Deck 45: Mobility and Immobility

Question 1

The nurse is assessing body alignment for a patient who is immobilized.What must the nurse do?

A)Place the patient in the supine position.
B)Remove the pillow from under the patient's head.
C)Insert positioning supports to help the patient.
D)Place the patient in a lateral position.

Answer 1

Place the patient in a lateral position.

Question 2

Immobilized patients frequently have hypercalcemia,which increases their risk for what?

A)Osteoporosis.
B)Renal calculi.
C)Pressure ulcers.
D)Thrombus formation.

Answer 2

Renal calculi.

Question 3

A patient has been on prolonged bed rest,and the nurse is observing for signs associated with immobility.While assessing the patient,the nurse is alert to which of the following signs?

A)Increased blood pressure.
B)Decreased heart rate.
C)Increased urinary output.
D)Decreased peristalsis.

Answer 3

Decreased peristalsis.

Question 4

Patients on bed rest or otherwise immobile are at risk for what condition?

A)Increased metabolic rate.
B)Increased diarrhea (peristalsis).
C)Altered metabolic function.
D)Increased appetite.

Question 5

When assessing the body alignment of a patient while he or she is standing,the nurse is aware of which of the following?

A)When observed posteriorly,the hips and shoulders form an S pattern.
B)When observed laterally,the spinal curves align in a reversed S pattern.
C)The arms should be crossed over the chest or in the lap.
D)The feet should be close together with toes pointed out.

Question 6

The nurse is caring for an older patient with the diagnosis of urinary tract infection (UTI).The patient is confused and agitated.It is important for the nurse to realize that confusion in older people is which of the following?

A)Not a normal expectation.
B)Purely psychological in origin.
C)Not a common manifestation with UTIs.
D)Acceptable and needs no further assessment.

Question 7

The nurse is caring for a patient who has suffered a stroke.As part of her ongoing care,what should the nurse do?

A)Encourage the patient to perform as many self-care activities as possible.
B)Provide a complete bed bath to promote patient comfort.
C)Place the patient on bed rest to prevent fatigue.
D)Understand that the patient will not eat because energy needs are decreased.

Question 8

The nurse is aware that patients who are immobile are at increased risk of developing deep vein thromboses (DVTs).Because of this,what action does the nurse take?

A)Make sure that elastic stockings are not removed.
B)Measure the calf circumference of both legs.
C)Dorsiflex the foot while assessing for patient discomfort.
D)Measure both ankles to determine size.

Question 9

The patient has sequential compression stockings in place.The nurse evaluates that the stockings have been implemented appropriately by the new staff nurse when the nurse observes what?

A)Intermittent pressure is set at 40 mm Hg.
B)Initial measurement is made around the patient's calves.
C)Stockings are wrapped directly over the leg from ankle to knee.
D)Stockings are removed every hour during application.

Question 10

Immobility is a major risk factor for pressure ulcers.In caring for the patient who is immobilized,the nurse needs to be aware of which of the following?

A)Breaks in skin integrity are easy to heal.
B)Preventing a pressure ulcer is more expensive than treating one.
C)A 30-degree lateral position is recommended
D)Pressure ulcers are caused by a sudden influx of oxygen to the tissue.

Question 11

The patient with torticollis would exhibit

A)Exaggeration of the lumbar spine curvature.
B)Increased convexity of the thoracic spine.
C)Abnormal anteroposterior and lateral curvature of the spine.
D)Contracture of the sternocleidomastoid muscle with a head incline.

Question 12

A patient is admitted to the medical unit after a CVA.There is evidence of left-sided hemiparesis,and the nurse will be following up on range-of-motion (ROM)and other exercises performed in physiotherapy.Which of the following principles of ROM exercises does the nurse correctly teach the patient and family members?

A)Flex the joint to the point of discomfort.
B)Work from proximal to distal joints.
C)Move the joints quickly.
D)Provide support to the extremity.

Question 13

A 61-year-old patient recently had left-sided paralysis from a cerebrovascular accident (CVA;also known as stroke).In planning care for this patient,the nurse would do which of the following?

A)Encourage an even gait when walking in place.
B)Assess the extremities for unilateral swelling and muscle atrophy.
C)Encourage holding the breath frequently to hyperinflate the lungs.
D)Teach the use of a two-point crutch technique for ambulation.

Question 14

In caring for a patient who is immobile,what is important for the nurse to understand?

A)The effects of immobility are the same for everyone.
B)Immobility helps maintain sleep-wake patterns.
C)Changes in role and self-concept may lead to depression.
D)Immobile patients are often eager to help in their own care.

Question 15

The nurse is assessing the way the patient walks.The manner of walking is known as what?

A)Activity tolerance.
B)Body alignment.
C)Range of motion.
D)Gait.

Question 16

When a patient with impaired physical mobility is in the recumbent position,what angle of lateral position is recommended?

A)15 degrees.
B)30 degrees.
C)45 degrees.
D)90 degrees.

