A nurse knows that the major effect of immobility on the gastrointestinal system is the lack of natural movement of the intestines, which is known as
Atelectasis
Peristalsis
Shearing
Deep vein thrombosis
The Correct Answer is B
A. Atelectasis refers to the collapse of lung tissue due to blockage or pressure on the airways, commonly caused by immobility but primarily affects the respiratory system.
B. Peristalsis is the natural movement of the intestines that propels food and waste products through the digestive tract. Immobility can lead to decreased peristalsis, causing constipation and other gastrointestinal issues.
C. Shearing refers to the force that causes layers of tissue to move on each other, often leading to skin breakdown and pressure ulcers. It is not directly related to
the gastrointestinal system.
D. Deep vein thrombosis (DVT) is the formation of blood clots in deep veins,
typically in the legs, due to reduced blood flow and stasis caused by immobility. It primarily affects the circulatory system, not the gastrointestinal system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Deep vein thrombosis (DVT) is a condition characterized by the formation of blood clots in deep veins, commonly occurring in the lower extremities. DVT can be acquired during hospitalization due to factors such as immobility, surgery, or certain medical treatments.
B. Hypothyroidism, diabetes mellitus, and hypertension are chronic medical
conditions that may be managed or exacerbated during hospitalization but are not typically considered hospital-acquired injuries. They are often present before
hospitalization and may require ongoing management during the hospital stay.
C. Diabetes mellitus is a chronic condition characterized by elevated blood sugar levels due to either insufficient insulin production or the body's inability to use
insulin effectively. While diabetes management may be necessary during
hospitalization, it is not considered a hospital-acquired injury. Instead, it is a pre- existing condition that requires ongoing monitoring and treatment.
D. Hypertension, or high blood pressure, is a chronic condition that may require management during hospitalization but is not typically considered a hospital- acquired injury. Hypertension is often managed with medications and lifestyle modifications and may be monitored and treated during the hospital stay.
Correct Answer is B
Explanation
The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis. The rationale for this answer is based on the clinical findings noted in the nurse's notes. The presence of a reddened area on the client's calf, along with a difference in calf circumference between the left and right legs,suggests the possibility of deep vein thrombosis (DVT). DVT is a condition where a blood clot forms in a deep vein, typically in the legs. This can lead to a pulmonary embolism if a part of the clot breaks off and travels to the lungs, blocking blood flow. The client's recent long-duration car trip could have contributed to the development of DVT, as prolonged immobility is a known risk factor. The client's high fiber diet and adequate fluid intake are more likely to prevent constipation, and there is no indication of lead exposure, breath sounds issues, or atherosclerosis based on the information provided. Therefore, the most appropriate selections are 'pulmonary embolism' for the condition and 'possible deep vein thrombosis' for the client finding.
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