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 B
Explanation
A. Maximum assist is when the client requires total assistance from one or more persons to perform the activity. In this scenario, the client is able to rise from a seated position
independently with the assistance of a cane, so maximum assist is not appropriate.
B. Minimal assist is when the client requires some assistance or supervision to perform the activity but is able to complete most of the task independently. Since the client can rise from a seated position using a cane for support, they require minimal assistance.
C. Moderate assist is when the client requires more help than minimal assist but can still contribute to the activity. Since the client can perform the task with minimal assistance, moderate assist is not appropriate.
D. No assist is when the client is able to perform the activity without any assistance.
While the client uses a cane for support, they are still able to rise from a seated position independently, so no assist is not appropriate.
Correct Answer is C
Explanation
C. Keep the client's personal items within reach.Keeping the client's personal items within reach can provide a sense of familiarity and comfort, which may reduce anxiety or disorientation, thereby decreasing the tendency to wander.
Incorrect options:
A. "Tell the family that someone should plan to stay with the client.": While family involvement is important, this suggestion may not always be feasible. Additionally, it’s the nurse’s role to ensure the safety of the client within the facility.
B. "Place the client in a quiet room at the end of the hallway.": Isolating the client may increase confusion and feelings of disorientation.
D. "Provide bright lighting in the client's room at night.": Bright lights at night can disrupt sleep and may cause further disorientation. Dim or soft lighting or use of night lights in the room is generally more appropriate to promote restful sleep.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.