The client who is recovering from severe trauma remains confined ...

[waynest]

The client who is recovering from severe trauma remains confined to the bed due to a broken leg. The nurse plans care for this client based on a nursing diagnosis of Impaired Physical Mobility. Which intervention should the nurse plan for this client?
 
  1. Monitoring the client's level of consciousness.
  2. Monitoring the client for jaundice.
  3. Evaluating the legs for heat and swelling.
  4. Ensuring a urinary output of 30 mL/hour.

Question 2

The nurse is assessing the client experiencing shock, and notes that the client's urinary output is 20 mL/hour. The nurse concludes the client:
 
  1. Has decreased blood flow to the kidneys.
  2. Is experiencing liver failure.
  3. Might be experiencing acute respiratory distress syndrome.
  4. Is experiencing disseminated intravascular coagulation.

[makaylafy]

Answer to Question 1

Answer: 3

1. If the client who is recovering has a decreased level of consciousness, the nurse might suspect infection, and the nursing diagnosis would be Risk for Infection.
2. Jaundice relates to liver failure, and is not a part of Impaired Physical Mobility.
3. The client with Impaired Mobility is at risk for developing deep vein thrombosis, which is manifested by heat, swelling, and pain in the lower extremities.
4. Urinary retention is a risk for the client with impaired mobility.

Answer to Question 2

Answer: 1

1. The urinary output will decrease when blood flow to the kidneys is shunted away from the kidneys to protect the brain and heart.
2. Jaundice would be a sign that the client is in liver failure.
3. The client experiencing respiratory distress syndrome shows signs of decreased oxygenation, such as cyanosis.
4. The client with disseminated intravascular coagulation will have bleeding around catheter sites, in the urine, and in stools, as well as in other areas of the body.