A nurse is caring for a client on a psychiatric unit.

Exhibits

For each potential action, click to specify if the action is indicated or. contraindicated for the client.

Choice A rationale:
Contractures are a risk for this client due to the lack of movement and constant positioning on one side. Contractures occur when the muscles, tendons, or ligaments shorten and tighten, limiting range of motion and flexibility. This can be a result of prolonged immobility or lack of use of the muscles.
Choice B rationale:
Calcium resorption is not a risk for this client. Calcium resorption refers to the process where bone tissue is broken down and calcium is released into the bloodstream. This process is not directly related to immobility or multiple sclerosis.
Choice C rationale:
Hypocalcemia, or low calcium levels in the blood, is also not a direct risk for this client. While immobility can lead to bone loss over time, it does not directly cause hypocalcemia.
Choice D rationale:
Diarrhea is not a risk for this client based on the information provided. Diarrhea can be a symptom of many conditions but there is no indication in the scenario that this client is at risk.
Choice E rationale:
Urinary stasis is a risk for this client due to their immobility. When a person is immobile, urine can pool in the bladder, creating an environment where bacteria can grow, potentially leading to urinary tract infections.

Choice F rationale:
Hypertension, or high blood pressure, is not a direct risk for this client based on the information provided. While chronic diseases like multiple sclerosis can indirectly contribute to hypertension through stress or medication side effects, it’s not directly caused by immobility or multiple sclerosis.

Choice G rationale:

Pressure injury is a significant risk for this client due to their constant positioning on one side and refusal to change positions. Pressure injuries occur when there is prolonged pressure on one area of the body, restricting blood flow and leading to tissue damage and necrosis.

Choice H rationale:

Atelectasis, or collapse of part of the lung, is also a risk for this client due to their immobility. When a person is immobile, they may take shallow breaths which do not fully inflate the lungs, leading to areas of collapse.

Choice A rationale:

An altered level of consciousness is a common finding in clients with Alzheimer's disease. This may range from mild confusion to severe cognitive impairment. It is caused by the degeneration of brain cells and affects memory, thinking, and behavior.

Choice B rationale:

Rapid mood swings are not specific to Alzheimer's disease. While mood changes can occur, they are not typically characterized by rapid swings. Mood disturbances may include depression, apathy, or irritability, but these symptoms are not unique to Alzheimer's disease.

Choice C rationale:

Excessive motor activity is not a typical finding in clients with Alzheimer's disease. Instead, clients often experience a decline in motor skills and coordination as the disease progresses. Restlessness or agitation might occur, but excessive motor activity is not a characteristic feature.

Choice D rationale:

Failure to recognize familiar objects, people, or places is a common symptom of Alzheimer's disease. This is due to the damage and loss of nerve cells in the brain. As the disease advances, clients may have difficulty recognizing even close family members or their own reflection in the mirror.