Mobility & Immobility

Question 1

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client?

A. Decreased subcutaneous fat
B. Muscle atrophy
C. Pressure injury
D. Fecal impaction

Answer 1

C. CORRECT: The greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift his weight every 15 min and reposition the client after 1 hr.

Question 2

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.)

A. Instruct the client not to perform the Valsalva maneuver.
B. Apply elastic stockings.
C. Review laboratory values for total protein level.
D. Place pillows under the client’s knees and lower extremities.
E. Assist the client to change positions often.

Answer 2

B. CORRECT: Elastic stockings promote venous return and prevent thrombus formation.

E. CORRECT: Frequent position changes
prevents venous stasis.

Question 3

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?

A. Encourage the client to perform antiembolic exercises every 2 hr.
B. Instruct the client to cough and deep breathe every 4 hr.
C. Restrict the client’s fluid intake.
D. Reposition the client every 4 hr.

Answer 3

A. CORRECT: Encourage the client to perform antiembolic exercises every 1 to 2 hr to promote venous return and reduce the risk of thrombus formation

Question 4

A nurse is evaluating a client’s understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding?

A. “This device will keep me from getting sores on my skin.”
B. “This device will keep the blood pumping through my leg.”
C. “With this device on, my leg muscles won’t get weak.”
D. “This device is going to keep my joints in good shape.”

Answer 4

B. CORRECT: Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation.

Question 5

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.)

A. Hold the cane on the right side.
B. Keep two points of support on the floor.
C. Place the cane 38 cm (15 in) in front of the feet before advancing.
D. After advancing the cane, move the weaker leg forward.
E. Advance the stronger leg so that it aligns evenly with the cane.

Answer 5

A. CORRECT: The client should hold the cane on the uninjured side to provide support for the injured left leg.
B. CORRECT: The client should keep two points of support on the ground at all times for stability.
D. CORRECT: The client should advance the weaker leg first, followed by the stronger leg.

Question 6

A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure?

A. Age 78 years
B. History of cancer
C. Previous joint replacement
D. Bronchitis 2 weeks ago

Answer 6

D. CORRECT: The client who recently had bronchitis or a recent infection can experience failure of the prosthesis if micro-organisms are still present in the body and migrate to the surgical site

Question 7

A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? (Select all that apply.)

A. Check continuous passive motion device settings.
B. Palpate dorsal pedal pulses.
C. Place a pillow behind the knee.
D. Elevate heels off bed.
E. Apply heat therapy to incision.

Answer 7

A. CORRECT: Check the continuous passive motion device settings to determine if the settings are as prescribed.
B. CORRECT: Assess the strength of the pulses of both lower extremities to help determine adequate circulation.
D. CORRECT: Prevent pressure injuries on the client’s heels by elevating the heels off the bed with a pillow

Question 8

A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (Select all that apply.)

A. Clean the incision daily with soap and water.
B. Turn the toes inward when sitting or lying.
C. Sit in a straight‑backed armchair.
D. Bend at the waist when putting on socks.
E. Use a raised toilet seat.

Answer 8

A. CORRECT: The client should wash the surgical incision daily with soap and water to decrease the risk of infection.
C. CORRECT: Using a straight‑backed armchair decreases the chance of bending at a greater than 90° angle, which can cause dislocation of the hip prosthesis.
E. CORRECT: Using a toilet riser decreases the chance of bending greater than 90°, which can cause dislocation of the hip prosthesis.

Question 9

A nurse is assessing a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings? (Select all that apply.)

A. Skin reddened over the joint
B. Pain when bearing weight
C. Joint crepitus
D. Swelling of the affected joint
E. Limited joint motion

Answer 9

B. CORRECT: Pain when bearing weight is an expected finding due to degeneration of the joint.
C. CORRECT: Joint crepitus due to degeneration of the joint tissue is an expected finding.
D. CORRECT: Swelling of the affected joint due to degeneration of the joint tissue is an expected finding.
E. CORRECT: Limited joint motion is due to degeneration of the joint tissue and is an expected finding

Question 10

A nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? (Select all that apply.)

A. Encourage complete autologous blood donation.
B. Sit in a low reclining chair.
C. Instruct the client to roll onto the operative hip.
D. Use an abductor pillow when turning the client.
E. Perform isometric exercises.

Answer 10

A. CORRECT: Encourage the client to donate blood that can be used postoperatively.
D. CORRECT: Place an abductor device or pillow between the client’s legs when turning to prevent dislocation of the affected hip.
E. CORRECT: Instruct the client to perform isometric exercises to prevent blood clots and maintain muscle tone.

