immobility complications

Question

The nurse reviews the following note and responds to the questions.

Step 1

Which finding is most concerning for a clot in a deep vein?

1. AOne calf is swollen, warm and painful✓ Correct

   One-sided swelling, warmth and pain can occur with deep vein thrombosis.

2. BBoth hands are warm after washing✗ Incorrect

   Warm hands after washing do not show the one-sided calf symptoms associated with DVT.

3. CThe client requests a second pillow✗ Incorrect

   A pillow request does not identify a symptom of DVT.

4. DThe client asks to read in bed✗ Incorrect

   A request to read does not identify a symptom of DVT.

Rationale. New one-sided calf discomfort, warmth and swelling are findings associated with DVT. They require prompt follow-up.

Step 2

The best interpretation is Reduced activity can slow blood movement in veins.

• Blank 1 choices: Reduced activity can slow blood movement in veins / Reduced activity exposes the dermis directly / Reduced activity guarantees a swallowing disorder / Reduced activity makes a blister a stage 4 injury

Rationale. With less movement, venous flow can slow and a clot can form. This is a circulatory complication of immobility.

Step 3

Which hypothesis best accounts for the calf findings?

1. ADeep vein thrombosis✓ Correct

   DVT can cause one-sided limb swelling, pain, warmth and redness.

2. BStage 2 pressure injury✗ Incorrect

   A stage 2 pressure injury involves partial-thickness skin loss, not the described calf pattern.

3. CDifficulty swallowing✗ Incorrect

   Difficulty swallowing does not explain the described calf pattern.

4. DLoss of joint motion alone✗ Incorrect

   Reduced joint motion alone does not explain the described calf symptoms.

Rationale. The unilateral calf changes fit a possible deep vein clot. The other conditions do not explain this pattern.

Step 4

For a different client recovering from fracture without suspected DVT, which prescribed measure helps prevent DVT?

1. AEarly mobilization when appropriate✓ Correct

   Early mobilization is a DVT prevention measure after fracture repair when appropriate.

2. BContinuous immobility✗ Incorrect

   Immobility can slow venous blood flow; early mobilization is a preventive measure.

3. CWithholding all activity indefinitely✗ Incorrect

   Indefinite inactivity conflicts with early mobilization as a preventive measure.

4. DAvoiding ordered compression stockings✗ Incorrect

   Compression stockings are among the preventive measures used after fracture repair.

Rationale. After fracture repair, early movement when appropriate is one preventive measure. It is distinct from managing a suspected clot.

Step 5

Before new symptoms arose, the care plan included joint exercises. Which action fits that plan?

1. AAssist with prescribed range-of-motion exercises when directed and safe✓ Correct

   Range-of-motion exercises support joint movement and help prevent musculoskeletal complications of immobility.

2. BForce the joint past resistance✗ Incorrect

   Forcing a joint past resistance does not fit a safe exercise plan.

3. CReplace all movement with prolonged bed rest✗ Incorrect

   Prolonged bed rest replaces the joint movement that range-of-motion exercises provide.

4. DAssume joint exercise treats a suspected clot✗ Incorrect

   Range-of-motion exercises address mobility; they are not a treatment for a suspected clot.

Rationale. Joint movement exercises can help prevent musculoskeletal consequences of immobility. Follow the care plan only when the activity is directed and safe.

Step 6

Which finding would suggest the calf problem remains unresolved and needs follow-up?

1. AThe affected calf remains painful and swollen✓ Correct

   Persistent one-sided pain and swelling remain concerning signs associated with DVT.

2. BThe client asks for a book✗ Incorrect

   A book request does not indicate whether calf symptoms have resolved.

3. CThe room is quiet during rest✗ Incorrect

   Room noise does not indicate whether calf symptoms have resolved.

4. DThe client requests a blanket✗ Incorrect

   A blanket request does not indicate whether calf symptoms have resolved.

Rationale. Persistent pain and swelling remain concerning for a deep vein clot. The nurse should continue to report and follow up the finding.

Rationale

Immobility can contribute to circulation and joint complications. New one-sided calf changes require follow-up.