Deck 36: Immobility

Question 1

Which patient is most likely to have developmental effects due to prolonged immobility?

A) Toddler patient in traction for a congenital skeletal anomaly
B) Young adult patient with burns on the hands
C) Teenage patient with a bacterial infection in isolation
D) Middle-age adult patient with a fractured ankle on crutches

Answer 1

Toddler patient in traction for a congenital skeletal anomaly

Question 2

The patient is recovering from a cerebrovascular accident (stroke).The patient is having problems with balance and coordination.The patient asks the nurse what part of the brain has been damaged.How should the nurse respond?

A) The hypothalamus has been damaged.
B) The cerebellum has been damaged.
C) The thalamus has been damaged.
D) The medulla oblongata has been damaged.

Answer 2

The cerebellum has been damaged.

Question 3

Nurses implement therapeutic immobilization for patients to achieve which result?

A) Reducing pain
B) Restraining an unstable patient in bed
C) Increasing active movement of the body
D) Strengthening joints and muscles

Answer 3

Reducing pain

Question 4

Which action should the nurse implement to help prevent thrombus formation in postsurgical patients?

A) Maintain complete bed rest.
B) Place tight clothing on the legs and waist.
C) Put pillows under the knees.
D) Position properly with use of antiembolic stockings.

Question 5

A nurse is caring for a patient in Buck's traction on bed rest for a fracture of the femur.Which action should the nurse take to help preserve skin integrity?

A) Provide meticulous skin care.
B) Use pain medication to prevent excessive movement.
C) Limit range of joint motion so the patient is not disturbed.
D) Reduce the amount of protein intake so renal function can be preserved.

Question 6

Which assessment finding should the nurse expect to observe on an immobilized patient?

A) Increased serum glucose levels
B) Decreased urine excretion
C) Positive nitrogen balance
D) Increased serum potassium levels

Question 7

The nurse is observing a patient's posture while sitting,standing,and assessing gait.What is the rationale for the nurse's assessment?

A) To determine type of assistance with anthropometric measurements
B) To determine type of assistance with joint mobility
C) To determine type of assistance with range of motion (ROM)
D) To determine type of assistance with ambulation

Question 8

Which patient is at greatest risk for developing a pressure ulcer?

A) Young adult paraplegic with pneumonia
B) Middle age adult that can turn by self in bed
C) Teenager with a sprained ankle on crutches
D) Middle-age adult with breast cancer

Question 9

A young adult patient was involved in a motorcycle accident.The patient was in the intensive care unit of the hospital for 2 months with immobility and was just discharged to a rehabilitation hospital.The patient asks the nurse,"Why am I so weak?" What is the best response from the nurse?

A) "When you are in bed for a long time, your body begins to break down its own protein."
B) "When you don't use it, you lose it."
C) "You haven't eaten much for the past couple of months."
D) "Your body has spent energy trying to heal itself by increasing the metabolic rate."

Question 10

A nurse has finished preoperative teaching for a surgical patient.Which statement by the patient indicates teaching was successful about the use of elastic stockings?

A) "I do not have to worry about wrinkles."
B) "I can roll them no lower than my calf."
C) "I will massage my legs regularly."
D) "I should remove and reapply them every 8 hours."

Question 11

The nurse working with a new nursing assistive personnel (NAP),is explaining about the importance of repositioning immobile patients to prevent pressure ulcers.At a minimum,the nurse tells the NAP to reposition patients how often?

A) Every 2 hours
B) Every 3 hours
C) Every 4 hours
D) Once every shift

Question 12

A nurse notes a typical cardiovascular change in an immobilized postoperative patient.Which of the following did the nurse find upon assessment?

A) Atelectasis
B) Negative nitrogen balance
C) Orthostatic hypotension
D) Bleeding

Question 13

A nurse is caring for an immobile patient.What is the most appropriate nursing intervention to implement?

A) Turn the patient every 4 hours.
B) Apply an abdominal binder while the patient is lying in bed.
C) Encourage the regular use of incentive spirometry while awake.
D) Maintain the patient's maximum fluid intake of 1000 mL daily.

