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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Applying an ice pack to the client's knee can help reduce inflammation, swelling, and pain after a total knee arthroplasty. The nurse should avoid placing pillows under the client's knee, as this can cause flexion contractures and impair mobility and healing. Massaging or manipulating the incision site can increase pain and risk of infection or bleeding. Range-of-motion exercises are important for recovery, but they should be done with caution and under supervision, not when the client is experiencing severe pain.
Correct Answer is B
Explanation
The nurse should consult the client before approaching the dog, as the service animal is working and may have specific instructions from the handler on how to interact with others. The nurse should respect the client's autonomy and preferences regarding their service animal and not interfere with their bond or function.
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