A nurse is caring for an immobile client. What is the priority assessment in this client?
Assessment for the presence of peripheral edema
Auscultation of lung sounds
Auscultation of bowel sounds
Assessment of skin turgor
The Correct Answer is B
Choice A reason: This is not the priority assessment because peripheral edema is not a lifethreatening complication of immobility. Peripheral edema is the swelling of the lower extremities due to fluid accumulation. It can be caused by various factors, such as venous insufficiency, heart failure, kidney disease, or medication side effects. The nurse should monitor the client's fluid status and provide elevation and compression therapy as needed.
Choice B reason: This is the priority assessment because lung sounds can indicate the presence of respiratory complications, such as pneumonia or atelectasis, which are common and serious consequences of immobility. Pneumonia is an infection of the lungs that causes inflammation, mucus production, and impaired gas exchange. Atelectasis is the collapse of alveoli, which are the tiny air sacs in the lungs that facilitate oxygen and carbon dioxide exchange. The nurse should auscultate the client's lung sounds regularly and report any abnormal findings, such as crackles, wheezes, or diminished breath sounds. The nurse should also encourage the client to cough, deep breathe, and use incentive spirometry to prevent or treat respiratory problems.
Choice C reason: This is not the priority assessment because bowel sounds can reflect the status of the gastrointestinal system, which is not directly affected by immobility. Bowel sounds are the noises produced by the movement of food and gas through the intestines. They can vary in frequency and intensity depending on the client's diet, activity, and medications. The nurse should auscultate the client's bowel sounds and assess for any signs of constipation, diarrhea, or obstruction. The nurse should also promote the client's bowel function by providing adequate hydration, fiber, and laxatives as ordered.
Choice D reason: This is not the priority assessment because skin turgor can indicate the level of hydration, which is not a primary concern of immobility. Skin turgor is the elasticity of the skin that allows it to return to its normal shape after being pinched or pulled. It can be affected by factors such as age, weight loss, dehydration, or edema. The nurse should assess the client's skin turgor and provide adequate fluids and electrolytes as needed. The nurse should also pay attention to the client's skin integrity and prevent or treat any pressure ulcers or wounds that may result from immobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "In order to avoid flareups of Raynaud's, ensure to keep cool." is not a correct answer, because it can worsen the symptoms of Raynaud's phenomenon. Raynaud's phenomenon is a condition that causes the blood vessels in the fingers and toes to narrow and spasm in response to cold or stress, resulting in reduced blood flow and color changes. Keeping cool can trigger or aggravate the spasms and decrease the blood flow.
Choice B reason: "In order to avoid flareups of Raynaud's, ensure you wear sunscreen." is not a correct answer, because it is not related to Raynaud's phenomenon. Sunscreen is a protective measure for clients with lupus, who may have increased sensitivity to ultraviolet rays and increased risk of skin damage and flareups. However, sunscreen does not prevent or treat Raynaud's phenomenon, which is caused by cold or stress, not by sun exposure.
Choice C reason: "In order to avoid flareups of Raynaud's, ensure you wear gloves in winter." is a correct answer, because it can help prevent or reduce the symptoms of Raynaud's phenomenon. Wearing gloves in winter can keep the hands warm and prevent the blood vessels from narrowing and spasming due to cold. This can improve the blood flow and prevent color changes, numbness, pain, or ulcers in the fingers.
Choice D reason: "In order to avoid flareups of Raynaud's, ensure you brush your teeth for two minutes." is not a correct answer, because it is not related to Raynaud's phenomenon. Brushing the teeth for two minutes is a good oral hygiene practice that can prevent dental problems, such as plaque, cavities, or gingivitis. However, brushing the teeth does not affect the blood vessels in the fingers and toes, nor does it prevent or treat Raynaud's phenomenon.
Correct Answer is A
Explanation
Choice A reason: Inflammatory is the phase of wound healing that occurs at the time of injury and lasts about 35 days, because it is the first and immediate response to tissue damage. Inflammatory is the phase of wound healing that involves the activation of the immune system, the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of a clot. Inflammatory is the phase of wound healing that aims to control bleeding, prevent infection, and prepare the wound for healing.
Choice B reason: Proliferative is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the inflammatory phase and lasts about 23 weeks. Proliferative is the phase of wound healing that involves the growth and multiplication of new cells, the formation of granulation tissue, the synthesis of collagen, the contraction of the wound edges, and the development of epithelial tissue. Proliferative is the phase of wound healing that aims to fill the wound, restore the strength, and cover the defect.
Choice C reason: Maturation is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the proliferative phase and lasts about several months to years. Maturation is the phase of wound healing that involves the remodeling and reorganization of the collagen fibers, the reduction of scar tissue, the improvement of elasticity, and the restoration of function. Maturation is the phase of wound healing that aims to refine the wound, enhance the quality, and optimize the outcome.
Choice D reason: Intentional is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather a classification of wound healing that depends on the type and extent of tissue damage, the degree of contamination, and the method of closure. Intentional is a classification of wound healing that refers to wounds that are surgically created, have minimal tissue loss, are clean and sterile, and are closed by primary intention, which means that the wound edges are approximated with sutures, staples, or glue. Intentional is a classification of wound healing that results in faster healing, less scarring, and lower risk of infection.
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