The length of immobilization can adversely affect a patient. When assessing patients, nurses need to assess muscle mass for:
A. increased fat.
B. increases in strength.
C. decreases in strength.
D. increases in lean muscle.
C
Examining metabolic functioning, the nurse uses anthropometric measurements. Immobilized patients will lose skin fat, thus indicating a decrease in nutritional status. The major musculo-skeletal changes identified during assessment of the immobilized patient include decreased mus-cle strength, loss of muscle tone and mass, and contractures. Because immobilized patients are weakened, determine if difficulty in moving joints is the result of fatigue or decreased range of joint motion.
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A patient has developed a decubitus ulcer on the coccyx. What defense mechanism is most affected by this homeostatic change?
A) The mucous membrane is affected. B) The respiratory tract is affected. C) The skin is affected. D) The gastrointestinal tract is affected.
The nurse is reinforcing teaching for a patient who has been diagnosed with rheumatoid arthritis (RA). Which of these, if stated by a patient, indicates to the nurse correct understanding of symptoms of RA?
a. Fatigue b. Paralysis c. Shortness of breath d. Crepitation
A patient is to receive 500 mL lactated Ringer solution infused at a rate of 80 mL/hr. If the IV was started at 7:00 PM, when will it be completed? _______________
a. 2:00 AM b. 1:20 PM c. 1:15 AM d. 1:00 PM
What instructions should the nurse give to the client for stoma care at home after a laryn-gectomy?
A. "Gently wash the stoma with soap and water, then apply a water-based lubricant." B. "Use cotton-tipped applicators to clean out the stoma lumen at least twice per day." C. "Use a syringe or Water Pik to irrigate the stoma with a solution of sterile normal saline and peroxide." D. "Gently scrape crusts away from the stoma opening with a tongue blade and ap-ply petroleum jelly to the external stump."