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) Droplet: Droplet precautions are used for infections that spread through respiratory droplets when an infected person coughs, sneezes, or talks. While measles is transmitted through respiratory droplets, the virus is highly contagious and requires airborne precautions, not just droplet precautions.

B) Contact: Contact precautions are used for infections spread through direct contact with the patient or their environment, such as gastrointestinal or skin infections. Measles is primarily spread through the air and is not classified as a contact transmission infection.

C) Airborne: Measles is an airborne illness, which means that it can be transmitted through small respiratory droplets that remain suspended in the air for long periods of time. Airborne precautions are necessary to protect healthcare workers and other patients from exposure. These precautions include placing the child in a negative pressure room and requiring healthcare workers to wear N95 respirators.

D) Protective environment: Protective environment precautions are used for patients with severely weakened immune systems, such as those undergoing chemotherapy or organ transplantation. These precautions are designed to protect the patient from infections, not to prevent the spread of contagious illnesses like measles.

A. Tanning beds are much safer then lying in the sun. B. "Share piercing needles only with close friends you trust." C. Your need for sleep will increase during periods of growth." D. "Limit your caloric intake to avoid becoming overweight."

Correct Answer is C

Explanation

A) Tanning beds are much safer than lying in the sun: This statement is inaccurate. Tanning beds can actually be more harmful than sun exposure, as they expose the skin to concentrated ultraviolet (UV) radiation, which increases the risk of skin cancer, premature aging, and other skin damage. Health promotion teaching should focus on the dangers of tanning and emphasize safe sun practices, such as using sunscreen and avoiding tanning beds.

B) "Share piercing needles only with close friends you trust": This statement is dangerous and misleading. Sharing needles for piercings or tattoos, regardless of trust, can transmit bloodborne infections such as HIV, hepatitis B, and hepatitis C. The nurse should emphasize the importance of using sterilized, single-use needles and ensuring proper hygiene to prevent infections.

C) Your need for sleep will increase during periods of growth: This statement is accurate. Adolescents experience significant physical and cognitive growth, which increases their need for sleep. The nurse should encourage adolescents to prioritize adequate sleep, as it is essential for physical development, emotional well-being, and overall health.

D) "Limit your caloric intake to avoid becoming overweight": While maintaining a balanced diet is important, the focus should not be solely on limiting caloric intake. Adolescents are in a period of rapid growth and development, and their nutritional needs are higher. Health promotion should emphasize eating a balanced diet with appropriate portions of nutrients rather than focusing on restricting calories.

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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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