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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.

Urinary stasis

Calcium resorption

Contractures

Hypocalcemia

Hypertension

Diarrhea

Pressure ulcer

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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Correct Answer is B

Explanation

Rationale:

A. Thoroughly explain each procedure to the toddler: Toddlers have limited cognitive ability to understand detailed explanations. Overexplaining may cause anxiety rather than reassurance, especially if unfamiliar medical terms are used.

B. Allow the toddler to handle the equipment: Allowing the toddler to touch and explore safe medical equipment, like a stethoscope, helps reduce fear and builds trust. This play-based approach fosters cooperation and makes the exam less intimidating.

C. Completely undress the toddler: Toddlers can feel vulnerable when fully undressed. It is more appropriate to remove clothing gradually, only as needed for each part of the examination, to ensure comfort and security.

D. Start the examination with routine immunizations: Beginning with painful procedures like injections can create fear and resistance, making the rest of the exam more difficult. Immunizations should be done at the end of the visit.

A. naloxone B. an additional dose of propofol C. oxygen 10 L/min via face mask D. acetaminophen E. an additional dose of fentanyl F. propranolol

Correct Answer is ["A","C"]

Explanation

Rationale:

• Naloxone: The client received fentanyl and is now showing signs of opioid-induced respiratory depression. Respiratory rate has decreased to 10/min and oxygen saturation to 87%. Naloxone will reverse the opioid’s effects and restore adequate respiratory effort.

• An additional dose of propofol: The client’s level of sedation is already too deep, as shown by low respiratory rate and blood pressure. Additional propofol would worsen central nervous system depression. It may cause complete apnea or cardiac compromise in this situation.

• Oxygen 10 L/min via face mask: The current oxygen flow via nasal cannula is insufficient given the client's low oxygen saturation. A face mask delivers higher oxygen concentration and flow. This is critical to correct hypoxia until the cause is reversed.

• Acetaminophen: There is no fever or current complaint of pain requiring antipyretics or analgesics. Administering acetaminophen now would not address the acute respiratory issue. It would delay more urgent and appropriate interventions.

• An additional dose of fentanyl: Administering more opioid would increase the risk of further respiratory depression. The client is already showing hypoventilation and declining oxygenation. More fentanyl would worsen sedation and endanger airway and breathing.

• Propranolol: The client is already hypotensive with a BP of 80/51 mm Hg and a heart rate of 68/min. Giving a beta blocker could severely depress cardiac output. This would increase the risk of organ hypoperfusion and cardiac arrest.

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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.

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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.