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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Elevate the bed to waist height: Raising the bed to waist level promotes proper body mechanics and reduces back strain for caregivers.
B. Position the client toward the edge of the bed on the side the client will face after turning: This makes repositioning easier and safer, allowing for better leverage and control.
C. Remove pillows prior to repositioning: Pillows may support body parts during turning and should be removed only if they obstruct repositioning, not as a general rule.
D. Stand with their feet wide apart: A wide base of support ensures better balance and stability when repositioning a client.
E. Face the direction of movement when repositioning the client: Facing the direction of movement maintains spinal alignment and prevents twisting injuries.
Correct Answer is A
Explanation
A. Lower the client to the floor: This action helps prevent injury to both the client and the nurse by controlling the descent.
B. Maintain a narrow base of support: A wide base of support provides greater stability and balance.
C. Provide support by holding the client's arm: Holding the client's arm can lead to injury for both parties. Instead, support the client at the waist or trunk.
D. Lean the client toward the wall: Guiding the client toward a wall could increase injury risk. The nurse should control the fall toward the floor instead.
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