The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?

Frequent change of position

Antibiotics

Oxygen humidification

Chest physiotherapy

Answer and Explanation

The Correct Answer is A

A. Frequent change of position:

Frequent changes in position help prevent pooling of secretions and promote lung expansion. This simple and cost-effective measure is important in preventing complications related to immobility, such as pneumonia and atelectasis. It aids in maintaining optimal respiratory function.

B. Antibiotics: Antibiotics are used to treat bacterial infections and would not directly address the risks associated with decreased mobility.

C. Oxygen humidification: While oxygen therapy may be necessary in some cases, humidification is typically used to prevent drying of mucous membranes and is not a primary intervention for preventing complications of decreased mobility.

D. Chest physiotherapy: Chest physiotherapy involves techniques to mobilize respiratory secretions and may be indicated in specific situations. However, it is not as simple and cost-effective as frequent changes in position.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Retinal Hemorrhage

Uncontrolled hypertension can damage the blood vessels in the eyes, leading to retinal hemorrhages. This can result in vision problems and, in severe cases, vision loss.

B. Ventricular Hypertrophy

Uncontrolled hypertension causes the heart to pump against increased resistance, leading to the thickening and enlargement of the left ventricle. Ventricular hypertrophy is a response to the increased workload on the heart and is associated with an increased risk of heart failure.

C. Cerebrovascular Disease

Hypertension is a major risk factor for cerebrovascular diseases, including strokes. Elevated blood pressure can damage the blood vessels in the brain, increasing the risk of stroke. Strokes can have serious consequences, affecting various neurological functions.

D. Venous Insufficiency

Venous insufficiency is not typically directly associated with uncontrolled hypertension. It is more commonly related to problems with the venous system, such as damaged valves in the veins, leading to poor blood flow back to the heart. While hypertension can affect arteries, venous insufficiency is a distinct condition.

E. Transient Ischemic Attacks (TIAs)

Uncontrolled hypertension increases the risk of transient ischemic attacks (TIAs), which are brief episodes of neurological dysfunction caused by temporary disruption of blood flow to the brain. TIAs are often considered warning signs of an increased risk of stroke.

A. Visible clubbing of the fingers and toes B. Unequal peripheral pulses between extremities C. Reddened extremities with muscle atrophy D. Loss of hair on the distal extremities

Correct Answer is D

Explanation

A. Visible clubbing of the fingers and toes

Clubbing is a condition characterized by changes in the shape and appearance of the fingers and toes. It involves enlargement of the fingertips and the nails becoming curved and rounded. Clubbing is not typically associated with peripheral arterial occlusive disease (PAD). It is more commonly seen in conditions such as chronic respiratory or cardiovascular diseases.

B. Unequal peripheral pulses between extremities

Unequal peripheral pulses can be indicative of vascular abnormalities. However, in PAD, the characteristic finding is diminished or absent pulses rather than unequal pulses between extremities. Other conditions, such as arterial embolism or thrombosis, may present with unequal pulses.

C. Reddened extremities with muscle atrophy

Reddened extremities and muscle atrophy are not typical findings in PAD. These symptoms are more characteristic of conditions associated with chronic inflammation or compromised venous circulation, such as chronic venous insufficiency or venous stasis.

D. Loss of hair on the distal extremities

Loss of hair on the distal extremities, particularly on the lower legs and feet, is a common finding in PAD. It results from reduced blood flow and oxygen supply to the hair follicles in the affected areas.

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The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe. (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","E"]

Explanation

The nurse is providing care for a client recently diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis?

Correct Answer is D

Explanation

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