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 D
Explanation
Choice A rationale: Removing excess drainage and wet tissue to prevent maceration is more related to wound care than debridement.
Choice B rationale: Stimulating the wound bed to promote the growth of granulation tissue is a goal of debridement.
Choice C rationale: Removing purulent drainage from the wound bed is more related to wound care than debridement.
Choice D rationale: The primary goal of debridement is to remove dead or infected tissue to promote wound healing and create an environment conducive to tissue regeneration.
Correct Answer is D
Explanation
Choice A rationale: Purulent drainage is thick and opaque, often indicating infection.
Choice B rationale: Serous drainage is thin and watery, typically clear or slightly yellow.
Choice C rationale: Sanguineous drainage is bright red and indicates fresh bleeding.
Choice D rationale: Serosanguineous drainage is thin and pale pink-yellow, representing a mixture of serous and sanguineous components.
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