A nurse is monitoring a client for complications of immobility. Which of the following findings does the nurse identify as a complication of immobility?
(Select All that Apply.)

Hypertension

Diarrhea

Pressure injury

Contractures of extremities

Answer and Explanation

Correct Answer : C,D,E

A. Hypertension: Immobility more commonly leads to orthostatic hypotension, not hypertension.
B. Diarrhea: Immobility often causes constipation due to reduced peristalsis, not diarrhea.
C. Pressure injury: Prolonged pressure on bony prominences in immobile clients can cause skin breakdown and ulcers.
D. Contractures of extremities: Lack of movement leads to muscle shortening and joint contractures.
E. Crackles in the lungs: Crackles may indicate atelectasis or pneumonia, both of which are risks due to decreased lung expansion and secretion retention in immobile clients.

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Correct Answer is D

Explanation

A. Inadequate staffing ratio between clients and health care providers: Restraints should never be used for staff convenience or due to understaffing.
B. Discipline for throwing chairs at staff: Restraints must not be used for punishment.
C. Refusal to take medication: This does not justify restraints unless the client is a danger to themselves or others.
D. Continued self-destructive behavior: Restraints may be used when there is a risk of self-harm and other alternatives have failed, following institutional protocols and provider orders.

A. Use safety pins to keep the pad in place. B. Set the pad's temperature to 42.2° C (108° F). C. Stop the treatment if the client's skin becomes red. D. Leave the pad in place for at least 40 min.

Correct Answer is C

Explanation

A. Use safety pins to keep the pad in place: Safety pins can puncture the pad, leading to leaks or burns.
B. Set the pad's temperature to 42.2° C (108° F): That is too hot. Safe temperatures for heat application are usually around 40–41°C (104–105.8°F).
C. Stop the treatment if the client's skin becomes red: Redness may indicate burning or tissue damage; the application must be discontinued immediately.
D. Leave the pad in place for at least 40 min: Heat therapy is usually applied for 20–30 minutes to avoid rebound vasoconstriction and tissue injury.

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A nurse is monitoring a client for complications of immobility. Which of the following findings does the nurse identify as a complication of immobility? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is discussing restraints with a newly licensed nurse. Which of the following situations should the nurse identify as an acceptable indication for using restraints for a client?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?

Correct Answer is C

Explanation

A nurse is monitoring a client for complications of immobility. Which of the following findings does the nurse identify as a complication of immobility? (Select All that Apply.)

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A nurse is monitoring a client for complications of immobility. Which of the following findings does the nurse identify as a complication of immobility?
(Select All that Apply.)