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.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A Reason: Superficial palpation
Superficial palpation is typically performed after auscultation to avoid altering bowel sounds. It involves gently pressing on the abdomen to detect tenderness, masses, or other abnormalities. This step helps in identifying areas that may require deeper examination.
Choice B Reason: Auscultation
Auscultation is performed after inspection and before palpation to listen to bowel sounds without interference. Using a stethoscope, the nurse listens for the presence, frequency, and character of bowel sounds. This step is crucial as palpation can stimulate bowel activity, potentially leading to inaccurate findings.
Choice C Reason: Inspection
Inspection is the first step in an abdominal assessment. The nurse visually examines the abdomen for any abnormalities such as distension, scars, or discoloration. This step provides initial information about the child’s abdominal health and helps guide the subsequent steps of the assessment.
Choice D Reason: Deep palpation
Deep palpation is performed last to assess the deeper structures of the abdomen. This step involves applying more pressure to feel for masses, organ size, and tenderness. It is important to perform this step last to avoid causing discomfort or altering the findings of the other assessment steps.
Correct Answer is C
Explanation
Choice A Reason: Cerebral edema is caused by cerebrospinal fluid flowing from the intraventricular space to the interstitial area of the brain
This statement is not accurate. Cerebral edema in meningitis is not primarily caused by the flow of cerebrospinal fluid (CSF) from the intraventricular space to the interstitial area. Instead, it is more related to the inflammatory response triggered by the infection.
Choice B Reason: Cerebral edema is caused by osmotic cerebral edema
Osmotic cerebral edema occurs when there is an imbalance in the osmotic pressure, leading to fluid accumulation in the brain. However, this is not the primary mechanism in meningitis. The edema in meningitis is more related to the inflammatory response and the by-products of the pathogen.
Choice C Reason: Cerebral edema is caused by the by-products of the pathogen that causes the meningitis
This statement is the most accurate. In meningitis, the infection triggers an inflammatory response, leading to the release of various by-products such as cytokines and other inflammatory mediators. These substances increase the permeability of the blood-brain barrier, resulting in fluid leakage and cerebral edema.
Choice D Reason: Cerebral edema is caused by whole body inflammation which affects the brain the most
While systemic inflammation can contribute to cerebral edema, the primary cause in meningitis is the localized inflammatory response in the brain and meninges. The by-products of the pathogen and the resulting inflammation are the main factors leading to cerebral edema.
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