A home care nurse is caring for a client who has advanced multiple.
sclerosis.
Nurses' Notes.
2 weeks ago:Today: The client reports depression is increasing as they are unable to. participate in activities they once enjoyed because of the.
advancing multiple sclerosis.
Even getting up to the wheelchair.
is "just too much" for them.
The home health aide reported client will not permit turning. position changes.
The client states, "I can only get comfortable.
curled on my left side.
I'm not moving.". Vital Signs.
Today:Temperature 36.8° C (98.2° F). Heart rate 80/min.
Respiratory rate 20/min.
BP 116/76 mm Hg. Client Education.
1 week ago:Educated the client about the importance of getting out of bed.
changing positions in bed.
Client stated, ""l try.". Select the 5 complications the client is at risk for.
Contractures.
Calcium resorption.
Hypocalcemia.
Diarrhea.
Urinary stasis.
Correct Answer : A,E
Choice A rationale:
Contractures are a risk for this client due to the lack of movement and constant positioning on one side. Contractures occur when the muscles, tendons, or ligaments shorten and tighten, limiting range of motion and flexibility. This can be a result of prolonged immobility or lack of use of the muscles.
Choice B rationale:
Calcium resorption is not a risk for this client. Calcium resorption refers to the process where bone tissue is broken down and calcium is released into the bloodstream. This process is not directly related to immobility or multiple sclerosis.
Choice C rationale:
Hypocalcemia, or low calcium levels in the blood, is also not a direct risk for this client. While immobility can lead to bone loss over time, it does not directly cause hypocalcemia.
Choice D rationale:
Diarrhea is not a risk for this client based on the information provided. Diarrhea can be a symptom of many conditions but there is no indication in the scenario that this client is at risk.
Choice E rationale:
Urinary stasis is a risk for this client due to their immobility. When a person is immobile, urine can pool in the bladder, creating an environment where bacteria can grow, potentially leading to urinary tract infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
No explanation
Correct Answer is C
Explanation
The correct answer is choice C: Initiate continuous cardiac monitoring.
Choice A rationale:
Implementing fluid restrictions is not recommended for a child with diabetic ketoacidosis (DKA). DKA is characterized by severe dehydration due to osmotic diuresis, and fluid replacement is a critical component of treatment to restore hydration and circulatory volume.
Choice B rationale:
Monitoring vital signs every 8 hours is not sufficient for a child with DKA. DKA is an acute, life-threatening condition that requires close monitoring of vital signs to detect changes in the patient’s condition promptly. Vital signs should be monitored more frequently, typically every 1 to 2 hours, depending on the severity of the DKA and institutional protocols.
Choice C rationale:
Continuous cardiac monitoring is recommended for a child with DKA. DKA can lead to serious electrolyte imbalances, such as hypokalemia, which can cause cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these potential complications.
Choice D rationale:
Administering subcutaneous insulin 30 minutes before meals is not appropriate for the acute management of DKA. In DKA, insulin is typically administered intravenously to rapidly decrease blood glucose levels and correct metabolic acidosis. Subcutaneous insulin is not used until the patient is stable and able to eat.
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