An 82-year-old client with multiple comorbidities is admitted to the medical unit with generalized weakness and decreased mobility. The nurse is developing a comprehensive care plan that addresses age-related physiological changes. Which nursing intervention should be the highest priority to prevent complications related to these changes?
1Encourage the client to remain in bed to prevent falls and conserve energy
2Implement a structured mobility program with frequent position changes and ambulation✓ 정답
3Provide high-protein supplements three times daily to prevent malnutrition
4Administer prescribed medications exactly as ordered without modification
해설
A structured mobility program is the priority to prevent complications like pressure ulcers, muscle atrophy, and pneumonia in elderly clients with age-related changes. Other options are less comprehensive (e.g., bed rest can increase risks, supplements are supportive but not primary, medication adherence is standard but not specific to aging).
Core Nursing ExplanationKey Concept Analysis: This question assesses the nurse's ability to prioritize interventions for an older adult with age-related physiological changes and decreased mobility. The core theme is preventing immobility complications. In gerontological nursing, the principle of "use it or lose it" is paramount. Age-related changes like decreased muscle mass (sarcopenia), reduced skin integrity, and a less effective cough reflex make the elderly highly susceptible to complications from inactivity, such as pressure ulcers, deep vein thrombosis (DVT), pneumonia, and contractures.
Answer Rationale: Key Point! The highest priority intervention is Implement a structured mobility program with frequent position changes and ambulation. This single, comprehensive intervention directly addresses the root cause of multiple high-risk complications. It promotes circulation (preventing DVT and pressure ulcers), maintains muscle strength and joint mobility (preventing atrophy and contractures), and facilitates lung expansion (preventing atelectasis and pneumonia). It aligns with the nursing process by being a proactive, preventative measure based on the patient's primary problem of weakness and decreased mobility.
Distractor Analysis:
Option 1 (Encourage bed rest): This is Watch out for confusion! a dangerous intervention for this population. Bed rest accelerates all the complications of immobility it aims to prevent. It leads to deconditioning, increases fall risk upon getting up, and is contrary to evidence-based geriatric care principles.
Option 3 (High-protein supplements): While nutrition is important for wound healing and maintaining muscle mass, it is a supportive measure, not the priority for preventing immobility-related complications. The primary problem is lack of movement, not primarily malnutrition.
Option 4 (Administer medications): This is a standard nursing responsibility for all patients. It does not specifically address the age-related changes or the identified problem of decreased mobility and weakness. Medication management is important but not the highest-priority intervention in this context.
Related Concepts: This question integrates fundamentals of nursing (mobility), gerontology (age-related changes), and medical-surgical nursing (complications of immobility). The nurse must apply the concept of Maslow's Hierarchy of Needs, where physiological needs (preventing physical deterioration from immobility) take precedence. It also touches on Healthy People 2030 goals related to maintaining functional ability in older adults.
Concept Summary
The priority for an elderly client with weakness is to prevent the cascade of complications caused by immobility. A structured mobility program is proactive, addresses multiple systems, and is foundational to maintaining the client's functional status and independence.
Side-by-Side Comparison!
Intervention
Primary Goal
Rationale & Risk if Omitted
Structured Mobility Program
Prevent complications of immobility (DVT, pneumonia, pressure ulcers, contractures)
Promotes circulation, muscle strength, joint ROM, and lung expansion. Without it, rapid deconditioning occurs.
Bed Rest
Often mistakenly used for "safety" or energy conservation
Increases risk of all immobility complications, orthostatic hypotension, and falls. Contraindicated for generalized weakness.
Nutritional Support
Address malnutrition, support tissue repair
Important but secondary. Muscles need protein AND activity to be maintained.
Anatomy, Physiology & Pharmacology Points
Musculoskeletal: Age-related sarcopenia (loss of muscle mass) accelerates with disuse. Weight-bearing activity is needed to slow this process.
Integumentary: Thinner skin, less subcutaneous fat, and reduced capillary density increase susceptibility to pressure injuries. Frequent position changes (turning q2h) is non-negotiable.
Cardiopulmonary: Immobility leads to venous stasis (DVT risk) and decreased thoracic expansion, promoting atelectasis and pneumonia.
Pharmacology: While not the correct answer, always review medications (Option 4) for those that may contribute to weakness or fall risk (e.g., sedatives, antihypertensives).
Memory Tips
Mnemonic: "MOVE to Prevent DEEP Trouble" – Mobility prevents DVT, Edema, Elder complications, Pneumonia.
