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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale: Elevating the head of the bed is not the recommended action when moving a client up in bed.
Choice B rationale: Having the client fold the arms across the chest is not the primary action when moving a client up in bed.
Choice C rationale: Asking another nurse about the plan of care is not necessary in this situation and does not directly address the action needed when moving the client.
Choice D rationale: Maintaining a pillow under the client's head helps provide comfort and support during the movement.

A. A client 92 years of age who uses a walker, is incontinent, and has an extensive cardiac history B. A client 45 years of age who has paraplegia C. A client 68 years of age who is comatose due to a traumatic brain injury D. A client 75 years of age who uses a cane and has dementia

Correct Answer is A

Explanation

Choice A rationale: The client who is 92 years old, uses a walker, is incontinent, and has an extensive cardiac history is at higher risk for the development of pressure injuries due to age, immobility, and additional risk factors.
Choice B rationale: A client with paraplegia may be at risk for pressure injuries, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.
Choice C rationale: A comatose client with a traumatic brain injury is at risk, but other factors in Choice A contribute to a higher overall risk.
Choice D rationale: A client who uses a cane and has dementia may be at risk, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When moving a client up in bed with the assistance of another caregiver, the nurse should:

Correct Answer is B

Explanation

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

Correct Answer is A

Explanation

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