what is the priority nursing diagnosis for a client with immobility

ATI RN

Multi Dimensional Care | Final Exam

1. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

2. Convert 30 ml to ounces. (Type the answer as numeric only)

A. 1
B. 2
C. 3
D. 4

Correct answer: A

Rationale: 30 ml is equivalent to 1 ounce.

3. The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?

A. "My grandfather always had problems with his arthritis, and he would tell me that it is better to be more stoic and not let pain interrupt your life"?
B. "There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."?
C. "Place throw rugs throughout your home. You will enjoy how pretty they are, and you can use them to cover up power cords, so you do not trip on them."?
D. "Lack of home safety may be an issue of compliance. Are you being compliant with your medication?"?

Correct answer: B

Rationale: The correct answer is B. This statement is the most appropriate because it focuses on providing practical solutions to enhance the client's safety at home while managing rheumatoid arthritis. Adaptive devices like grab bars, reaching tools, grasping devices, and adaptive silverware can help the client maintain independence and prevent accidents. Choice A is incorrect as it does not provide practical advice on home safety but rather a personal anecdote. Choice C is incorrect as throw rugs can pose a tripping hazard instead of enhancing safety. Choice D is also incorrect as it does not directly address home safety measures but rather shifts the focus to medication compliance.