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 A
Explanation
Choice A rationale:
Documenting the desire to be an organ donor in writing is a legal requirement and ensures that the individual's wishes are respected after their passing. It also provides clear guidance to healthcare providers and family members about the individual's decision.
Choice B rationale:
There is no specific age requirement to become an organ donor. People of various ages can register as organ donors, and eligibility often depends on the condition of the organs at the time of death.
Choice C rationale:
Once someone is listed as an organ donor, their name can be removed if they change their mind. It's essential for individuals to inform their family members about their decision and ensure their wishes are respected.
Choice D rationale:
The nurse can indeed be a witness for the consent to donate. Being a witness ensures the authenticity of the individual's decision to become an organ donor and can be helpful in legal and ethical contexts.
Correct Answer is D
Explanation
The correct answer is D. Contractions.
Choice A Reason: Hypertension Hypertension in pregnancy is a condition that can occur independently of an amniocentesis and is typically monitored throughout the pregnancy. It is characterized by a sustained high blood pressure of 140/90 mmHg or higher. While hypertension is a concern in pregnancy, it is not a direct complication of amniocentesis. Normal ranges for blood pressure in the third trimester are 101.6 to 143.5 mmHg systolic and 62.4 to 94.7 mmHg diastolic.
Choice B Reason: Vomiting Vomiting is not a typical complication following an amniocentesis. It may be associated with other conditions during pregnancy such as hyperemesis gravidarum or gastrointestinal disturbances but is not directly related to the procedure of amniocentesis.
Choice C Reason: Epigastric Pain Epigastric pain is typically associated with conditions like preeclampsia or other gastrointestinal issues in pregnancy, not with amniocentesis. It is characterized by pain in the upper abdomen and is not a common complication post-amniocentesis.
Choice D Reason: Contractions After an amniocentesis, especially at 33 weeks of gestation, monitoring for contractions is crucial because they can indicate preterm labor, which is a known risk associated with the procedure. The normal range for contractions would be none to infrequent Braxton-Hicks contractions, which are not regular and do not signify labor.
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