Author Question: A patient has been on prolonged bed rest, and the nurse is observing for signs associated with ... (Read 25 times)

Alainaaa8 · **on:** Jul 22, 2018

A patient has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. While assessing the patient, the nurse is alert to which of the following signs?

a. Increased blood pressure
b. Decreased heart rate
c. Increased urinary output
d. Decreased peristalsis

Question 2

The client is assessed by the nurse as having a high risk for aspiration. The nursing diagnosis identified for the client is Self-care deficit, feeding related to unilateral weakness.

Which of the following is an appropriate technique for the nurse to use when assisting this client with feeding? a. Place food to the unaffected side of the mouth.
b. Place the client in semi-Fowler's position.
c. Have the client use a straw.
d. Use thinner liquids.

javimendoza7 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D

Feedback
A In the immobilized patient, decreased circulating fluid volume, pooling of blood in the lower extremities, and decreased autonomic response occur. These factors result in decreased venous return, followed by a decrease in cardiac output, which is reflected by a decline in blood pressure.
B Recumbency increases cardiac workload and results in an increased pulse rate.
C Fluid intake can diminish with immobility, and this, combined with other causes, such as fever, increases the risk of dehydration. Urinary output may decline on or about the fifth or sixth day after immobilization, and the urine is often highly concentrated.
D Immobility disrupts the normal functioning of the gastrointestinal system, resulting in decreased appetite and slowed peristalsis.

Answer to Question 2

A
If the client has unilateral weakness, the nurse should place food in the stronger side of the mouth.
The client should be positioned in an upright, seated position to prevent aspiration.
Clients with unilateral weakness often have difficulty using a straw.
Thickened liquids are often tolerated better and will help prevent aspiration, as clients with im-paired swallowing often choke more with thin liquids.