The nurse designs care for the immobilized patient to help combat the major dangers of immobilization, which include: Select all that apply.
Loss of calcium from bone matrix
Stasis of respiratory secretions
Increased cardiac workload
Decreased circulation from pressure
Increased mental activity
Correct Answer : A,B,C,D
A. Loss of calcium from bone matrix
Immobility causes bone demineralization, increasing the risk for osteoporosis and fractures.
B. Stasis of respiratory secretions
Lack of movement decreases chest expansion, leading to retained secretions and risk of pneumonia or atelectasis.
C. Increased cardiac workload
Immobilization leads to venous stasis and reduced venous return, increasing cardiac workload and risk of thromboembolism.
D. Decreased circulation from pressure
Prolonged pressure leads to reduced perfusion, increasing risk for pressure ulcers.
E. Increased mental activity
Immobilization often results in decreased mental stimulation, potentially leading to depression or confusion, especially in older adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. maintaining strength in muscles.
This is a benefit of ROM exercises, but it does not directly explain how venous return improves.
B. compression of muscles on venous walls.
Muscle contraction compresses veins, helping to push blood back toward the heart, improving venous return.
C. vasodilation.
Vasodilation increases blood flow, but doesn’t directly enhance venous return in the context of ROM.
D. increased metabolism.
Increased metabolism is a systemic benefit of exercise but is not the primary mechanism of improved venous circulation.
Correct Answer is D
Explanation
A. The pads should be 1/2 to 2 inches (1.3cm to 5cm) below the axilla
This is true and helps avoid pressure on the axilla and nerves.
B. When walking, the patient will need to straighten the elbow and the wrist during weight bearing
Elbows should be slightly flexed (~15–30 degrees); straightening the elbow and wrist fully can cause injury and reduce control.
C. Resting the body's weight on the axillary bar does not put pressure on vital nerves which can occlude blood vessels in the axilla causing permanent or temporary damage
Resting on the axillary bar can compress the brachial plexus and axillary vessels, causing nerve damage or paralysis.
D. They will need to be adjusted in both overall length and from the axillary bar to the handgrip
Proper crutch fitting includes adjusting both the overall length and the handgrip height.
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