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

Explanation

A) History of smoking: Smoking is a modifiable risk factor, meaning it can be reduced or eliminated through lifestyle changes. While smoking significantly increases the risk of stroke, it is not a nonmodifiable risk factor. Educating clients about the benefits of quitting smoking is important to reduce stroke risk.

B) Obesity: Obesity is also a modifiable risk factor. Lifestyle changes such as diet and exercise can help manage and reduce obesity, which in turn reduces the risk of stroke. While obesity increases the likelihood of stroke, it is not considered nonmodifiable.

C) Genetics: Genetics are a nonmodifiable risk factor. A family history of stroke or certain genetic predispositions can increase the risk of stroke. These genetic factors cannot be altered, which is why they should be included in the discussion about stroke risk factors.

D) History of hypertension: Hypertension, or high blood pressure, is a significant risk factor for stroke, but it is modifiable through medication, diet, and lifestyle changes. It is not a nonmodifiable risk factor. Managing blood pressure through appropriate treatment and lifestyle changes can reduce the risk of stroke.

A. Focusing on helping patients be disease free B. Providing care that involves the whole person C. Assuring that care is strictly personal in nature D. Directing focus only on the pathological state

Correct Answer is B

Explanation

A) Focusing on helping patients be disease free: The World Health Organization (WHO) definition of health goes beyond the absence of disease. It emphasizes the complete state of physical, mental, and social well-being, rather than simply the absence of illness. Focusing solely on being disease-free does not align with this holistic view of health.

B) Providing care that involves the whole person: This is the correct approach in line with the WHO definition of health. WHO defines health as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. Therefore, the nurse should focus on addressing all aspects of a person’s health, including emotional, social, and physical needs, to promote overall well-being.

C) Assuring that care is strictly personal in nature: While personal care is important, the WHO definition of health emphasizes a broader, more holistic approach that incorporates physical, mental, and social aspects of health, not just personal care. It’s about treating the whole person in context, including their environment and social relationships.

D) Directing focus only on the pathological state: The WHO definition moves beyond just focusing on the pathological (disease) state and emphasizes wellness in all aspects of life. While addressing medical issues is important, focusing solely on pathology ignores the broader concept of health that includes mental and social well-being.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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