Question

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

a) Increased muscle strength in the lower extremities.
b) Presence of dependent edema in the lower limbs.
c) Pink and warm skin in the sacral area.
d) Decreased bowel sounds and abdominal distension.

Answer 1

The nurse should intervene for the finding of decreased bowel sounds and abdominal distension in the immobile client.

Step-by-step explanation:

The nurse should intervene for the finding of decreased bowel sounds and abdominal distension in the immobile client. This could indicate a possible bowel obstruction or impairment in gastrointestinal motility.

Increased muscle strength in the lower extremities is actually a positive finding, as immobility often leads to muscle weakness.

Dependent edema in the lower limbs is a common finding in clients who are immobile for long periods of time and does not require immediate intervention.

Pink and warm skin in the sacral area is also a normal finding and does not require intervention.