An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

Stiffness in the lower extremities

A reddened area over the sacrum

Difficulty hearing some types of sounds

Difficulty moving the upper extremities

Answer and Explanation

The Correct Answer is B

A.   Stiffness in the lower extremities can occur due to lack of movement and muscle disuse. Prolonged immobility leads to muscle atrophy and contractures, causing stiffness and reduced range of motion. This is a common complication seen in clients who are bedridden or have limited mobility.
B.   A reddened area over the sacrum indicates a potential pressure injury or pressure ulcer. Immobility increases the risk of pressure ulcers due to prolonged pressure on bony prominences, such as the sacrum. Regular repositioning and pressure relief strategies are essential to prevent skin breakdown in immobile clients.
C.   Difficulty hearing certain types of sounds is not typically associated with immobility. It may be related to age-related changes in hearing or other auditory issues but is not a direct complication of immobility.
D.   Difficulty moving the upper extremities can occur due to muscle weakness or disuse atrophy, which can result from immobility. However, it is less common compared to stiffness and difficulty in the lower extremities because upper extremities are often more frequently moved or exercised even in bedridden clients.

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Correct Answer is A

Explanation

A. This temperature is slightly elevated (normal range is typically around 36.5-37.5°C or 97.7-99.5°F). While a mild temperature elevation could indicate infection or other underlying issues, it may not be immediately critical unless accompanied by other symptoms such as chills, increased heart rate, or signs of respiratory distress.
B. Hematocrit measures the proportion of red blood cells in the blood. A hematocrit of 45% is within the normal range for adults. However, changes in hematocrit levels over time can indicate fluid balance issues

or nutritional status, which are important to monitor but may not be an acute priority unless significantly abnormal.
C. A respiratory rate of 12 breaths per minute is within the normal range for adults. However, it's essential to consider if this rate is stable or if there are signs of respiratory distress such as increased effort or decreased oxygen saturation. Respiratory status should always be closely monitored, but a normal rate alone is not a priority concern.
D. Urine specific gravity measures the concentration of urine and can indicate hydration status. A specific gravity of 1.015 is within the normal range for urine concentration. However, changes in urine output or specific gravity can provide insights into fluid balance and renal function over time.

A. Butter B. Yogurt C. Pears D. Orange juice E. Cabbage

Correct Answer is ["B","D"]

Explanation

A. Butter is a dairy product, but it is not typically high in potassium. It is generally safe for clients following a low-potassium diet. Therefore, clients do not need to avoid butter specifically for its potassium content.
B. Yogurt, especially the varieties that are not low-fat or non-fat, can have a significant amount of potassium.
C Pears are generally considered low in potassium and are usually safe to include in a low-potassium diet.
D. Orange juice is a fruit juice and is naturally high in potassium. Clients should avoid or limit orange juice when following a low-potassium diet due to its potassium content.
E. Cabbage is a vegetable that is generally low in potassium. It is safe for clients following a low-potassium diet and does not need to be avoided for its potassium content.

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An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

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Explanation

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Correct Answer is ["B","D"]

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