A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select All that Apply.)
Contractures
Diarrhea
Polyuria
Atelectasis
Pressure ulcers
Correct Answer : A,D,E
Choice A rationale: Contractures are a common complication of immobility due to the shortening of muscles and connective tissues.
Choice B rationale: Diarrhea is not typically associated with complications of immobility.
Choice C rationale: Polyuria is not typically associated with complications of immobility.
Choice D rationale: Atelectasis, the collapse of lung tissue, can occur in immobile clients due to reduced lung expansion and ventilation.
Choice E rationale: Pressure ulcers are a significant risk in immobile clients due to prolonged pressure on specific areas of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Inserting an indwelling urinary catheter is an invasive intervention and should be reserved for specific indications. It does not prevent skin breakdown.
Choice B rationale: Applying a moisture barrier ointment to the client's skin helps protect the skin from the harmful effects of urine and prevents breakdown.
Choice C rationale: Cleaning the client's skin and perineum with hot water after each episode of incontinence can lead to skin irritation and breakdown.
Choice D rationale: Checking the client's skin every 8 hours is not sufficient to prevent skin breakdown. Continuous assessment and prompt intervention are needed.
Correct Answer is B
Explanation
Choice A rationale: A client who is confined to bedrest may not need a gait belt as they are not ambulating.
Choice B rationale: A client with leg strength who can cooperate with movement is a likely candidate for a gait belt. This device provides support and stability during ambulation.
Choice C rationale: A client with a thoracic incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.
Choice D rationale: A client with an abdominal incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.
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