Question 11

A nurse is admitting an adult client who has suspected osteoporosis. Which of following findings are risk factors for osteoporosis? (Select all that apply.)

A. History of consuming one glass of wine daily
B. Loss in height of 2 in (5.1 cm)
C. Body mass index (BMI) of 18
D. Kyphotic curve at upper thoracic spine
E. History of lactose intolerance

Answer 11

B. CORRECT: The loss of 2 inches of height is suggestive of osteoporosis due to fractures of the vertebral column.
C. CORRECT: A client who has a BMI of 18 is at risk of developing osteoporosis due to low body weight and thin body build, suggesting decreased bone mass.
D. CORRECT: Kyphosis curve is highly suggestive of osteoporosis due to fractures of the vertebrae causing the curve.
E. CORRECT: Lactose intolerance is highly suggestive of osteoporosis due to possible lack of calcium intake

Question 12

A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following actions should the nurse take?

A. Apply heat to the puncture site.
B. Place the client in a supine position.
C. Turn the client every 1 hr.
D. Ambulate the client within the first hour postprocedure.

Answer 12

B. CORRECT: The client should remain in a supine position with the bed flat for the first 1 to 2 hr following the procedure to allow for hardening of the cement

Question 13

A nurse is providing dietary teaching about calcium‑rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions?

A. White bread
B. Kale
C. Apples
D. Brown rice

Answer 13

B. CORRECT: Green leafy vegetables (broccoli, kale, mustard greens) are good sources of calcium

Question 14

A nurse is performing health screenings at a health fair. Which of the following clients have a risk factor for osteoporosis? (Select all that apply.)

A. A 40‑year‑old client who has been taking prednisone for 4 months
B. A 30‑year‑old client who jogs 3 miles daily
C. A 45‑year‑old client who takes phenytoin for seizures
D. A 65‑year‑old client who has a sedentary lifestyle
E. A 70‑year‑old client who has smoked for 50 years

Answer 14

A. CORRECT: Prednisone affects the absorption and metabolism of calcium and places the client at risk for osteoporosis
when taken for an extended time (at least 3 months).
C. CORRECT: Phenytoin affects the absorption and metabolism of calcium and places the client at risk for osteoporosis.
D. CORRECT: A sedentary lifestyle places the client at risk for osteoporosis because bones need the stress of weight bearing activity for bone rebuilding and maintenance.
E. CORRECT: Smoking increases the risk for osteoporosis because it decreases osteogenesis.

Question 15

A nurse is planning discharge teaching on home safety for an adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A. Remove throw rugs in walkways.
B. Use prescribed assistive devices.
C. Remove clutter from the environment.
D. Wear soft-bottomed shoes.
E. Maintain lighting of doorway areas

Answer 15

A. CORRECT: Removing throw rugs in walkways can help to prevent a fall and bone fracture.
B. CORRECT: Using prescribed assistive devices can help to prevent a fall and bone fracture.
C. CORRECT: Removing clutter from the environment can help to prevent tripping, falling, and a bone fracture.
D. The client should wear rubber-bottomed
shoes to prevent slipping.
E. CORRECT: Good lighting in doorway areas can prevent a fall and bone fracture

Question 16

A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates understanding? (Select all that apply.)

A. “I will clean the pins more often if drainage from the pins increases.”
B. “I will use a separate cotton swab for each pin.”
C. “I will report loosening of the pins to my doctor.”
D. “I will move my leg by lifting the device in the middle.”
E. “I will report increased redness at the pin sites.”

Answer 16

A. CORRECT: Clean the external fixation pins more frequently than prescribed if the amount of drainage increases or infection is suspected.
B. CORRECT: Using a separate cotton swab on each pin will decrease the risk of cross‑contamination, which could cause pin site infection.
C. CORRECT: Notify the provider if a pin is loose because the provider will know how much to tighten the pin and prevent damage to the tissue and bone.
D. The external fixation device should never be used to lift or move the affected leg, due to the risk of injuring and dislocating the fractured bone.
E. CORRECT: The client should report redness, heat, and drainage at the pin sites, which can indicate an infection that can lead to osteomyelitis.

Question 17

A nurse is assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat embolus?

A. Altered mental status
B. Reduced bowel sounds
C. Swelling of the toes distal to the injury
D. Pain with passive movement of the foot distal to the injury

Answer 17

A. CORRECT: Altered mental status is an early manifestation of fat emboli. Initial manifestations include dyspnea, chest pain, and hypoxemia.

