TB Ch: 28 - Immobility Flashcards
A nurse is assessing body alignment. What is the nurse monitoring?
a. The relationship of one body part to another while in different positions
b. The coordinated efforts of the musculoskeletal and nervous systems
c. The force that occurs in a direction to oppose movement
d. The inability to move about freely
ANS: A
The terms body alignment and posture are similar and refer to the positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Body alignment means that the individual’s center of gravity is stable. Body mechanics is a term used to describe the coordinated efforts of the musculoskeletal and nervous systems. Friction is a force that occurs in a direction to oppose movement. Immobility is the inability to move about freely.
A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take?
a. Moves patient’s arm in a full circle
b. Moves patient’s arm cross the body as far as possible
c. Moves patient’s arm behind body, keeping elbow straight
d. Moves patient’s arm until thumb is upward and lateral to head with elbow flexed
ANS: D
External rotation: With elbow flexed, move arm until thumb is upward and lateral to head. Circumduction: Move arm in full circle (Circumduction is combination of all movements of ball-and-socket joint.) Adduction: Lower arm sideways and across body as far as possible. Hyperextension: Move arm behind body, keeping elbow straight.
A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?
a. Each movement is repeated 5 times by the patient.
b. Each movement is performed until the patient experiences pain.
c. Each movement is completed quickly and smoothly by the nurse.
d. Each movement is moved just to the point of resistance by the nurse.
ANS: D
Passive ROM exercises are performed by the nurse. Carry out movements slowly and smoothly, just to the point of resistance; ROM should not cause pain. Never force a joint beyond its capacity. Each movement needs to be repeated 5 times during the session. The patient moves all joints through ROM unassisted in active ROM.
A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse’s action?
a. Prevention of atelectasis
b. Prevention of renal calculi
c. Prevention of pressure ulcers
d. Prevention of joint contractures
ANS: D
Goal achievement for passive ROM is prevention of joint contractures. Contractures develop in joints not moved periodically through their full ROM. ROM exercises reduce the risk of contractures. Researchers noted that prompt use of splinting with prescribed ROM exercises reduced contractures and improved active range of joint motion in affected lower extremities. Deep breathing and coughing and using an incentive spirometer will help prevent atelectasis. Adequate hydration helps prevent renal calculi and urinary tract infections. Interventions aimed at prevention of pressure ulcers include positioning, skin care, and the use of therapeutic devices to relieve pressure.
A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel?
a. Determining the level of comfort
b. Changing the patient’s position
c. Identifying immobility hazards
d. Assessing circulation
ANS: B
The skill of moving and positioning patients in bed can be delegated to nursing assistive personnel (NAP). The nurse is responsible for assessing the patient’s level of comfort and for any hazards of immobility and assessing circulation.
A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?
a. Thermometer
b. Elastic stockings
c. Blood pressure cuff
d. Sequential compression devices
ANS: C
A blood pressure cuff is needed. Orthostatic hypotension is a drop of blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure and symptoms of dizziness, light-headedness, nausea, tachycardia, pallor, or fainting when the patient changes from the supine to standing position. A thermometer is used to assess for fever. Elastic stockings and sequential compression devices are used to prevent thrombus.
The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?
a. Maintain a narrow base of support.
b. Dangle the patient at the bedside.
c. Encourage isometric exercises.
d. Suggest a high-calcium diet.
ANS: B
To prevent injury, nurses implement interventions that reduce or eliminate the effects of orthostatic hypotension. Mobilize the patient as soon as the physical condition allows, even if this only involves dangling at the bedside or moving to a chair. A wide base of support increases balance. Isometric exercises (i.e., activities that involve muscle tension without muscle shortening) have no beneficial effect on preventing orthostatic hypotension, but they improve activity tolerance. A high-calcium diet can help with osteoporosis but can be detrimental in an immobile patient.
A nurse reviews an immobilized patient’s laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?
a. Hypostatic pneumonia
b. Renal calculi
c. Pressure ulcers
d. Thrombus formation
ANS: B
Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi because they frequently have hypercalcemia. Hypercalcemia does not lead to hypostatic pneumonia, pressure ulcers, or thrombus formation. Immobility is one cause of hypostatic pneumonia, which is inflammation of the lung from stasis or pooling of secretions. A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) within tissues. A thrombus is an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel.
A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient?
a. Increased appetite
b. Increased diarrhea
c. Increased metabolic rate
d. Altered nutrient metabolism
ANS: D
Immobility disrupts normal metabolic functioning: decreasing the metabolic rate, altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis, leading to constipation.
