A nurse is assisting with the care of a client who has decreased mobility and requires repositioning every 2 hr. Which of the following outcomes should the nurse expect?
The client was discharged to home without developing complications of immobility.
The client returned to the facility 2 days after being discharged due to a urinary tract infection.
The client developed a rash on their back and lower extremities.
The client refuses to eat because they are nauseated.
The Correct Answer is A
A. The client was discharged to home without developing complications of immobility: Repositioning a client every 2 hours is a key intervention to prevent pressure injuries, improve circulation, and reduce the risk of complications such as skin breakdown, deep vein thrombosis, and pneumonia. Achieving discharge without immobility-related complications indicates that preventive measures were effective.
B. The client returned to the facility 2 days after being discharged due to a urinary tract infection: Development of a urinary tract infection shortly after discharge may be related to catheter use, incontinence, or urinary stasis, but frequent repositioning does not directly prevent UTIs. This outcome suggests a complication occurred despite nursing interventions.
C. The client developed a rash on their back and lower extremities: Skin rashes may indicate irritation, allergic reactions, or moisture-associated skin damage. Repositioning helps relieve pressure and reduce friction but does not directly prevent all types of rashes. The appearance of a rash reflects a complication related to skin integrity rather than an expected outcome.
D. The client refuses to eat because they are nauseated: Nausea and refusal of food are unrelated to repositioning frequency. While immobility can contribute to gastrointestinal stasis, this outcome does not reflect the effectiveness of repositioning interventions for preventing pressure injuries or related complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Tell the family to adhere to the facility menu when choosing food for the child: Forcing adherence to the facility menu may conflict with the child’s cultural preferences and could lead to poor intake or refusal to eat. Respecting cultural practices promotes adequate nutrition and comfort.
B. Advise the family to offer a 14 serving size of solid foods at mealtime: A 14-serving portion is excessive for a 2-year-old and could lead to overeating, digestive discomfort, or obesity. Appropriate serving sizes for toddlers should be small, age-appropriate portions that meet nutritional needs.
C. Instruct the family to bring familiar food from home for the child: Allowing culturally familiar foods supports adequate nutrition, encourages eating, and respects the family’s cultural preferences. Familiar foods can also reduce anxiety and improve acceptance of hospital or care environment meals.
D. Inform the family to offer a cup of juice with each meal: Excessive juice can contribute to diarrhea, dental caries, or nutritional imbalance. Guidelines recommend limiting juice for toddlers to no more than 4–6 ounces per day, not with every meal.
Correct Answer is A
Explanation
A. The adolescent brother criticizes the parents' plan to have a funeral service: Adolescents often struggle with complex emotions such as anger, denial, and a desire for control when facing a sibling’s terminal illness. Criticizing parental decisions reflects attempts to assert independence and process grief in a way that aligns with their developmental stage.
B. The school-age sister views death as being a type of temporary sleep: Viewing death as temporary sleep is more typical of preschool-aged children, who think concretely and cannot yet understand the permanence of death. School-age children begin to understand that death is irreversible and final.
C. The adolescent brother fears the terminal illness is contagious: Fear of contagion is more characteristic of younger children, who may have difficulty distinguishing biological facts from magical thinking. Adolescents usually have a more realistic understanding of disease transmission.
D. The school-age sister is concerned about the impact of her sibling's death on herself: While school-age children do experience grief, their understanding of death is concrete, and self-focused concerns are less common than for adolescents. They are more likely to express concern about changes in routines or the well-being of surviving family members rather than abstract personal impact.
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