Question 18

A nurse is assessing a client who had an external fixation device applied 2 hr ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of compartment syndrome? (Select all that apply.)

A. Intense pain when the client’s left foot is passively moved
B. Capillary refill of 3 sec on the client’s left toes
C. Hard, swollen muscle in the client’s left leg
D. Burning and tingling of the client’s left foot
E. Client report of minimal pain relief following a second dose of opioid medication

Answer 18

A. CORRECT: Intense pain of the left foot when passively moved can indicate pressure from edema on nerve endings and is a manifestation of compartment syndrome.
C. CORRECT: A hard, swollen muscle on the affected extremity indicates edema build‑up in the area of injury and is a manifestation of compartment syndrome.
D. CORRECT: Burning and tingling of the left foot indicates pressure from edema on nerve endings and is an early manifestation of compartment syndrome.
E. CORRECT: Minimal pain relief after receiving opioid medication can indicate pressure from edema on nerve endings and is an early manifestation of compartment syndrome.

Question 19

A nurse is completing discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include?

A. Antibiotic therapy should continue for 3 months.
B. Relief of pain indicates the infection is eradicated.
C. Airborne precautions are used during wound care.
D. Expect paresthesia distal to the wound

Answer 19

A. CORRECT: Treatment of osteomyelitis includes continuing antibiotic therapy for 3 months.

Question 20

A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care?

A. Skeletal traction
B. Buck’s traction
C. Halo traction
D. Bryant’s traction

Answer 20

B. CORRECT: Buck’s traction is a temporary immobilization device applied to a client who has a femur or hip fracture to diminish muscle spasms and immobilize the affected extremity until surgery is performed.

Question 21

A nurse is assessing a client who has
osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? (Select all that apply.)

A. Heberden’s nodes
B. Swelling of all joints
C. Small body frame
D. Enlarged joint size
E. Limp when walking

Answer 21

A. CORRECT: Heberden’s nodes are enlarged nodules on the distal interphalangeal joints of the hands and feet of a client who has osteoarthritis.
D. CORRECT: A client can manifest enlarged joints due to bone hypertrophy.
E. CORRECT: A client can manifest a limp when walking due to pain from inflammation in the localized joint.

Question 22

A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? (Select all that apply.)

A. Apply heat to joints to alleviate pain.
B. Ice inflamed joints for 30 min following activity.
C. Reduce the amount of exercise done
on days with increased pain.
D. Prop the knees with a pillow while in bed.
E. Active range of motion is more effective than passive.

Answer 22

A. CORRECT: Applying heat to joints can
provide temporary relief of pain.
C. CORRECT: It is important to exercise consistently, but the client should reduce the amount of exercises on days of increased pain to prevent harm to the joints.
E. CORRECT: Performing active range-of-motion of joints is more beneficial.

Question 23

A nurse is providing information about capsaicin cream to a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse include in the discussion?

A. Continuous pain relief is provided.
B. Put on gloves before applying the cream to other parts of the body.
C. Leave cream on the hands for 10 min following application.
D. Apply the medication every 2 hr during the day.

Answer 23

B. CORRECT: Because capsaicin can cause burning, the client should put on gloves before applying it to parts of the body other than the hands.

Question 24

A nurse is caring for a client who received a lower back injury during a fall and describes sharp pain in the back and down the left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease the pain?

A. Prone without use of pillows
B. Semi‑Fowler’s with a pillow under the knees
C. High‑Fowler’s with the knees flat on the bed
D. Supine with the head flat

Answer 24

B. CORRECT: Williams position, with the client in semi‑Fowler’s position with the knees flexed by pillows, has been found to relieve low‑back pain caused by a bulging disk and nerve root involvement.

Question 25

A nurse is providing teaching for a client who has a history of low back injury. Which of the following instructions should the nurse give the client to prevent future problems with low back pain? (Select all that apply.)

A. Engage in regular exercise including walking.
B. Sit for up to 10 hr each day to rest the back.
C. Maintain weight within 25% of ideal body weight.
D. Create a smoking cessation plan.
E. Wear low‑heeled shoes.

Answer 25

A. CORRECT: Regular exercise, including walking or swimming, is a strategy that can prevent low back pain.
D. CORRECT: Stopping or cutting down on smoking is a strategy that can decrease problems with low‑back pain, as smoking can cause disk degeneration.
E. CORRECT: Wearing low‑heeled, well‑fitting shoes can prevent low back pain. Instruct the client to avoid high‑heeled shoes.