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

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

Hypocalcemia

Atelectasis

Hypertension

Urinary stasis

Pressure ulcer

Diarrhea

Contractures

calcium resorption

Answer and Explanation

Correct Answer : B,D,E,G,H

A. Hypocalcemia: Prolonged immobility is more commonly associated with calcium loss from bones into the bloodstream rather than decreased serum calcium levels. Neuromuscular inactivity does not typically produce hypocalcemia as a primary complication.

B. Atelectasis: Immobility and prolonged bed rest reduce lung expansion and impair effective ventilation. Decreased chest wall movement increases the risk of alveolar collapse, especially when the client avoids repositioning. This places the client at risk for impaired gas exchange.

C. Hypertension: Blood pressure is within normal limits, and immobility does not directly cause elevated blood pressure. Cardiovascular deconditioning may occur, but hypertension is not an expected immobility-related complication.

D. Urinary stasis: Reduced mobility interferes with complete bladder emptying and normal voiding patterns. Urinary stasis increases the risk for urinary tract infection and bladder distention. Clients with multiple sclerosis are particularly vulnerable due to neurogenic bladder dysfunction.

E. Pressure ulcer: Refusal to turn or change position places sustained pressure on bony prominences, impairing tissue perfusion. Prolonged pressure leads to ischemia, skin breakdown, and ulcer formation. This is a major and immediate risk in immobile clients.

F. Diarrhea: Decreased mobility is more commonly associated with constipation due to slowed gastrointestinal motility. Diarrhea is not a typical complication of immobility or positioning refusal.

G. Contractures: Prolonged positioning without movement leads to muscle shortening and joint stiffness. Lack of range-of-motion activity accelerates the development of fixed joint deformities. Clients with neurologic disease are at especially high risk.

H. Calcium resorption: Immobility causes increased bone demineralization due to lack of weight-bearing activity. Calcium is released from bones into the bloodstream, increasing fracture risk over time. This is a well-recognized complication of prolonged immobility.

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Correct Answer is A

Explanation

A. Client report of uterine cramping: Oxytocin stimulates uterine contractions to control postpartum bleeding. Mild to moderate cramping is an expected and therapeutic effect of the medication, indicating the uterus is responding appropriately.

B. Boggy fundus 3 fingerbreadths above the umbilicus: A boggy, elevated fundus suggests ongoing uterine atony and uncontrolled bleeding, which is not an expected finding after oxytocin administration. This would require immediate reassessment and intervention.

C. Client report of burning with urination: Oxytocin does not affect the urinary tract directly. Dysuria is unrelated to oxytocin administration and is not an expected outcome.

D. Saturation of perineal pad in 15 min: Excessive bleeding despite oxytocin indicates insufficient uterine contraction or another complication. Effective oxytocin therapy should reduce vaginal bleeding, so rapid saturation of pads is an abnormal finding.

A. Limit the personal toiletries in the client's room to cologne. B. Ensure the client swallows each dose of medication. C. Observe the client's behavior every 2 hr. D. Keep the client's door shut when they are in the room.

Correct Answer is B

Explanation

A. Limit the personal toiletries in the client's room to cologne: Cologne contains alcohol and glass containers that can pose safety risks. Personal items should be restricted, but cologne is not appropriate to allow in the room. Safer alternatives would be basic, nonhazardous hygiene items under supervision.

B. Ensure the client swallows each dose of medication: Clients who have attempted suicide may cheek or hoard medications for later self-harm. Verifying that each dose is swallowed reduces the risk of medication accumulation and overdose. This action directly supports client safety during a high-risk period.

C. Observe the client's behavior every 2 hr: Clients at risk for self-harm require close or continuous observation, often 1:1 or at least every 15 minutes, depending on policy and risk level. Two-hour intervals are insufficient during the acute phase following a suicide attempt.

D. Keep the client's door shut when they are in the room: Keeping the door shut limits visibility and delays response if the client becomes distressed or unsafe. Maintaining visual access allows for timely intervention and supports ongoing safety monitoring.

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

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