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A home care nurse is assisting with the care of a client.

Exhibits
The nurse is planning to focus data collection based on the general findings. Select 5 complications the client is at risk for.

A.

Urinary stasis

B.

Calcium resorption

C.

Contractures

D.

Hypocalcemia

E.

Hypertension

F.

Diarrhea

G.

Pressure ulcer

H.

Atelectasis

Answer and Explanation

Correct Answer : A,B,C,G,H

Rationale:
• Urinary stasis: Immobility slows bladder emptying and ureteral flow, increasing residual urine. This promotes bacterial growth and risk of urinary tract infection. MS clients with decreased mobility are especially vulnerable.

• Calcium resorption: Bone demineralization occurs during prolonged immobility. Without weight-bearing, calcium is released from bone into the bloodstream, raising serum calcium and weakening bones.

• Contractures: Lack of movement leads to shortening and stiffening of muscles and joints. Over time, joints lose flexibility, especially if the client remains curled in one position.

• Hypocalcemia: The client is more likely to develop hypercalcemia due to calcium resorption from bones. There's no evidence of low calcium symptoms like tetany or numbness.

• Hypertension: The client's vital signs are within normal range. Immobility may reduce cardiac output over time, but it does not typically cause high blood pressure.

• Diarrhea: Immobility usually causes constipation due to slowed peristalsis. There's no report of active GI symptoms or triggers for diarrhea in this case.

• Pressure ulcer: Continuous pressure on one area reduces capillary blood flow. This leads to tissue ischemia and skin breakdown, especially over bony prominences like the hip and shoulder.

• Atelectasis: Lying on one side restricts lung expansion, and refusal to change positions impairs ventilation. This can cause alveolar collapse and decreased oxygen exchange.


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Related Questions

Correct Answer is D

Explanation

Rationale:

A. Heparin 5000 U subcutaneous every 8 hr: Using "U" for units can be misread as zero, potentially causing a tenfold overdose. The correct transcription uses the full word "units" to prevent errors.

B. M50, 10g PO delly: This prescription contains multiple errors: "M50" is unclear, "10g" may be excessive or incorrect dosing, and "delly" is an incorrect abbreviation for daily. This transcription is inaccurate and unsafe.

C. Lorazepam 0.5 mg PO PRN at bedtime: Although mostly correct, "PRN at bedtime" can be confusing. It is clearer to specify "PRN for anxiety at bedtime" or "PRN as needed at bedtime" to clarify the indication and timing.

D. Doxazosin 5 mg PO at bedtime: This transcription is clear, uses accepted abbreviations, specifies route and time, and includes no dangerous abbreviations, making it an accurate and safe prescription transcription.

Correct Answer is B

Explanation

Rationale:

A. Notify the unit manager: Informing the unit manager is necessary for institutional follow-up and quality assurance. However, it is not the immediate concern. Client safety and clinical status must be assessed first to determine if harm has occurred due to the error.

B. Collect data on the client: Assessing the client is the priority to determine if the excessive fluid has caused complications such as fluid overload, pulmonary edema, or changes in vital signs. Early identification of adverse effects is essential to guide further intervention.

C. Notify the provider: The provider should be informed after assessing the client so that appropriate medical interventions or monitoring can be initiated. Immediate data collection ensures the nurse can give accurate information about the client’s status.

D. Complete an incident report: Documentation of the error is an important step for institutional learning and accountability. However, it is not time-sensitive in the way client safety and assessment are and should follow after urgent clinical actions are taken.

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