Deck 29: Immobility

Question 1

Which is the appropriate intervention for a patient with risk for constipation related to prolonged immobility?

A) Check the patient's rectum for the presence of a fecal impaction.
B) Encourage the patient to consume plenty of fluids and dietary fiber.
C) Instruct the patient about the body's need for daily bowel movements.
D) Recommend the use of daily laxatives to prevent constipation or impaction.

Answer 1

Encourage the patient to consume plenty of fluids and dietary fiber.

Question 2

Which action of the nurse will help to reduce the effects of orthostatic hypotension?

A) Perform isometric and range-of-motion exercises.
B) Encourage the patient to move from a sitting position to standing position slowly.
C) Place trochanter rolls on either side of the patient's hips.
D) Participate in chest physiotherapy and incentive spirometry.

Answer 2

Encourage the patient to move from a sitting position to standing position slowly.

Question 3

Which intervention will be most effective for prevention of foot drop in an immobile patient?

A) Apply high-top tennis shoes to the patient's feet.
B) Obtain a podiatry consult for all toenail and foot care.
C) Encourage the patient to wear sturdy shoes when ambulating.
D) Apply moisturizing lotion to the heels of the feet and between the toes.

Answer 3

Apply high-top tennis shoes to the patient's feet.

Question 4

The nurse is caring for a pregnant mother of two small children who is on bed rest for several months until the baby is born.Which outcome is most appropriate to address the diagnosis of compromised family coping related to mother's prolonged bed rest?

A) The family will verbalize need for support and identify available resources.
B) The family will discuss alternatives to bed rest with the health care provider.
C) The mother will verbalize need for bed rest to minimize risk of premature birth.
D) The mother will report increased psychological comfort with each passing week.

Question 5

Which is the priority nursing diagnosis for a patient with orthostatic hypotension after several days of bed rest?

A) Risk for falls related to light-headedness upon standing and getting out of bed
B) Dressing/grooming self-care deficit related to cognitive impairment and fatigue
C) Impaired bed mobility related to inability to move from supine to sitting position
D) Excess fluid volume related to insensible fluid loss due to prolonged immobility

Question 6

The nurse suspects that the postoperative patient has developed a deep vein thrombosis.Which is the priority action of the nurse?

A) Obtain an order for STAT bleeding time,D-dimer,and platelet count.
B) Elevate the patient's leg and assess for chest pain or shortness of breath.
C) Apply a mobile compression device (MCD)to the patient's affected leg.
D) Use a Doppler machine to confirm the presence of bilateral pedal pulses.

Question 7

Which assessment finding indicates that the patient developed osteoporosis after a long period of immobility?

A) The patient fractured three ribs after coughing on spicy food.
B) The patient is unable to dorsiflex the foot,leading to an unsteady gait.
C) The patient has a steppage gait with exaggerated flexion of the hip and knee.
D) The patient's knees curve inward and bump against each other with ambulation.

Question 8

Which patient would benefit from the use of a hand roll?

A) A patient with paralysis of the right hand after a left-sided stroke
B) A paraplegic patient who requires assistance moving up in the bed
C) A confused patient who is attempting to pull out the urinary catheter
D) A patient with lymphedema of the right arm and hand after mastectomy

Question 9

The nurse is caring for a patient who is recovering from a cerebrovascular accident.Which assessment finding indicates that the patient's cerebellum was damaged by the stroke?

A) The patient has continuous double vision.
B) The patient has slurred speech and dysphagia.
C) The patient is incontinent of bowel and bladder.
D) The patient has poor balance and has an unsteady gait.

Question 10

Which is the appropriate intervention for the patient with the diagnosis powerlessness related to pain and weakness after right hip fracture?

A) Place the patient's personal items within view on the left side of the bed.
B) Encourage the patient to participate in self-care and recreational activities.
C) Assess the patient's sleep patterns and potential for obstructive sleep apnea.
D) Reposition the patient and pad bony prominences to prevent skin breakdown.

Question 11

Which is an appropriate outcome for an elderly patient with the nursing diagnosis adult failure to thrive related to placement in extended care agency after right hip fracture?

A) The patient will participate in social activities and maintain usual weight.
B) The patient will exercise both legs to minimize effects of unilateral neglect.
C) The patient will verbalize need for extended nursing care during rehabilitation.
D) The patient will not demonstrate symptoms of deep vein thrombus development.

Question 12

The nurse is caring for a patient with nonblanchable redness of the coccyx after a lengthy surgical procedure in the supine position.Which nursing diagnosis is appropriate for this patient?

A) Risk for impaired skin integrity related to lengthy surgical procedure
B) Noncompliance related to failure to frequently reposition self
C) Ineffective therapeutic regimen management related to improper positioning
D) Impaired skin integrity related to tissue pressure from prolonged supine position

Question 13

The nurse is caring for a patient who is ordered to remain on bed rest.Which is the appropriate action of the nurse to facilitate emptying of the patient's bladder?

A) Assist the patient to the bedside commode for voiding.
B) Insert an indwelling urinary catheter to bedside drainage.
C) Place the patient in high Fowler's position when using the bedpan.
D) Place the patient in Trendelenburg's position when using the bedpan.

