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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Return any fresh linen not used for a client to the linen supply: Fresh linen that has been placed on a client’s bed but not used should not be returned to the linen supply. This is to prevent cross-contamination. Once linen is brought into a patient’s room, it should be considered contaminated, even if it was not used, and should be discarded properly.
B) Tie linen bags securely at the top: This is the correct action. When disposing of soiled linens, tying the linen bag securely helps to prevent the spread of pathogens and minimizes the risk of contamination. It also keeps the environment clean and safe for both staff and patients.
C) Fill linen bags with as much soiled linen as possible: Linen bags should not be overfilled. Overfilling bags can make them difficult to handle and can increase the risk of exposure to contaminants. Bags should be filled to a safe and manageable level to ensure proper handling and safety when transporting soiled linens.
D) Use double bagging to remove soiled linen from the client's room: Double bagging is typically not necessary unless there is a significant risk of contamination, such as with highly infectious material. Standard practice is to use a single, securely tied bag. Double bagging can create unnecessary waste and complicate disposal procedures unless specifically indicated by the situation or facility protocols.
Correct Answer is B
Explanation
A) Four wheel walker: While a four-wheel walker provides excellent support and stability for clients with significant mobility limitations, it is not always the best choice for someone who occasionally loses balance. It can be bulky and difficult to maneuver in tight spaces, and it may not provide as much support for clients who need only occasional assistance with balance. A gait belt allows for more hands-on assistance when needed.
B) Gait belt: A gait belt is the most appropriate device to use when assisting a client who occasionally loses balance. It allows the nurse to provide hands-on support and maintain the client’s safety during ambulation. The gait belt provides a secure hold, enabling the nurse to assist the client in regaining balance quickly, preventing falls if the client starts to lose their stability.
C) Jacket harness: A jacket harness is typically used in more severe cases of balance loss or in situations where the client has significant mobility impairments. While it provides more overall support, it may not be necessary for a client who only occasionally loses balance. It can also be more cumbersome than a gait belt for helping with short, occasional ambulation.
D) Cane: A cane is helpful for clients who need mild to moderate support while walking, but it might not offer enough stability for a client who occasionally loses balance. A cane may provide support in some cases, but using a gait belt would be more effective for safely supporting and guiding the client during ambulation.
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