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A nurse is collecting data from a client who has had paraplegia for several years. Which of the following physiologic changes due to immobility should the nurse consider when evaluating this client's overall status? (Select all that apply.)

Muscle atrophy

Venous pooling

Urinary stasis

Increased depth of respirations

Increased metabolic rate

Answer and Explanation

Correct Answer : A,B,C

A. Muscle atrophy

Lack of movement leads to wasting of muscle tissue over time, a common consequence of immobility.

B. Venous pooling

Immobility causes reduced venous return, leading to venous stasis or pooling, increasing the risk of DVT.

C. Urinary stasis

Lying flat for extended periods contributes to bladder emptying issues, increasing risk for UTIs and renal calculi.

D. Increased depth of respirations

Immobility leads to shallow breathing and reduced lung expansion, not deeper respirations.

E. Increased metabolic rate

Immobility generally results in a decreased metabolic rate due to lower energy needs.

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Correct Answer is D

Explanation

A. Hyperextension

Hyperextension refers to bending backward beyond the normal range.

B. Lateral flexion

Lateral flexion involves bending the neck to the side, ear toward shoulder.

C. Rotation

Rotation refers to turning the head side-to-side (e.g., shaking head “no”).

D. Flexion

Touching the chin to the chest is flexion of the neck-bending forward.

A. Log rolling every 2 hr B. Passive range-of-motion exercises of the right leg C. Active range-of-motion exercises of the left leg D. Isometric exercises of both legs

Correct Answer is D

Explanation

A. Log rolling every 2 hr

Log rolling is appropriate for spinal precautions, not necessary in Buck’s traction.

B. Passive range-of-motion exercises of the right leg

The leg in traction must remain immobilized; no ROM exercises on the affected leg.

C. Active range-of-motion exercises of the left leg

While this can help prevent deconditioning, it’s not as effective for overall mobility as isometric exercises.

D. Isometric exercises of both legs

Isometric exercises (e.g., quad or glute squeezes) promote circulation and prevent muscle atrophy in both limbs without disturbing traction.

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A nurse is collecting data from a client who has had paraplegia for several years. Which of the following physiologic changes due to immobility should the nurse consider when evaluating this client's overall status? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?

Correct Answer is D

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Correct Answer is D

Explanation

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