Question 17

The nurse must assess the patient for hazards of immobility by performing a head-to-toe physical assessment.When the respiratory system is assessed,what should the nurse do?

A)Assess the patient at least every 4 hours.
B)Inspect chest wall movements during the expiratory cycle only.
C)Auscultate the entire lung region to assess lung sounds.
D)Focus auscultation on the upper lung fields.

Question 18

The nurse expects to maintain the patient's legs in abduction after total hip replacement surgery with the use of which of the following?

A)Foot boot.
B)Wedge pillow.
C)Trochanter roll.
D)Sandbag.

Question 19

The patient is getting up for the first time after a period of bed rest.What is the initial nursing action?

A)Assess respiratory function.
B)Obtain a baseline blood pressure.
C)Assist the patient to sit at the edge of the bed.
D)Ask the patient if he or she feels lightheaded.

Question 20

The nurse is evaluating the body alignment of a patient in the sitting position.In this position,how is the body aligned?

A)The body weight is directly on the buttocks only.
B)Both feet are supported on the floor with ankles flexed.
C)The edge of the seat is in contact with the popliteal space.
D)The arms hang comfortably at the sides.

Question 21

The nurse is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine.To help prevent injury secondary to this rotation,what can the nurse use?

A)A trochanter roll.
B)The trapeze bar.
C)Hand rolls.
D)Hand-wrist splints.

Question 22

Of the following nursing goals,which is the most appropriate for a patient who has had a total hip replacement?

A)The patient will walk 305 m (1000 feet),using her walker,by the time of discharge.
B)The patient will ambulate by the time of discharge.
C)The patient will ambulate briskly on the treadmill by the time of discharge.
D)The nurse will assist the patient to ambulate in the hall.

Question 23

The patient is unable to move himself and needs to be pulled up in bed.For this repositioning to be done safely,what must the nurse understand?

A)The procedure can be done by one person if the bed is in the flat position.
B)Side rails should be in the up position to prevent the patient from falling out.
C)The pillow should be placed under the patient's head and shoulders.
D)Assistive devices or additional nurses should be used.

Question 24

The patient is being admitted to the neurological unit with the diagnosis of stroke.When should the nurse should begin discharge planning?

A)At the time of admission.
B)The day before the patient is to be discharged.
C)As soon as the patient's discharge destination is known.
D)When outpatient therapy will no longer be needed.

Question 25

In preparing to create a nursing diagnosis for a patient who is immobile,what is important for the nurse to understand?

A)Physiological issues should be the major focus.
B)Psychosocial issues should be the major focus.
C)Developmental issues should be the major focus.
D)All dimensions are important to health.

Question 26

The patient is immobilized after undergoing hip replacement surgery.Which of the following would place the patient at risk for hemorrhage?

A)Thick,tenacious pulmonary secretions.
B)Low-molecular-weight heparin doses to prevent DVT.
C)Sequential compression devices wrapped around the legs to prevent DVT formation.
D)Elastic stockings (thromboembolic disease [TED] hose)to promote venous return.

Question 27

When the nurse creates a plan of care for a patient who is experiencing alterations in mobility,which of the following is true?

A)The nurse cannot delegate interventions to nursing assistive personnel.
B)The nurse is solely responsible for modifying activities of daily living (ADLs).
C)The nurse consults other health care team members to help plan therapy.
D)The nurse consults wound care specialists only when wounds are apparent.

Question 28

The nurse needs to transfer the patient from the bed to the chair.What should the nurse remember?

A)To avoid using a transfer or gait belt around the patient's waist before transfer.
B)Not to allow the patient to help in any way because resistance can lead to injury.
C)To assess for the need of a mechanical lift and help.
D)To ensure that the patient has stockings on the feet for transfer.

Question 29

The nurse needs to reposition a 136.1 kg (300-pound)patient.Which of the following strategies is most likely to prevent back injury?

A)Turn the patient alone using the lift pad and applying pillows.
B)Put the bed in the Trendelenburg position and pull from the head of the bed.
C)Assess and obtain the number of people needed to help.
D)Bend at the waist and pull the lift pad,using the arms.

Question 30

The nurse is caring for a patient who is immobile and needs to be turned every 2 hours.The patient has poor lower extremity circulation,and the nurse is concerned about irritation of the patient's toes.What is one strategy that the nurse could use?

A)A foot cradle.
B)A trochanter roll.
C)The trapeze bar.
D)Hand rolls.

Question 31

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder.This diagnosis means that the nurse should do what?

A)Encourage the patient to perform self-care.
B)Keep the patient as mobile as possible.
C)Encourage the patient to perform ROM exercises.
D)Assist the patient with comfort measures.

Question 32

The nurse is caring for a patient who has had a stroke that caused total paralysis of the right side.To help maintain joint function and to prevent contractures,passive ROM exercises will be initiated.When should therapy begin?

