion or twisting of the neck and spine, which is critical for the safety of patients recovering from neck surgery.

C) A patient with hypostatic pneumonia: Hypostatic pneumonia, a type of lung infection due to immobility, is more commonly managed through respiratory interventions like deep breathing exercises, chest physiotherapy, and turning the patient to prevent secretion buildup in the lungs. While positioning is important, logrolling is not specifically indicated for this condition unless there is a concurrent spinal injury or surgery.

D) A patient with a total knee replacement: Logrolling is not typically required for patients with total knee replacements. The patient may need to be positioned carefully to protect the knee joint, but the primary focus in their care is on joint mobility, pain management, and preventing complications related to immobility, rather than performing logrolling to protect the spine or neck.

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The nurse is caring for a patient with impaired physical mobility. Which potential complications will the nurse monitor for in this pi(Select All that Apply.)

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