Question 14

A patient is recovering from an abdominal aortic bypass graft.To reduce the effects of orthostatic hypotension,what is the most appropriate action for the nurse to take?

A) Encourage moving positions slowly.
B) Perform isometric exercises.
C) Decrease the number of ankle pumps.
D) Participate in chest physiotherapy.

Question 15

An elderly patient was admitted to the hospital after falling in the nursing home.The patient has a fractured right femur and is awaiting surgery.The surgeon orders bed rest.The patient asks the nurse what this means.What is the nurse's best explanation?

A) "You are to be immobile."
B) "You cannot move."
C) "You need restraints."
D) "You have to remain in bed."

Question 16

Which patient is most at risk for developing a urinary tract infection?

A) Teenage comatose patient on a ventilator lying supine
B) Middle-age adult after abdominal surgery sitting in a chair
C) Elderly adult with Alzheimer disease who is wandering at night
D) Middle-age adult postcardiac catheterization being discharged home

Question 17

A student nurse is caring for a young adult patient who is immobile with a back injury.On auscultation,the student nurse hears rhonchi in the lower lobes.The student nurse reports this symptom because the patient is developing which complication?

A) Increased lung expansion
B) Hypostatic pneumonia
C) Aspiration pneumonia
D) Increased diuresis

Question 18

Patients on prolonged bed rest are at risk for a deep vein thrombosis.Which information indicates the nurse needs more teaching about the factors in Virchow's triad?

A) One of the factors is loss of integrity of the vessel wall.
B) One of the factors is abnormalities of blood flow.
C) One of the factors is alterations in blood constituents.
D) One of the factors is atrophy of the muscles.

Question 19

An elderly nursing home resident fell 2 weeks ago and has been on bed rest.The patient has become increasingly fatigued during activities of daily living (ADLs).The family is concerned about the patient's declining condition.The best explanation that the nurse can give the family is that the patient's fatigue is caused by which of the following?

A) Decreased muscle endurance caused by immobility
B) Advanced age
C) Increased metabolism
D) Urinary stasis

Question 20

While planning care for an immobilized patient,which physiological process will the nurse consider about the patient's musculoskeletal system?

A) Increased muscle mass
B) Decreased rate of bone resorption
C) Muscle atrophy
D) Bone tissue density elevated

Question 21

A young adult was involved in a motor vehicle accident and suffers from brain trauma.The patient has decrease mobility in all joints.The nurse should assess for which common,debilitating contracture?

A) Lordosis
B) Bowlegs
C) Footdrop
D) Kyphosis

Question 22

Immobilized patients often become depressed.A nurse can best combat this effect of immobilization by doing which of the following? (Select all that apply.)

A) Limiting visitors so the patient is not bothered
B) Involving the patient in planning time for care and activities
C) Placing the patient in a private room to reduce the interruptions by a roommate
D) Encouraging the patient to comb hair, wear make-up, and/or use cologne if appropriate
E) Having the patient in a room with another patient who is interactive.

Question 23

When completing the assessment of an immobilized patient,the most likely place for the nurse to assess edema includes which of the following? (Select all that apply.)

A) Face
B) Feet
C) Sacrum
D) Abdomen
E) Legs

Question 24

The patient was involved in a motor vehicle accident.The patient has a fractured right hip and is on bed rest.Because of the prolonged immobility the nurse is concerned about complications such as which of the following? (Select all that apply.)

A) Decreased nutrients/fluids
B) Increased disuse osteoporosis
C) Increased gastrointestinal motility
D) Decreased lung expansion
E) Decreased pooling of lung secretions

Question 25

A patient has decrease mobility in all joints.Because of the lack of mobility,the nurse expects the health care provider to order what medication to prevent venous thromboembolisms that will reduce the side effect of hemorrhage?

A) Oral anticoagulant
B) Aspirin
C) Low-molecular-weight heparin
D) Unfractionated heparin