The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?
Progress diet slowly from ice chips to clear liquids.
Maintain intervascular infusion rate.
Apply intermittent pneumatic compression devices.
Obtain frequent pain level assessments.
The Correct Answer is C
A. Progressing the diet is important but does not address immobility-related complications.
B. Maintaining the IV infusion rate is necessary but not specific to preventing complications from immobility.
C. Applying intermittent pneumatic compression devices helps prevent deep vein thrombosis (DVT), a significant risk for immobile clients post-surgery. This is a critical preventative measure for immobility-related complications.
D. Frequent pain assessments are important but do not specifically prevent complications from immobility.
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Related Questions
Correct Answer is D
Explanation
A. While concerning, a single refusal to eat is not immediately life-threatening.
B. While being yelled at could escalate, the situation is not as urgent as others.
C. While refusing to participate in group is concerning, it is not immediately life- threatening.
D. Pacing in a client with bipolar disorder may indicate agitation or the onset of a manic episode, which could lead to dangerous behavior and requires immediate attention.
Correct Answer is ["A","B","C","D"]
Explanation
A) This is a common symptom as individuals may avoid social interactions and isolate themselves due to ongoing distress.
B) Exaggerated startle response: Individuals may have an increased startle reflex following trauma, which can persist over time.
C) Intrusive thoughts: These are unwanted and distressing thoughts related to the trauma that can continue to affect the individual.
D) Avoidance of places associated with the assault: This behavior is a protective mechanism to prevent re-experiencing the traumatic event.
E) Overeating: Overeating is not a characteristic sequalae of rape trauma.
F) Hallucinations: Hallucinations are not typically associated with long-term symptoms of rape- trauma syndrome. Hallucinations can occur in severe cases, particularly if there are co-occurring mental health disorders such as PTSD.
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