Which physiological effect of immobility can lead to impaired circulation and increased risk of deep vein thrombosis?

Correct Answer: C

Rationale: Immobility reduces cardiac output by limiting muscle activity that aids venous return, leading to sluggish circulation and blood pooling, heightening deep vein thrombosis risk. This cardiovascular effect stems from less demand on the heart and poor venous flow, a serious concern in bedridden patients. Reduced breathing capacity affects oxygenation, not circulation directly, while muscle weakness and bone density loss impact strength and structure, not blood flow. Nurses monitor this to prevent clot formation, using interventions like leg exercises or compression devices, recognizing that circulation impairment is a critical link to thrombosis in prolonged stillness.

Correct Answer: A

Rationale: Ensuring the reservoir bag stays inflated (A) is critical for a non-rebreather, maintaining a high oxygen reserve (up to 95%) for inhalation. Client-preferred flow (B) lacks medical basis. Q2h SpO2 (C) may be too infrequent. Meal removal (D) disrupts therapy. Bag inflation, per respiratory care, ensures efficacy.

Correct Answer: C

Rationale: Timoptic, a beta-blocker eyedrop for glaucoma, requires caution in clients with emphysema due to potential systemic absorption causing bronchoconstriction, exacerbating respiratory issues. Diabetes, ulcers, or pancreatitis aren't directly contraindicated beta-blockers more critically affect airway resistance. Nurses monitor breathing in such clients, ensuring safe use while managing intraocular pressure, balancing ocular benefits against pulmonary risks.

Correct Answer: C

Rationale: Diplopia (double vision) is a frequent symptom during multiple sclerosis (MS) exacerbations, reflecting inflammation of optic or cranial nerves, disrupting coordination a hallmark of this demyelinating disease. Anorexia, seizures, or insomnia may occur but aren't as specific to MS flares. Nurses identify this visual disturbance to gauge relapse severity, guiding steroid or symptomatic treatment, and educate clients to report it, enhancing disease monitoring and quality of life.

Correct Answer: D

Rationale: Phenytoin (Dilantin) causes gingival hyperplasia, necessitating oral hygiene and gum care every shift to prevent overgrowth and infection a key nursing focus in seizure management. Intake/output, pulse checks, or meal timing aren't priorities. Nurses plan this to maintain oral health, enhancing client comfort and medication adherence.