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A nurse on a medical-surgical unit is caring for a client.
Exhibits
Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing and

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

The client is at risk for developing pressure injury and foot drop. Given the client's history of a recent cerebrovascular accident (CVA) and the inability to reposition themselves, there is a heightened risk for pressure injuries due to prolonged periods of immobility. Additionally, the observed occasional movement of the left arm and leg with the right side without movement suggests a potential for muscle weakness or paralysis, which can lead to foot drop, characterized by difficulty in lifting the front part of the foot.


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Related Questions

Correct Answer is B

Explanation

A. Alcohol abuse disorder can lead to dehydration and electrolyte imbalances but is not directly linked to low potassium levels.
B. NG tube to gastric suction can lead to potassium loss through gastric secretions, potentially causing hypokalemia.
C. Drinking large amounts of water is not typically associated with low potassium levels; excessive water intake can dilute electrolytes but is less likely to cause hypokalemia.
D. Spironolactone is a potassium-sparing diuretic that can actually increase potassium levels, making it less likely to cause hypokalemia.

Correct Answer is C

Explanation

A. A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.

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