Association: Think of the body as a machine. A machine that sits idle rusts (joints stiffen), parts seize up (muscles atrophy), and fluids settle (DVT). You must keep it moving.
High-Frequency NCLEX Topics
Prioritizing safety and prevention is a Key Point! on the NCLEX. Questions on elderly care, mobility, and fall prevention are extremely common. The exam consistently tests the understanding that activity is therapeutic and that bed rest is rarely the correct answer unless specifically ordered for an acute condition (e.g., unstable fracture).
Watch Out for Question Variations!
Shift from "Priority Intervention" to "Expected Outcome": "Which client outcome indicates the mobility program is effective?" (Answer: Client ambulates 50 feet with assistive device twice daily without shortness of breath).
Shift to "Select All That Apply": "Which interventions should the nurse include in the mobility plan for this client? (Select all that apply.)" Correct answers might include: Active/Passive ROM exercises, scheduled ambulation, use of a walker, sitting in a chair for meals.
Shift to "Delegation": "Which task can the nurse delegate to the unlicensed assistive personnel (UAP) regarding the client's mobility program?" (Answer: Ambulating the client in the hallway as specified in the care plan).
Nursing Clinical Practice GuideClinical Scenario: You are assigned to Mr. Johnson, an 82-year-old with a history of Congestive Heart Failure (CHF) and Osteoarthritis, admitted for weakness. He spends most of his time in bed watching TV and says he's too tired to get up.
Nursing Intervention Strategy:
Assessment: Perform a comprehensive assessment including Fall Risk (Morse Fall Scale), Skin Integrity (Braden Scale), baseline strength (ability to lift legs against gravity), and pain level (using a numeric scale).
Planning: Collaborate with physical therapy (PT) to create a realistic, progressive mobility plan. Set SMART goals: "Client will sit on edge of bed (dangle) for 5 minutes TID with assistance by day 2."
Implementation:
Frequent Repositioning: Turn and reposition at least every 2 hours. Use pillows for support.
Scheduled Ambulation: After morning care and before lunch, assist him to walk to the bathroom or chair. Use a gait belt and a walker. "Mr. Johnson, let's walk to the chair for your lunch. It will help keep your legs strong."
Active Range of Motion (AROM): Encourage him to perform ankle pumps, knee extensions, and arm circles while in bed or seated.
Dangling: Have him sit on the side of the bed with feet supported for a few minutes before standing to assess for orthostatic hypotension.
Evaluation: Monitor for increased endurance (walking farther), maintained skin integrity, and absence of signs of DVT (unilateral calf pain, swelling). Adjust the plan as he progresses.
Patient Safety and Precautions:
Fall Prevention: Always use a gait belt. Ensure the floor is dry and clutter-free. Have non-slip footwear on the patient.
Monitor Vital Signs: Check blood pressure and heart rate before, during (if possible), and after activity. Stop if the patient experiences chest pain, severe dyspnea, or a significant drop in BP.
Pain Management: Administer prescribed analgesics (e.g., Acetaminophen) 30-60 minutes before planned mobility if pain from arthritis is a barrier.
Nursing Procedure & Medication FlowProcedure: Assisting with Ambulation
1. Explain the procedure and its benefits to the client.
2. Perform pain assessment and manage if needed.
3. Elevate the head of the bed, have the client dangle.
4. Apply a gait belt snugly over clothing.
5. Assist client to stand using the "rock-and-roll" technique (rock forward 3 times, then stand on the 3rd).
6. Stand to the side and slightly behind the client, holding the gait belt.
7. Ambulate at the client's pace, providing verbal encouragement.
8. After activity, assist back to bed or chair, remove gait belt, and assess vital signs and tolerance.
Medication Note: If the client is on Diuretics (e.g., Furosemide), schedule ambulation for times when they are not immediately post-dose and likely to need the bathroom urgently, to prevent accidents and falls.
A Word from Your Senior Nurse
"In the real world, getting an elderly patient moving is one of the most impactful things you can do. I've seen patients come in weak and 'failure to thrive' and turn around completely with a consistent, encouraging mobility routine. It's not just about the body—it's about their spirit and independence. On the NCLEX, they are testing your clinical judgment: can you see the forest (preventing major complications) through the trees (individual tasks)? Always ask yourself, 'What is the biggest threat to this patient right now?' For an immobile elder, it's not just one thing—it's the domino effect of staying still. Your job is to keep those dominoes from falling."