A nurse is caring for a client who is on bed rest.
The nurse should recognize that which of the following findings is a complication of immobility?
                            
                                                                                                    Swollen area on calf.
Increased blood pressure.
Decreased serum calcium levels.
Urinary frequency.
The Correct Answer is A
Choice A rationale:
A swollen area on the calf can indicate deep vein thrombosis (DVT), which is a serious complication of immobility. Immobilization can lead to blood stasis in the veins, increasing the risk of clot formation. DVT can result in severe complications, such as pulmonary embolism, making it a critical concern that requires immediate attention.
Choice B rationale:
Increased blood pressure is not a direct complication of immobility. However, immobility can contribute to hypertension over time due to factors such as weight gain and reduced cardiovascular fitness. While hypertension is a concern, it is not an acute complication of immobility that necessitates immediate intervention.
Choice C rationale:
Decreased serum calcium levels are not a direct complication of immobility. Immobility can lead to bone density loss and potential fractures due to reduced weight-bearing activities, but it does not cause an acute decrease in serum calcium levels.
Choice D rationale:
Urinary frequency is not a typical complication of immobility. Immobility can affect the urinary system, potentially leading to urinary stasis and increased risk of urinary tract infections, but urinary frequency is not a direct result of immobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Soaking in a warm bath every day is not a preventative measure for chronic urinary tract infections. Warm baths might provide temporary relief for discomfort but do not prevent UTIs.
Choice B rationale:
Taking an oral estrogen supplement is not a standard preventative measure for chronic urinary tract infections. Estrogen therapy might be recommended for postmenopausal women with recurrent UTIs, but it's not a general preventive method for all women.
Choice C rationale:
"Drink 2 liters of water per day." This is the correct answer. Staying well-hydrated is essential to prevent urinary tract infections. Drinking an adequate amount of water can help flush out bacteria from the urinary system, reducing the risk of infections. The normal range for daily water intake varies but is generally around 2-3 liters or eight 8-ounce glasses per day.
Choice D rationale:
Emptying the bladder every 6 hours is a good practice, but it might not be sufficient for someone prone to chronic UTIs. Regular and frequent urination can help prevent the buildup of bacteria in the urinary tract. However, specific time intervals might vary from person to person, so a fixed 6-hour rule might not apply to everyone.
Correct Answer is ["A","C","D","E","F","G"]
Explanation
The correct answers are Choices A, C, D, E, F, and G.
Choice A rationale: Antihypertensive medication is indicated due to sustained elevated BP (≥160/110 mm Hg), which increases risk for stroke, placental abruption, and eclampsia. Prompt control reduces maternal and fetal morbidity.
Choice B rationale: Routine vaginal exams are contraindicated unless signs of labor are present. Frequent exams increase infection risk and are not part of standard care for hypertensive or preeclamptic clients.
Choice C rationale: A low-stimulation environment (dim lights, quiet room) reduces CNS irritability and seizure risk in preeclampsia. It supports neuroprotection and aligns with seizure precaution protocols.
Choice D rationale: Betamethasone promotes fetal lung maturity in preterm gestation when delivery is likely. It reduces neonatal respiratory distress syndrome and improves outcomes in hypertensive pregnancies.
Choice E rationale: A 24-hour urine specimen quantifies proteinuria, essential for diagnosing preeclampsia severity. Protein 3+ on dipstick warrants confirmation via timed collection for accurate staging.
Choice F rationale: Hourly intake and output monitoring detects fluid shifts, renal compromise, and early signs of pulmonary edema. It’s critical in hypertensive disorders to guide fluid management.
Choice G rationale: Bed rest minimizes physical stress, stabilizes BP, and reduces risk of placental disruption. Left lateral positioning enhances uteroplacental perfusion and supports fetal oxygenation.
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