what is the priority nursing diagnosis for a client with immobility

ATI RN

Multi Dimensional Care | Final Exam

1. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

2. What is not a potential complication of RA?

A. Paresthesia's
B. Fibromyalgia
C. Joint deformity
D. Dry eyes

Correct answer: A

Rationale:

3. The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse?

A. "Ice packs can be used to reduce swelling but should be removed after 20 minutes."?
B. "Heat always makes the swelling go down. You do not need any other interventions."?
C. "Try high impact exercise exercise like running to loosen up your joints and reduce pain."?
D. "Apply ice packs. It is generally okay to keep them on for up to one hour at a time."?

Correct answer: A

Rationale:

4. What is a classic symptom assessed in clients with lupus?

A. Butterfly rash
B. Chvostek's sign
C. Ovid's sign
D. Heberden's nodes

Correct answer: A

Rationale:

5. What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?

A. Encouraging bedrest
B. Applying antiembolism stockings
C. Tell the client to take anticoagulants
D. Teaching about smoking cessation

Correct answer: B

Rationale: The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.