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. Body weight is one of the most reliable indicators of fluid status in a dialysis patient. Before and after each hemodialysis session, the nurse should weigh the client using the same scale under similar conditions (e.g., same clothing). The difference in weight reflects fluid loss during the dialysis treatment. This measurement helps guide adjustments in fluid management and dialysis prescriptions.
B. Abdominal girth can increase due to fluid accumulation in the abdomen (ascites) but is less specific for measuring fluid losses during dialysis. It may be more indicative of fluid retention over a longer period rather than immediate changes related to a single dialysis session.
C. Neck vein distention can be a sign of fluid overload but is not typically used to assess fluid losses during dialysis. It may be more relevant for assessing fluid status over time rather than immediate changes post- dialysis.
D. Blood pressure can fluctuate based on various factors, including fluid status. While blood pressure monitoring is essential in dialysis patients, it alone does not reliably reflect fluid losses during dialysis sessions.

A. Baked potato with sour cream B. Fruit salad and carrot sticks C. Bagel with cream cheese D. Peanut butter and jelly with enriched bread

Correct Answer is D

Explanation

A. Sour cream is a dairy product, providing protein. This option provides protein from the sour cream, which is suitable for a vegetarian who consumes dairy products.
B. Fruits and vegetables generally do not provide significant protein. While fruits and vegetables are nutritious, they do not provide sufficient protein for a meal, especially for someone who is vegetarian and needs adequate protein sources.
C. Cream cheese is a dairy product that provides protein. This option also provides protein from the cream cheese, which is suitable for a vegetarian who consumes dairy products.
D. Peanut butter is a plant-based protein source and enriched bread provides carbohydrates. Peanut butter is a good source of protein for vegetarians and is a suitable option for the adolescent client who does not like beans.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses?

Correct Answer is A

Explanation

A nurse is assisting an adolescent client in the selection of complementary protein sources on the lunch menu. The client is a vegetarian who eats milk products but does not like beans. Which of the following food items should the nurse recommend?

Correct Answer is D

Explanation

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