An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?

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Question 1 of 5

An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?

Correct Answer: A

Rationale: Stiffness in the right ankle indicates an immobility complication, per the document, suggesting early contracture or atrophy from disuse. Gum soreness , memory loss , and appetite decrease aren't directly tied to immobility. A signals musculoskeletal decline, a common elderly risk, making it the relevant complaint.

Question 2 of 5

A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

Correct Answer: C

Rationale: Accepting the client's report of pain is the first step in assessment. Pain is subjective; validating it builds trust and ensures accurate data collection, per standards. Coping methods and location/intensity follow. Status is vague. C aligns with pain management principles, prioritizing patient experience, making it the initial action.

Question 3 of 5

Which of these clients would be appropriate to assign to a practical nurse (PN)?

Correct Answer: B

Rationale: An elderly client with cystitis and catheter is appropriate for a PN. Stable care aligns with PN skills, unlike complex dressings , family complaints , or unstable TIA , which need RN expertise. B fits PN scope, making it suitable.

Question 4 of 5

The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP?

Correct Answer: A

Rationale: Reporting redness over a joint requires supervision. It involves assessment, beyond UAP scope; RN must interpret. Monitoring response is RN-only, but encouragement and transfers are delegable. A ensures RN oversight, making it the supervised task.

Question 5 of 5

A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?

Correct Answer: D

Rationale: Good morning. You're in the hospital. I am your nurse Elaine Jones' provides the best reality orientation. It clearly states place and person, aiding a confused client, unlike vague recall prompts (A, C) or intro-only . D supports cognition, making it the top choice.

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