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 ["C","D","E"]

Explanation

A) Assess the client every 4 hr: Assessing the client every 4 hours is not frequent enough, especially for patients at high risk for falls. A more frequent assessment, such as every 1-2 hours or as clinically appropriate, is recommended to monitor the patient's safety and to ensure timely intervention if needed.

B) Keep the client's room dark at night: Keeping the room dark at night would increase the risk of falls. Adequate lighting should be provided to ensure the client can safely navigate the room and call for assistance if necessary. Nightlights or low-level lighting are often used to prevent accidents in the dark.

C) Teach the client to use the call light: This is an essential action to prevent falls. Teaching the client to use the call light ensures that they can summon help if they need assistance to get out of bed or move around, reducing the risk of attempting to move independently and falling.

D) Keep the client's bed in the lowest position: This is a key safety measure. Keeping the bed in the lowest position reduces the risk of injury if the client attempts to get out of bed independently or if they fall. It also makes it easier for the client to safely exit the bed with assistance.

E) Place a fall-risk identification band on the client's wrist: This is an important action to alert all healthcare staff about the client's fall risk. A fall-risk identification band helps ensure that everyone involved in the patient's care is aware of the need for extra precautions to prevent falls.

A. When observed posteriorly, the hips and shoulders form an ‘’S’’ pattern B. When observed laterally, the spinal curves align in a reversed S pattern C. the arms should be crossed over the chest or in the lap D. LThe feet should be close together with toes pointed out

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.

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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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Correct Answer is B

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