A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse consider?
a. Loss of bone mass
b. Loss of strength
c. Loss of weight
d. Loss of hope
ANS: D
Loss of hope is a psychosocial aspect. Patients with restricted mobility may have some depression. Depression is an affective disorder characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion to reality. All the rest are physiological aspects: bone mass, strength, and weight.
The nurse is preparing to lift a patient. Which action will the nurse take first?
a. Position a drawsheet under the patient.
b. Assess weight and determine assistance needs.
c. Delegate the task to a nursing assistive personnel.
d. Attempt to manually lift the patient alone before asking for assistance.
ANS: B
When lifting, assess the weight you will lift, and determine the assistance you will need. The nurse has to assess before positioning a drawsheet or delegating the task. Manual lifting is the last resort, and it is used when the task at hand does not involve lifting most or all of the patient’s weight; most facilities have a no-lift policy.
The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?
a. Encourage the patient to perform as many self-care activities as possible.
b. Provide a complete bed bath to promote patient comfort.
c. Coordinate with occupational therapy for gait training.
d. Place the patient on bed rest to prevent fatigue.
ANS: A
Nurses should encourage the older-adult patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient’s immobility by providing unnecessary help with activities such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. After a stroke or brain attack, a patient likely receives gait training from a physical therapist; speech rehabilitation from a speech therapist; and help from an occupational therapist for ADLs such as dressing, bathing and toileting, or household chores.
The nurse is observing the way a patient walks. Which aspect is the nurse assessing?
a. Activity tolerance
b. Body alignment
c. Range of motion
d. Gait
ANS: D
Gait describes a particular manner or style of walking. Activity tolerance is the type and amount of exercise or work that a person is able to perform. Body alignment refers to the position of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Range of motion is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, or transverse.
A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal?
a. When observed laterally, the spinal curves align in a reversed “S” pattern.
b. When observed posteriorly, the hips and shoulders form an “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.
ANS: A
When the patient is observed laterally, the head is erect and the spinal curves are aligned in a reversed “S” pattern. When observed posteriorly, the shoulders and hips are straight and parallel. The arms hang comfortably at the sides. The feet are slightly apart to achieve a base of support, and the toes are pointed forward.
The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding?
a. The edge of the seat is in contact with the popliteal space.
b. Both feet are supported on the floor with ankles flexed.
c. The body weight is directly on the buttocks only.
d. The arms hang comfortably at the sides.
ANS: B
Both feet are supported on the floor, and the ankles are comfortably flexed. Body weight is evenly distributed on the buttocks and thighs. A 1- to 2-inch space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee to ensure that no pressure is placed on the popliteal artery or nerve. The patient’s forearms are supported on the armrest, in the lap, or on a table in front of the chair.
The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use?
a. Supine position
b. Lateral position
c. Lateral position with positioning supports
d. Supine position with no pillow under the patient’s head
ANS: B
Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position, not supine. Remove all positioning supports from the bed except for the pillow under the head, and support the body with an adequate mattress.
The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take when assessing the respiratory system?
a. Inspect chest wall movements primarily during the expiratory cycle.
b. Auscultate the entire lung region to assess lung sounds.
c. Focus auscultation on the upper lung fields.
d. Assess the patient at least every 4 hours.
ANS: B
Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes. Perform a respiratory assessment at least every 2 hours for patients with restricted activity. Inspect chest wall movements during the full inspiratory-expiratory cycle. Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions.
The nurse is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the nurse take?
a. Remove elastic stockings every 4 hours.
b. Measure the calf circumference of both legs.
c. Lightly rub the lower leg for redness and tenderness.
d. Dorsiflex the foot while assessing for patient discomfort.
ANS: B
Measure bilateral calf circumference and record it daily as an assessment for DVT. Unilateral increases in calf circumference are an early indication of thrombosis. Homan’s sign, or calf pain on dorsiflexion of the foot, is no longer a reliable indicator in assessing for DVT, and it is present in other conditions. Remove the patient’s elastic stockings and/or sequential compression devices (SCDs) every 8 hours, and observe the calves for redness, warmth, and tenderness. Instruct the family, patient, and all health care personnel not to massage the area because of the danger of dislodging the thrombus.
A nurse is assessing the skin of an immobilized patient. What will the nurse do?
a. Assess the skin every 4 hours.
b. Limit the amount of fluid intake.
c. Use a standardized tool such as the Braden Scale.
d. Have special times for inspection so as to not interrupt routine care.
ANS: C
Consistently use a standardized tool, such as the Braden Scale. This identifies patients with a high risk for impaired skin integrity. Skin assessment can be as often as every hour. Limiting fluids can lead to dehydration, increasing skin breakdown. Observe the skin often during routine care.
