A nurse is caring for a hospitalized client at risk for complications of immobility. Which of the following interventions should the nurse include to prevent complications?

Instruct the client to wear a hospital gown every day, even when out of bed.

Have the client remain in bed for self-care activities.

Encourage the client to sit in the chair for all meals.

Elevate the head of the bed to 30° to 45° for medication administration.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Instruct the client to wear a hospital gown every day, even when out of bed

This intervention does not directly address the prevention of complications related to immobility. Wearing a hospital gown may be necessary for medical reasons, but it does not promote mobility or prevent complications such as pressure ulcers, muscle atrophy, or deep vein thrombosis (DVT). Encouraging the client to wear regular clothes when out of bed might actually promote a sense of normalcy and encourage more movement.

Choice B Reason: Have the client remain in bed for self-care activities

Keeping the client in bed for self-care activities is counterproductive in preventing complications of immobility. Prolonged bed rest can lead to muscle atrophy, decreased joint mobility, and increased risk of pressure ulcers and DVT. Encouraging the client to get out of bed and perform self-care activities while standing or sitting can help maintain muscle strength and joint flexibility.

Choice C Reason: Encourage the client to sit in the chair for all meals

Encouraging the client to sit in a chair for meals is an effective intervention to prevent complications of immobility. Sitting up helps improve digestion and respiratory function and reduces the risk of pressure ulcers by changing the pressure points on the body. It also promotes muscle activity and circulation, which are crucial in preventing DVT and maintaining overall physical health.

Choice D Reason: Elevate the head of the bed to 30° to 45° for medication administration

While elevating the head of the bed can be beneficial for certain medical conditions and for medication administration, it does not significantly contribute to preventing complications of immobility. This position can help with respiratory function and prevent aspiration during medication administration, but it does not promote overall mobility or prevent muscle atrophy and pressure ulcers.

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Correct Answer is A

Explanation

Choice A Reason:

This is the correct answer. Long-term GERD can lead to Barrett’s esophagus, a condition where the esophageal lining changes and can increase the risk of developing esophageal cancer. Regular surveillance by a GI specialist is crucial for early detection and management of Barrett’s esophagus.

Choice B Reason:

Monitoring for liver issues is not directly related to GERD. While liver health is important, it is not a primary concern for patients with long-term GERD.

Choice C Reason:

There is no direct link between GERD and an increased risk of diabetes. Therefore, follow-up with an endocrinologist for diabetes risk is not specifically relevant to GERD management.

Choice D Reason:

Pancreatic cancer is not a known complication of GERD. The primary concerns with long-term GERD are esophageal complications, such as Barrett’s esophagus and esophageal cancer.

A. Rubeola B. Clostridium difficile C. Varicella D. Tuberculosis

Correct Answer is ["A","C","D"]

Explanation

Choice A Reason:

Rubeola, also known as measles, is highly contagious and spreads through airborne transmission. The virus can remain infectious in the air for up to two hours after an infected person coughs or sneezes. This makes it one of the most easily spread diseases through airborne particles.

Choice B Reason:

Clostridium difficile (C. diff) is primarily transmitted through the fecal-oral route, not through airborne transmission. It spreads via spores that can survive on surfaces and be ingested, leading to infection.

Choice C Reason:

Varicella, or chickenpox, is transmitted through airborne particles. The virus can spread through direct contact with the fluid from the blisters or through respiratory droplets when an infected person coughs or sneezes. This makes it an airborne disease.

Choice D Reason:

Tuberculosis (TB) is caused by Mycobacterium tuberculosis and spreads through the air when an infected person coughs, speaks, or sings. The bacteria can remain suspended in the air for several hours, making TB an airborne disease.

Choice E Reason:

Staphylococcus aureus is not typically transmitted through airborne means. It spreads through direct contact with infected wounds, contaminated surfaces, or through respiratory droplets in some cases. However, it is not considered an airborne disease.

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A nurse is caring for a hospitalized client at risk for complications of immobility. Which of the following interventions should the nurse include to prevent complications?

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