A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?
Confusion
Blurred vision
Diarrhea
Polyuria
The Correct Answer is A
Confusion can be a sign of delirium, which is a common complication of immobility in older adults due to sensory deprivation, sleep disturbance, medication side effects, or dehydration. The nurse should assess for other causes of confusion, such as infection or hypoxia, and implement interventions to prevent or treat delirium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should plan to confirm the correct position of the line by obtaining a blood sample, as this is one of the methods to verify placement and patency of a central venous catheter. The nurse should also instruct the client to perform a Valsalva maneuver (bearing down) as the catheter is inserted, place the head of the client's bed higher than 30 degrees, and cleanse the site with an antiseptic solution such as chlorhexidine.
Correct Answer is B
Explanation
This indicates hyperkalemia, which is a common complication of severe burn injuries due to massive cell destruction and fluid lossfrom damaged tissues. Hyperkalemia can lead to cardiac dysrhythmias and arrest, which are signs of hypovolemic shock.
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