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
The correct answer is A. Interlace the fingers while rubbing hands together. This is one of the steps of performing a surgical hand scrub, which is an antiseptic surgical scrub or antiseptic hand rub that is performed prior to donning surgical attire. Interlacing the fingers helps to remove microorganisms from the spaces between the fingers and under the nails.
Correct Answer is D
Explanation
Choice A rationale:
An angiocatheter is not appropriate for accessing an implanted venous access port. Angiocatheters are large-bore catheters designed for rapid fluid administration and are typically used for peripheral venous access. They are not suitable for accessing the small, specialized ports used for central venous access.
Choice B rationale:
A 25-gauge needle is too small for accessing an implanted venous access port. While smaller gauge needles are suitable for delicate procedures and patients with fragile veins, they might not provide adequate flow for certain therapies or blood draws. Accessing a port with a needle that is too small can lead to increased pressure, potentially damaging the port or causing discomfort to the patient.
Choice C rationale:
A butterfly needle is also not the best choice for accessing an implanted venous access port. Butterfly needles, also known as winged infusion sets, are commonly used for short-term peripheral venous access. They are not designed for accessing implanted ports, which require a noncoring needle for precise and safe access without damaging the port membrane.
Choice D rationale:
(Correct Choice) A noncoring needle, also known as a Huber needle, is the correct choice for accessing an implanted venous access port. Noncoring needles have a specially designed tip that creates a smaller puncture hole, reducing damage to the port membrane and minimizing patient discomfort. They are specifically designed for accessing ports and are the standard choice for this procedure.
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