A)After the acute phase of the disease has passed.
B)As soon as the ability to move is lost.
C)Once the patient enters the rehabilitation unit.
D)No ROM exercise is needed.

Question 33

Prevention of plantar flexion through the use of pillows to support the lower legs and elevate the toes is a priority intervention for which patient?

A)A 54-year-old with a diagnosis of osteoarthritis in all lower extremity joints.
B)A 25-year-old with a fractured pelvis as a result of a motorcycle accident.
C)A 78-year-old who has experienced left-sided paralysis caused by a CVA.
D)A 15-year-old who has been comatose for 2 years as a result of a head injury sustained from a fall off a roof.

Question 34

When the nurse is preparing a plan of care for an immobilized patient,what should the nurse keep in mind?

A)To use established expected outcomes to evaluate the patient's response to care.
B)To display an air of professional superiority when interventions are not successful.
C)Never to vary from interventions that have been successful for other patients.
D)To use only objective data in determining whether interventions have been successful.

Question 35

The nurse is admitting a patient who has had a stroke.The physician writes orders for "ROM as needed." What does the nurse understand about this situation?

A)The nurse will have to move all the patient's extremities.
B)The patient is unable to move his extremities.
C)Further assessment of the patient is needed.
D)The patient needs to restrict his mobility as much as possible.

Question 36

In developing an individualized plan of care for a patient,what is important for the nurse to do?

A)Set goals that are a little beyond the capabilities of the patient.
B)Use his or her judgement and not be swayed by family desires.
C)Establish goals that are measurable and realistic.
D)Explain that without taking alignment risks,there can be no progress.

Question 37

It has been determined that each of the following patients is at risk for falling.Which one requires the nurse's priority for ambulation?

A)A 16-year-old with a sprained ankle being discharged from the emergency department.
B)A 54-year-old who has taken the initial dose of an antihypertensive medication.
C)A 45-year-old postoperative patient up for the first time since knee surgery.
D)An 81-year-old who is asthmatic and had a hip replaced 18 months ago.

Question 38

While performing passive ROM exercises,the nurse stands at the side of the bed closest to the joint being exercised and does what else?

A)Forces the joint just a bit beyond the point of resistance.
B)Moves the joint until the patient complains of pain.
C)Repeats each movement twice.
D)Carries out movements slowly and smoothly.

Question 39

In applying for a job on a nursing unit that requires frequent patient positioning,of what should the nurse should be aware?

A)That nurses are at low risk for back injury.
B)That nurses are especially at risk for upper back injuries.
C)That nurses should be aware of agency policies.
D)That nurses should not need to use assistive devices.

Question 40

Many patients who experience an alteration in mobility have one or more nursing diagnoses.For whom would the nurse would use the diagnosis of Impaired physical mobility?

A)A patient who is not completely immobile.
B)A patient who is completely immobile.
C)A patient who is at risk for multisystem problems.
D)A patient who is at risk for single-system involvement.

Question 41

Correct body alignment reduces strain on musculoskeletal structures and contributes to balance.Balance control is attained by which of the following? (Select all that apply. )

A)Keeping the body's centre of gravity high.
B)Maintaining a wide base of support.
C)Keeping the body's centre of gravity low.
D)Maintaining correct body posture.
E)Maintaining immobility to prevent falls.

Question 42

Two nurses are standing on opposite sides of the bed to move the patient up in bed with a drawsheet.Which of the following describes the correct position for the nurses in order to safely position the patient?

A)The nurses should face the patient.
B)The nurses should face the direction of movement.
C)The nurses should face each other.
D)The nurses should face opposite the direction of movement.

Question 43

The nurse is caring for a patient who has had a recent stroke and is paralyzed on his left side.He has no respiratory or cardiac issues,but he cannot walk.He becomes extremely frustrated when he cannot button his shirt and cannot feed himself because he was left-handed.He has shown no signs of dysphagia,but he has been eating very little and has lost 0.9 kg (2 pounds).He asks the nurse,"How can I go home like this? I'm not getting better.I can't ask my wife to take care of me like a baby." Of the following list of health care team members,which member would the nurse need to consult? (Select all that apply. )

A)Physiotherapy.
B)Occupational therapy.
C)Respiratory therapy.
D)Cardiac rehabilitation.
E)Psychology services.

Question 44

The patient has suffered a spinal cord injury and needs to be repositioned through the log-rolling technique to keep the spinal column in straight alignment.Which of the following is the proper technique for nurses to perform log-rolling?

A)Obtaining assistance from at least two or three other people.
B)Having the patient reach for the opposite side rail when turning.
C)Moving the top part of the patient's torso,then the bottom part.
D)Not using pillows after turning because the softness causes misalignment.

Question 45

The nurse is caring for a patient with the nursing diagnosis of Impaired physical mobility.The nurse needs to be alert for which of the following potential complications? (Select all that apply. )

A)Pulmonary emboli.
B)Pneumonia.
C)Impaired skin integrity.
D)Somnolence.
E)Increased socialization.