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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 C

Explanation

Rationale:

A. Restrict alcohol intake to 350 mL (12 oz) of wine per day: This recommendation exceeds the safe alcohol limit for individuals at risk for hypertension. For women, the limit is typically one drink per day, and for men, up to two.

B. Limit caloric intake to 2,500 calories per day: 2,500 calories may still be excessive for many individuals, especially those with sedentary lifestyles. Hypertension risk is more effectively reduced through balanced nutrition and physical activity, not just calorie limits.

C. Walk for 30 min 5 days per week: Regular aerobic exercise like walking improves cardiovascular health and is strongly recommended to prevent and manage hypertension. This frequency and duration align with guidelines to lower blood pressure and support overall wellness.

D. Increase dietary intake of canned vegetables: Canned vegetables often contain high sodium levels, which can contribute to elevated blood pressure. Clients at risk for hypertension should be encouraged to choose fresh or low-sodium alternatives to help control sodium intake.

A. Case manager B. Primary care provider C. Nutritionist D. Pediatric nurse practitioner

Correct Answer is A

Explanation

Rationale:

A. Case manager: Case managers coordinate resources and support services for clients, including assistance with financial concerns and access to programs that provide free or low-cost baby formula. They are the best resource to help the client navigate community aid and social services.

B. Primary care provider: While the primary care provider manages the client’s overall health, they are not typically responsible for connecting clients with financial assistance programs related to infant feeding.

C. Nutritionist: Nutritionists provide dietary advice and education but generally do not address financial barriers or resource allocation for obtaining formula.

D. Pediatric nurse practitioner: Pediatric nurse practitioners focus on the infant’s health and development and may provide feeding guidance, but addressing the client’s financial inability to pay for formula falls outside their primary role.

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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.