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 D
Explanation
Choice A rationale:
Taking temperature within 30 minutes after the first morning void is specific to ovulation prediction kits, not the basal body temperature method.
Choice B rationale:
Taking temperature 1 hour after getting out of bed is not accurate for tracking basal body temperature fluctuations related to the menstrual cycle.
Choice C rationale:
Taking temperature every night before going to bed does not provide consistent basal body temperature readings, as the body temperature needs to be taken at the same time every morning to detect subtle changes related to the menstrual cycle.
Choice D rationale:
This is the correct answer. To use the basal body temperature method effectively, the client should take their temperature immediately after waking and before getting out of bed every morning. This helps in detecting the slight rise in basal body temperature that occurs after ovulation, indicating the fertile period.
Correct Answer is C
Explanation
C) Eat a light snack before bedtime.
The nurse should include the instruction to eat a light snack before bedtime to promote nighttime sleep in an older adult. A light snack can help prevent hunger pangs during the night, making it easier to fall asleep and stay asleep.
The other options are not recommended for promoting nighttime sleep:
A) Performing exercises prior to bedtime can increase alertness and make it more difficult to fall asleep.
B) Taking a 1-hour nap during the day can disrupt the sleep-wake cycle and make it more challenging to sleep at night.
D) Staying in bed for at least 1 hour if unable to fall asleep is not recommended. If the client cannot fall asleep, it's better to get out of bed, engage in a quiet and relaxing activity, and return to bed when feeling sleepy to avoid frustration and anxiety associated with not being able to sleep.
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