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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Avoid wearing tight-fitting clothing
Avoiding tight-fitting clothing is not specifically related to the management of acute pancreatitis. While comfortable clothing can be beneficial for general well-being, it does not directly impact the condition or its management. The primary focus for managing acute pancreatitis involves dietary and lifestyle changes that reduce stress on the pancreas.
Choice B Reason: Cease from smoking and consuming alcohol
Ceasing from smoking and consuming alcohol is crucial for clients with acute pancreatitis. Alcohol is a major risk factor for pancreatitis, and continued consumption can exacerbate the condition and lead to chronic pancreatitis or other complications. Smoking also has detrimental effects on the pancreas and can worsen the prognosis. Therefore, it is essential to advise clients to stop these habits to promote healing and prevent recurrence.
Choice C Reason: Practice good dental hygiene
While good dental hygiene is important for overall health, it is not specifically related to the management of acute pancreatitis. The primary concerns for pancreatitis management involve dietary adjustments, avoiding alcohol and smoking, and monitoring for symptoms of recurrence.
Choice D Reason: Stop exercising
Stopping exercise is not recommended for clients with acute pancreatitis. In fact, regular physical activity can be beneficial for overall health and well-being. However, clients should avoid strenuous activities during the acute phase of pancreatitis and gradually resume exercise as they recover. The focus should be on balanced, moderate physical activity that supports overall health without overexerting the body.
Correct Answer is B
Explanation
Choice A Reason:
A rigid abdomen is not a typical finding in a client with diarrhea. It may indicate a more serious condition such as peritonitis or an acute abdomen, which requires immediate medical attention.
Choice B Reason:
This is the correct answer. Dehydration is a common complication of prolonged diarrhea due to the significant loss of fluids and electrolytes. Symptoms of dehydration include excessive thirst, dry mouth, dark-colored urine, and dizziness.
Choice C Reason:
Hypothermia is not commonly associated with diarrhea. Diarrhea typically does not affect body temperature to the extent of causing hypothermia.
Choice D Reason:
Decreased bowel sounds are not typically expected with diarrhea. In fact, bowel sounds may be hyperactive due to increased intestinal activity.
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