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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. The client needs strict measurement of intake and output: This task can be delegated to assistive personnel as it involves routine data collection without complex clinical judgment.

B. The client develops a postoperative fever: A postoperative fever may indicate infection or other complications requiring assessment, clinical judgment, and intervention by a registered nurse.

C. The client is experiencing a therapeutic effect from their treatment: Monitoring expected therapeutic effects is routine and can often be overseen by licensed practical nurses or assistive personnel, depending on policy.

D. The client needs routine wound care performed: Routine wound care is generally a delegated nursing task that does not require the advanced assessment or clinical decision-making of an RN unless complications arise.

A. "I should use a firm mattress in my baby's crib." B. "I should set my hot water heater at 130 degrees Fahrenheit." C. “I should use a crib with side rails that drop" D. "I should position my baby on their stomach to sleep during the day."

Correct Answer is A

Explanation

Rationale:

A. "I should use a firm mattress in my baby's crib.": A firm mattress reduces the risk of sudden infant death syndrome (SIDS) and suffocation by providing a stable, flat surface for safe infant sleep. This is a key recommendation in safe sleep guidelines.

B. "I should set my hot water heater at 130 degrees Fahrenheit.": Setting the water heater at 130°F increases the risk of scald burns, especially for infants and young children. The recommended temperature to prevent burns is 120°F or lower.

C. “I should use a crib with side rails that drop": Drop-side cribs have been banned due to safety concerns, including risk of entrapment and suffocation. Using a crib with fixed side rails is safer and recommended.

D. "I should position my baby on their stomach to sleep during the day.": Placing infants on their stomach to sleep increases the risk of SIDS. The safest position for sleep is on the back, both during the day and night.

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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.