The nurse prepares to meet with assigned clients after receiving hand-off communication. Which statement or question demonstrates that the nurse is in the termination phase with a client?

A. Diarrhea: Diarrhea is not a typical finding associated with immobility. In fact, immobility often leads to constipation due to decreased gastrointestinal motility. Factors such as diet and medication can influence bowel habits, but diarrhea is not a direct complication of immobility.

B. Contractures of the extremities: Contractures are a common complication of immobility. When a joint is not moved regularly, the muscles and tissues can shorten, leading to stiffness and loss of mobility in the affected area. This is especially common in patients who are bedridden or have limited range of motion.

C. Polyuria: Polyuria, or increased urine output, is not typically associated with immobility. Immobility can lead to decreased kidney function and fluid retention, potentially resulting in oliguria (decreased urine output) rather than polyuria.

D. Pressure ulcers: Pressure ulcers, also known as bedsores, are a significant risk for individuals with limited mobility. They develop due to prolonged pressure on the skin, particularly over bony prominences, leading to skin breakdown and tissue damage. Regular repositioning and skin care are essential to prevent this complication.

E. Crackles in the lungs: Crackles can be heard during auscultation in patients who are immobile. They may develop due to fluid accumulation in the lungs, atelectasis (collapse of lung tissue), or pneumonia, which are all more likely to occur in individuals with limited mobility. Immobility can impair respiratory function, leading to these complications.

A. Vigorously brush the client's teeth: Vigorous brushing is not appropriate for an unconscious client. It can cause trauma to the gums or teeth and increase the risk of aspiration if the client has any residual secretions or fluids in the mouth. Gentle brushing should be employed to avoid injury.

B. Hold the toothbrush at a 90° angle: Holding the toothbrush at a 90° angle is not necessary for clients who are unconscious. A more effective angle may be around 45° to effectively clean the surfaces of the teeth while minimizing the risk of gagging or aspiration.

C. Place two fingers in the client's mouth: This action could be harmful, as placing fingers in the mouth of an unconscious client poses a risk of injury or could inadvertently trigger a gag reflex. Instead, proper oral care should be conducted using appropriate tools without placing fingers inside the mouth.

D. Turn the client to the side: Turning the client to the side is the best action as it helps prevent aspiration of secretions or fluids during oral care. This position allows for safer access to the mouth while also promoting drainage of any excess fluids, reducing the risk of choking or aspiration pneumonia.