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 D
Explanation
The correct answer is choice d. Privately interview the client about the injuries.
Choice A rationale:
Contacting the family regarding the client’s condition might not be appropriate if the family is suspected of being involved in the abuse. It could potentially put the client at further risk.
Choice B rationale:
Notifying risk management is important for documentation and internal review, but it does not directly address the immediate need to assess and ensure the client’s safety.
Choice C rationale:
Informing the transferring agency of the client’s condition is necessary for continuity of care, but it does not address the immediate need to investigate the cause of the injuries and ensure the client’s safety.
Choice D rationale:
Privately interviewing the client about the injuries allows the nurse to gather more information about the cause of the injuries in a safe and confidential manner. This step is crucial in assessing the situation and determining if further action, such as reporting to authorities, is needed. It ensures the client’s safety and helps in identifying any potential abuse.
Correct Answer is C
Explanation
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