Deck 21: Immobility

Question 1

The nurse is providing discharge instructions to the family of an older adult patient who is unable to get out of bed.The nurse should instruct the family that the most effective way to prevent urinary incontinence associated with immobility is to:

A) Use absorbent under pads.
B) Set up a toileting program.
C) Restrict fluid intake to 500 ml per 24 hours.
D) Restrict fluids after dinner and throughout the night.

Answer 1

Set up a toileting program.

Question 2

To prevent respiratory complications resulting from immobility,the best nursing interventions would be to:

A) Suction every 4 to 6 hours.
B) Administer pain medications as frequently as possible.
C) Teach the patient the technique of pursed lip breathing.
D) Reposition the patient, and encourage him or her to cough and deep-breathe at least every 2 hours.

Answer 2

Reposition the patient, and encourage him or her to cough and deep-breathe at least every 2 hours.

Question 3

When the nurse's assessment reveals an area of erythema on an immobilized patient's sacrum,the first step should be to:

A) Apply a wet-to-dry dressing.
B) Massage the reddened area.
C) Reposition the patient.
D) Rub the area with alcohol.

Answer 3

Reposition the patient.

Question 4

The nursing assistant is bathing a patient who has a stage I pressure ulcer on the right shoulder.The nurse reminds the nursing assistant that the tissue could become more damaged if she:

A) Positions the patient on the left side.
B) Massages the reddened area.
C) Cleans the area with mild soap and water.
D) Positions the patient in a prone position.

Question 5

The most effective intervention to prevent constipation in a patient who recently suffered a fractured femur and is currently in traction is to:

A) Get the patient up and to the bathroom at least twice each day.
B) Administer enemas each day until the patient has a bowel movement.
C) Administer pain medication to prevent pain during defecation.
D) Encourage a high-fiber diet and increased amounts of fluids.

Question 6

The nurse knows that the best prevention of immobility-related disorders is:

A) Dietary supplements
B) Fluids
C) Adequate fiber
D) Exercise

Question 7

The negative impact of immobilization on a patient depends on the duration,degree,and type of:

A) Physical therapy
B) Mobility limitation
C) Nursing care
D) Family support

Question 8

The patient is complaining to the nurse that he feels the need to have a bowel movement but has not been able to defecate.He has had cramping and even a small amount of brown watery stool.The nurse recognizes these symptoms as:

A) Diarrhea
B) Fecal incontinence
C) Fecal impaction
D) Flatulence

Question 9

The patient complains that his "bottom" is sore.The nurse assesses the area and finds an open area on the sacrum that appears blistered.The nurse should:

A) Document the cause of the burn.
B) Clean with alcohol, apply moisturizer, and cover with a set dressing.
C) Massage the area to promote circulation.
D) Clean with mild soap, dry, and apply a light dressing.

Question 10

When preparing a plan care for an older adult patient,the nurse should consider the common problems associated with immobility.These problems may be classified as:

A) Environmental and intellectual
B) Internal and external
C) Mental and medical
D) Physical and psychosocial

Question 11

A patient in traction with a fractured hip is diagnosed with a stage I pressure ulcer.She asks the nurse how a pressure ulcer could occur after only 2 days of immobility.The nurse's response is based on her knowledge that:

A) "Erythema can occur in 1 to 2 hours, even in a person with healthy skin and adequate circulation."
B) "It takes several days for a pressure ulcer to form."
C) "The pressure ulcer probably occurred when you fell."
D) "The cause of pressure ulcers isn't really known."

Question 12

A nurse caring for a patient who has been prescribed bedrest for 1 week notices a reddened area on the patient's left hip.The skin is intact but,when the nurse presses on the area,the redness does not fade.The nurse recognizes this pressure ulcer as:

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Question 13

During the shift report,the nurse is told that the patient she will be caring for has a stage II pressure ulcer.During the dressing change,the nurse would expect to see a(n):

A) Ulcer that appears black with possible signs of infection
B) Shallow ulcer that appears blistered, cracked, or abraded
C) Craterlike sore with a distinct outer margin formed as the epidermis thickens and rolls over the edge toward the ulcer base
D) Redness of skin with no ulceration

Question 14

The nurse assesses a patient's risk for developing a pressure ulcer using the Norton scale.The patient's score is 18.The nurse should:

A) Call the physician immediately.
B) Implement a pressure ulcer prevention program.
C) Document the score.
D) Order an alternating air mattress.

Question 15

The nurse takes into consideration that immobilization has negative effects on the musculoskeletal system such as:

A) Demineralization of bone
B) Increase in aerobic capacity
C) Increased muscle oxidation
D) Lengthening of muscle fibers

Question 16

The nurse is performing a wet-to-dry dressing change on a stage IV pressure ulcer.The nurse understands that the purpose of this type of dressing is to:

A) Keep the wound moist.
B) Prevent infection.
C) Débride necrotic tissue.
D) Increase circulation to the tissue.

