The nurse is caring for a 48-year-old male client who was ...

[ishan]

The nurse is caring for a 48-year-old male client who was involved in a motor vehicle accident and had a fractured pelvis, a ruptured spleen, and multiple contusions. The client has been in the hospital for 5 days on bed rest.
 
  The nurse knows that this client is at risk for venous thrombus formation because of prolonged bed rest, potential damage to vessel walls during surgery, and the platelets he received in the trauma unit. These three factors are also known as:
  1. Trigeminy
  2. Virchow's triad
  3. Trigone
  4. Hutchinson's triad

Question 2

The nurse caring for a 73-year-old female client who has been hospitalized with a stroke instructs the client's daughter to continue to do passive range-of-motion exercises with her mother on her affected side to prevent contractures.
 
  The nurse explains to the daughter that this is very important in an immobile older adult client because contractures can form in as little as:
  1. 8 hours
  2. 24 hours
  3. 1 week
  4. 1 month

[bigsis44]

Answer to Question 1

ANS: 2
There are three factors that contribute to venous thrombus formation: (1) damage to the vessel wall (e.g., injury during surgical procedures), (2) alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity. These three factors are sometimes referred to as Virchow's triad

Answer to Question 2

ANS: 1
Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. When a contracture occurs, the joint cannot obtain full ROM. Contractures sometimes leave a joint or joints in a non-functional position, as seen in clients who are permanently curled in a fetal position. Early pre-vention of contractures is key; they can begin to form after only 8 hours of immobility in the old-er adult client.

[ishan]

Thank you!

[bigsis44]

Always glad to help...