Question 14

The nurse is to transfer an obese,hemiplegic patient from the bed to the chair.Which is the safest way for the nurse to do this?

A) Use of a mechanical patient lift device
B) Use of a gait belt around the patient's waist
C) Use of three staff members to assist the patient
D) Use of a roller board to slide from the bed to the chair

Question 15

A patient had surgery two days ago.Which intervention will be included in the plan of care for this patient wearing compression stockings?

A) The patient's stockings should be removed at night for washing.
B) Slippers should not be applied over the stockings for ambulation.
C) Regular size stockings are for females and large size are for males.
D) Make sure that the patient's toes are not sticking out of the stockings.

Question 16

Which scale is used to assess the patient's risk for development of pressure injury?

A) Baker
B) Morse
C) Braden
D) Hendrich

Question 17

The nurse is caring for a patient who must lay flat in bed for several days after spinal surgery.Which is the priority nursing diagnosis for this patient?

A) Impaired social interaction related to prolonged bed rest
B) Toileting self-care deficit related to inability to use the restroom
C) Ineffective breathing pattern related to prolonged supine position
D) Ineffective thermoregulation related to lengthy period of immobility

Question 18

Which outcome is most appropriate for a patient with the diagnosis impaired wheelchair mobility related to neuromuscular impairment and fatigue?

A) The patient will feel comfortable navigating the motorized wheelchair.
B) The patient will demonstrate ability to safely operate the motorized wheelchair.
C) The patient will understand the need to use a motorized wheelchair for mobility.
D) The patient will demonstrate correct use of the trapeze bar for repositioning self.

Question 19

Which is the appropriate outcome for the patient with the nursing diagnosis risk for ineffective peripheral tissue perfusion related to prolonged immobility?

A) The patient's urinary output will remain at least 30 mL/hour.
B) The patient's legs will maintain strong peripheral pulses and no edema.
C) The patient's abdomen will stay soft with bowel sounds present × 4 quadrants.
D) The patient will remain alert and appropriate with no changes in mental status.

Question 20

The nurse is caring for a patient who suffered a fractured arm.Which assessment finding is expected after the patient's cast is removed after 6 weeks?

A) The skin is thin with no hair growth.
B) The radial pulse is weak and thready.
C) The arm muscles are atrophied and weak.
D) The fingernail beds are thick and clubbed.

Question 21

Which are the appropriate interventions for the patient with the diagnosis impaired bed mobility related to hemiplegia after stroke?

A) Assist the patient to reposition in the bed at least every 3 hours.
B) Maintain the patient's bed in high Fowler's position whenever possible.
C) Instruct the patient how to use the over-bed trapeze to reposition self in bed.
D) Utilize a sliding sheet to minimize skin trauma during repositioning of the patient.
E) Position the patient's affected limbs in neutral alignment between ranges of motion.

Question 22

Which position should be avoided for a patient who is unconscious?

A) Semi-Fowler's
B) Sims'
C) Supine
D) Lateral

Question 23

Which outcome is appropriate for the patient with the nursing diagnosis ineffective protection related to use of anticoagulant medications?

A) The patient will remain free of signs or symptoms of infection.
B) The patient will have a soft formed stool at least every other day.
C) The patient will verbalize precautions to take in order to prevent bleeding.
D) The patient will have clear lung sounds bilaterally and no sign of cyanosis.

Question 24

Which assessment findings place the patient at high risk of pulmonary embolism due to immobility?

A) The patient has had polycythemia vera for the last 5 years.
B) The patient refuses daily injections of enoxaparin.
C) The patient has worn compression hose since the day of surgery.
D) The patient has an indwelling urinary catheter to bedside drainage.
E) The patient cannot tolerate intermittent sequential compression devices.

Question 25

Which is the best position for a patient who is acutely short of breath?

A) Lateral
B) Prone
C) High-Fowler's
D) Sims'

Question 26

Which intervention will help prevent the development of footdrop for a comatose patient?

A) Place high-top tennis shoes on the patient's feet.
B) Place pillows under the legs to keep the heels off the mattress.
C) Apply sequential compression devices to the patient's feet.
D) Assist the patient to a lateral position whenever possible.

Question 27

The patient refuses to get out of bed to ambulate after surgery.Which is the appropriate response of the nurse?

A) "No problem.You should rest quietly in bed today so that you can heal."
B) "It is important to get out of bed and walk to prevent blood clots or pneumonia."
C) "I will notify your doctor that you refused and make a notation in your chart."
D) "You can have your next dose of pain medication after you get up and walk."

Question 28

Which interventions are appropriate for the patient at risk for peripheral neurovascular dysfunction related to casted right ankle?

A) Regularly assess the patient's toes for warmth and capillary refill.
B) Apply graduated compression stockings to both legs to prevent DVT.
C) Encourage the patient to frequently wiggle the toes to increase circulation.
D) Educate the patient that numbness and tingling of the area is to be expected.
E) Elevate the ankle above the level of the heart and apply ice to the ankle area.