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","D","E"]
Explanation
Choice A Reason: Production of potassium
The musculoskeletal system does not produce potassium. Potassium is an essential mineral that is obtained through the diet and is crucial for various bodily functions, including muscle contraction and nerve function. The musculoskeletal system, however, is not involved in its production.
Choice B Reason: Maintains the body’s form and shape
One of the primary functions of the musculoskeletal system is to maintain the body’s form and shape. The skeletal system provides the framework that supports the body and gives it structure. Muscles attached to the bones help maintain posture and allow for movement, contributing to the overall form and shape of the body.
Choice C Reason: Provides reflexive responses to injuries
While the musculoskeletal system is involved in movement and support, reflexive responses to injuries are primarily mediated by the nervous system3. Reflex actions are automatic responses to stimuli that involve the spinal cord and peripheral nerves, not the musculoskeletal system directly.
Choice D Reason: Formation of blood cells through red or yellow marrow
The formation of blood cells, known as hematopoiesis, occurs in the bone marrow, which is part of the skeletal system. Red bone marrow is responsible for producing red blood cells, white blood cells, and platelets. Yellow bone marrow, primarily composed of fat cells, can also convert to red marrow if necessary to increase blood cell production.
Choice E Reason: Protection of soft organs
The musculoskeletal system plays a crucial role in protecting soft organs. For example, the rib cage protects the heart and lungs, the skull encases the brain, and the vertebrae shield the spinal cord. This protective function is vital for preventing injury to these essential organs.
Correct Answer is D
Explanation
Choice A Reason: Night sweats
Night sweats are not typically associated with liver disease. They are more commonly linked to conditions such as infections, hormonal imbalances, or certain cancers1. While liver disease can cause a variety of symptoms, night sweats are not a primary manifestation.
Choice B Reason: Acanthosis nigricans
Acanthosis nigricans is characterized by dark, velvety patches of skin, usually in body folds and creases. It is often associated with insulin resistance, obesity, and certain endocrine disorders. It is not a common manifestation of liver disease.
Choice C Reason: Hemosiderin staining
Hemosiderin staining refers to the deposition of iron in the skin, which can cause a brownish discoloration. This condition is more commonly associated with chronic venous insufficiency or hemochromatosis, a genetic disorder that causes iron overload. It is not a typical symptom of liver disease.
Choice D Reason: Pruritus
Pruritus, or itching, is a common symptom of liver disease. It is often caused by the accumulation of bile salts in the skin due to impaired bile flow, a condition known as cholestasis. This symptom can be particularly distressing for patients and is a significant indicator of liver dysfunction.
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