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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This position, where the client is seated in a semi-upright sitting position, helps to reduce the risk of aspiration and facilitates breathing. It is also conducive to the proper functioning of the nasogastric tube for decompression.
B. Moistening the client's lips is also important for comfort, but it does not directly relate to the management of the nasogastric tube.
C. Sterile water should be used for irrigation only if the tube becomes clogged.
D. Measuring abdominal girth is important but not specific to nasogastric tube care.
Correct Answer is C
Explanation
A. Apples are a good source of fiber, with about 4.4 grams of fiber in a medium-sized apple with the skin. Apples contain soluble and insoluble fiber, which can aid in digestion and help prevent constipation. This is a suitable choice for a high-fiber snack.
B. Almonds are nutritious and provide fiber, but they are not as high in fiber compared to other options like fruits, vegetables, and whole grains. One ounce of almonds contains about 3.5 grams of fiber. While almonds are beneficial, they are not typically the primary choice for increasing fiber intake to alleviate constipation.
C. Bran cereals are often recommended for their high fiber content. Half a cup of bran cereal can provide around 10 grams of fiber or more, depending on the brand and type. Bran cereals are particularly rich in insoluble fiber, which adds bulk to stool and helps promote regular bowel movements. This is an excellent choice for increasing fiber intake to manage constipation.
D. Sweet potatoes are nutritious and contain dietary fiber, with about 3.8 grams of fiber in half a cup of cooked sweet potatoes. While they contribute to fiber intake, they generally do not provide as much fiber compared to options like whole grains or bran cereals.
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.