A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

Decreased RBC production

Increased calcium excretion

Increased insulin production

Decreased sodium excretion

Answer and Explanation

The Correct Answer is B

A. Prolonged immobility does not directly decrease red blood cell (RBC) production. RBC production is primarily regulated by erythropoietin from the kidneys and oxygen demand, which may not be significantly altered by immobility alone.
B. Increased calcium excretion is a well-documented effect of immobility. When a person is immobile, bone resorption increases, leading to the release of calcium into the bloodstream and subsequent excretion through the urine. This can increase the risk of kidney stones and osteoporosis.
C. Immobility typically reduces metabolic demand and insulin sensitivity rather than increasing insulin production. Insulin resistance is more commonly associated with prolonged immobility.
D. Immobility does not directly affect sodium excretion in a way that would cause it to decrease. Sodium balance is primarily regulated by the kidneys and other hormonal mechanisms unrelated to immobility.

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Correct Answer is A

Explanation

A. A gait belt is the most appropriate device to assist with balance and support when walking, especially if the client is at risk of falling. It allows the nurse to provide support at the waist, helping the client maintain balance and preventing falls.
B. A jacket harness is typically used for more severe balance issues or when additional support is needed to prevent falls, but it is not commonly used for simple balance assistance during ambulation.
C. A cane can be used by clients with mild balance issues, but it is not as effective in providing the level of support needed for a client who is prone to losing balance.
D. A four-wheel walker is often used by clients with more significant mobility impairments, but it may not be necessary for a client who only occasionally loses balance. A gait belt is more appropriate for providing immediate support.

A. "You should place your nipple and some of the areola into her mouth." B. "Your baby's mouth is rather small so she will only take part of the nipple." C. "Babies know instinctively how much of the nipple to take into their mouth!" D. "Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth."

Correct Answer is D

Explanation

A. While including the areola is important, this response does not emphasize the need to include breast tissue beyond the areola, which is critical for effective latching.
B. This response is inaccurate because newborns require a deep latch that includes more than just the nipple to ensure proper feeding and avoid discomfort for the mother.
C. While babies have natural feeding instincts, they may need guidance to achieve an effective latch. This response does not provide the necessary instruction.
D. The ideal latch involves the nipple, areola, and some surrounding breast tissue to ensure efficient milk transfer and reduce nipple trauma. This response provides the most accurate and helpful guidance.

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A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?

Correct Answer is A

Explanation

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?

Correct Answer is D

Explanation

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