A home care nurse is assisting with the care of a client.
Urinary stasis
Calcium resorption
Contractures
Hypocalcemia
Hypertension
Diarrhea
Pressure ulcer
Atelectasis
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. The client is admitted due to noncompliance at home: The term "noncompliance" is vague and judgmental. Documentation should focus on specific behaviors or observations (e.g., "client was not taking prescribed medications") rather than generalizing or attributing motives.
B. The client uses neologisms when speaking to others: This statement is objective and describes a specific, observable behavior. Using clinical terms to document symptoms of schizophrenia aligns with accurate and professional documentation standards.
C. The client is disruptive and annoying to other clients in the facility: This phrasing is subjective and emotionally charged. Accurate documentation should avoid value-laden terms and instead describe the exact behavior (e.g., "client raised voice and interrupted group session").
D. The client's partner is making their symptoms worse: This is speculative and not based on objective observation. Unless the client specifically states this or it is directly witnessed, such assumptions should not be included in medical documentation.
Correct Answer is A
Explanation
Rationale:
A. Chromosomal abnormalities: Amniocentesis involves analyzing amniotic fluid to detect genetic and chromosomal disorders such as Down syndrome, trisomy 18, and neural tube defects. It is typically performed between 15 and 20 weeks gestation for diagnostic accuracy during this stage of fetal development.
B. Placental circulation: Assessment of placental blood flow and circulation is usually done via Doppler ultrasound, not amniocentesis. Amniocentesis does not evaluate the vascular function or perfusion status of the placenta.
C. Rh incompatibility: While amniocentesis may reveal fetal anemia due to Rh sensitization in rare cases, it is not the primary test used for diagnosing Rh incompatibility. Blood antibody screening and Doppler assessment of the middle cerebral artery are preferred for Rh-related concerns.
D. Fetal breathing movements: Fetal breathing is assessed through a biophysical profile or real-time ultrasound, not via amniotic fluid sampling. Amniocentesis does not provide information about the fetus’s respiratory activity or movement patterns.
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