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 D
Explanation
A. Protein intake, especially animal protein (such as meat and dairy), can increase the excretion of calcium and other minerals into the urine, potentially leading to the formation of certain types of kidney stones (like calcium stones). Therefore, clients with a history of kidney stones are generally advised to moderate their intake of animal protein.
B. Some types of tea, particularly black tea, contain oxalates, which are substances that can contribute to the formation of calcium oxalate kidney stones in susceptible individuals. Therefore, clients with kidney
stones may be advised to limit their intake of tea, especially if they have a history of calcium oxalate stones.
C. High dietary sodium intake can increase calcium excretion in the urine, which may lead to the formation of calcium-containing kidney stones. Therefore, clients with kidney stones are often advised to reduce their sodium intake to help prevent stone formation.
D. Adequate fluid intake, primarily in the form of water, is crucial for preventing kidney stones. Increased water intake helps dilute urine and reduces the concentration of stone-forming substances, making it less likely for crystals to form and grow into stones. The goal is typically to produce at least 2 to 2.5 liters (about 8 to 10 cups) of urine per day.
Correct Answer is B
Explanation
A. Standing with feet close together reduces the base of support, making the nurse less stable and increasing the risk of losing balance or straining muscles. It is not recommended for lifting because it compromises stability and balance.
B. Keeping the box close to the body reduces the leverage and strain on the back muscles. This technique utilizes the strength of the legs and core muscles more effectively and helps to maintain balance and stability while lifting.
C. Bending at the waist puts excessive strain on the lower back muscles and can lead to back injury, especially when lifting heavy objects. The correct technique is to bend at the knees and hips while keeping the back straight to maintain proper alignment and reduce strain on the spine.
D. Twisting while lifting or carrying heavy objects can strain the muscles and ligaments of the spine, leading to injury, particularly to the intervertebral discs. The nurse should avoid twisting and instead pivot the entire body with the feet to change direction.
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