Question 17

When positioning an immobile patient,the nurse should:

A) Ensure that the patient's knees and hips are flexed.
B) Visualize how a person looks while standing, and try to have the patient achieve that position while lying down.
C) Reposition the patient no more often than every 4 hours.
D) Always position the patient on his or her back with the head raised to prevent aspiration.

Question 18

The nurse points out that the National Pressure Ulcer Advisory Panel prefers to refer to skin breakdown as:

A) Bed sores
B) Pressure ulcers
C) Decubitus ulcers
D) Decubiti

Question 19

The care plan of an older adult patient states that the patient should be monitored while in the bathroom because of a history of vasovagal reflex.The nurse knows that she should assess for:

A) Extremely elevated blood pressure after ambulation
B) Nausea and vomiting after a meal
C) Lightheadedness and fainting during defecation
D) Inability to urinate

Question 20

A discharge order for the patient with left-sided weakness after having a stroke is to teach the patient to perform range-of-motion exercises on the affected extremities.The patient asks why she needs to do range-of-motion exercises.The nurse's best response would be:

A) "Because the physician has ordered it."
B) "You will regain full use of your arm and leg if you will do the exercised correctly."
C) "They prevent the muscles and tendons from shortening and becoming unmovable."
D) "It will give you something to do since you can't work anymore."

Question 21

The nurse evaluates the effectiveness of the treatment for a stage III pressure ulcer as satisfactory when the bed of the ulcer is pink,indicating the presence of _________________________,which is an indicator of tissue perfusion.

Question 22

When a bacteria is localized at the site of a Stage III pressure ulcer,it is said to be_____________.

Question 23

The nurse is talking with a patient who recently became paraplegic as a result of a cervical spinal cord injury.When some home equipment is discussed,the patient becomes angry and says,"I don't need to worry about any kind of home equipment." The best response by the nurse would be:

A) "I know you will be walking soon, but you may need some equipment until then."
B) "There is very little chance that you will ever walk."
C) "Tell me what it is about this equipment that bothers you."
D) "Let me call the physician to come explain your injuries to you."

Question 24

The nurse instructing a patient on performing isometric exercises should instruct the patient to:

A) Contract the muscle for several seconds, then relax the muscle for a few seconds, and contract it again.
B) Perform full range-of-motion exercises of each joint.
C) Have a family member perform full range-of-motion exercises on each of the patient's joints.
D) Stand in front of a wall and push with the arms without bending the elbow.

Question 25

The nurse is instructing a patient relative to the characteristics of a stage I pressure ulcer,which are: (Select all that apply.)

A) The area is regular and well-defined.
B) Tissue hardening is present.
C) Swelling has occurred at the site.
D) The condition is reversible.
E) Nonblanching erythema is observed.

Question 26

On a newly discovered pressure ulcer,the nurse should document which of the following? (Select all that apply.)

A) Precise measurement of the ulcer
B) Location of the wound and its description
C) Color of the ulcer
D) Amount and characteristics of the drainage
E) Probable cause of the ulcer

Question 27

The nurse takes into consideration that such emotions as worry,anxiety and depression can contribute to the common nutritional problem of ______.

Question 28

The nurse takes into consideration that many therapeutic reasons exist that explain why a patient might become immobile,and these include: (Select all that apply.)

A) Reduction of the work load of the heart
B) Fear of falling
C) Reversal of the effects of gravity
D) Bereavement
E) Healing of as fracture

Question 29

The nurse instructs a patient in a wheelchair that the risk for pressure ulcers can be diminished if the patient will:

A) Use a ring pillow on the seat of the chair.
B) Lift the weight of the body using the arms of the wheelchair every 15 minutes.
C) Scoot forward and back in the seat to stimulate circulation.
D) Wear underwear that holds moisture close to skin.

Question 30

During the skin integrity assessment,the nurse notices an area on the right heel that is black and draining purulent,foul-smelling exudate.The nurse should document this as a pressure ulcer in:

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Question 31

When planning the care of a patient who is immobile,the nurse should remember that the patient will be at risk for urinary tract infection because the:

A) Urine will pool in the bladder when the patient remains in a supine position.
B) Patient is likely to have urinary incontinence.
C) Patient's appetite may be decreased.
D) Patient may not be able to move quickly enough to get to the bathroom.

Question 32

Incontinence in older adults,which is related to the inability to get to the bathroom in time,is classified as:

A) Stress incontinence
B) Urge incontinence
C) Functional incontinence
D) Sporadic incontinence

Question 33

The home health nurse instructs a family about boosting the patient in bed so that a ____________________ type of skin injury will not occur.