in planning nursing care for a bedfast client which factor is most likely to contribute to the development of deep vein thrombosis dvt in an immobile
Logo

Nursing Elites

HESI LPN

Medical Surgical HESI 2023

1. In planning nursing care for a bedfast client, which factor is most likely to contribute to the development of deep vein thrombosis (DVT) in an immobile client?

Correct answer: B

Rationale: The correct answer is B: Stasis of blood flow. Stasis of blood flow in immobile clients increases the risk of DVT, as lack of movement can cause blood to pool and clot. Atherosclerotic plaque formation (choice A) and atherosclerotic vessel changes (choice D) are more related to arterial diseases rather than DVT. Endothelial damage (choice C) can contribute to the development of DVT, but in an immobile client, stasis of blood flow is the most significant factor.

2. A 55-year-old client with symptoms of osteoarthritis asks which form of exercise would be most beneficial. What is the best response by the nurse?

Correct answer: C

Rationale: The correct answer is C: 'Swimming.' Swimming is a low-impact exercise that helps maintain joint mobility and reduce pain in clients with osteoarthritis. Unlike running or weight lifting, swimming is gentle on the joints, making it an ideal choice for individuals with osteoarthritis. Walking can be beneficial too, but swimming is often preferred due to its low-impact nature. Running and weight lifting may exacerbate joint pain and should be avoided by individuals with osteoarthritis.

3. Which is a long-term complication of cleft lip and palate?

Correct answer: C

Rationale: The correct answer is C, 'Faulty dentition.' The older child with cleft lip and palate may experience psychological difficulties due to the cosmetic appearance of the defect, issues with impaired speech, and faulty dentition. This can lead to problems with dental alignment, crowding, missing or malformed teeth, and other dental issues. Choices A, B, and D are incorrect as cognitive impairment, altered growth and development, and physical abilities are not typically considered long-term complications of cleft lip and palate.

4. An older adult with chronic obstructive pulmonary disease (COPD) was recently admitted to the hospital with heart failure (HF). Which actions should the nurse take in providing care? (Select all that apply)

Correct answer: D

Rationale: In a patient with COPD and HF, monitoring electrolyte levels is essential due to potential imbalances caused by medications or fluid shifts. Maintaining pulse oximetry is crucial to assess oxygenation status in COPD and HF. Providing assistance with mobility helps prevent deconditioning and complications. Therefore, all the actions mentioned are necessary for comprehensive care in this scenario, making option D the correct answer. Choices A, B, and C are all important aspects of managing COPD and HF, ensuring holistic and effective care.

5. The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply)

Correct answer: D

Rationale: The correct answer is D, as all the listed factors - abdominal obesity, high blood pressure, and increased triglyceride levels - are components of metabolic syndrome. Addressing these findings is crucial to help reduce the client's risk for developing diabetes mellitus and vascular disease. Abdominal obesity is a key feature of metabolic syndrome, high blood pressure (150/96 mmHg) is a risk factor, and increased triglyceride levels are also indicative of the syndrome. Educating the client on lifestyle modifications, such as healthy eating habits, regular physical activity, and monitoring these parameters, is essential in managing metabolic syndrome and preventing associated complications. Choices A, B, and C are all correct, making choice D the correct answer.

Similar Questions

The client with chronic venous insufficiency is being taught about self-care measures. Which instruction should be included?
The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. What is the most likely cause of the pain?
The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?
A client with cirrhosis is receiving lactulose. What is the desired effect of this medication?
Which nursing problem has the highest priority when planning care for a client with Meniere’s disease?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses