Chapter 47: Mobility and Immobility [Practice Test]

Question 0

Describe your normal daily activity. Has this changed recently?
How have your appetite and diet change since you’ve had problems moving around?
Describe what you eat and a normal day.
What part of the nursing process is this?

Answer 0

Immobility Assessment

Question 1

What is meant by “concentric tension” of muscles?

a. Increased muscle contraction results in movement.
b. The speed and direction of movement are controlled.
c. Tension causes no shortening or active movement.
d. Tension does not result in isotonic contraction.

Answer 1

ANS: A
In concentric tension, increased muscle contraction causes muscle shortening, resulting in movement. Eccentric tension helps control the speed and direction of movement. Concentric and eccentric muscle actions are necessary for active movement and are referred to as dynamic or isotonic contraction. Isometric contraction (static contraction) causes an increase in muscle tension or muscle work but no shortening or active movement of the muscle.

Question 2

Description: increased convexity in curvature of the lumbar spine.

Cause: congenital condition, rickets, osteoporosis, tuberculosis of spine.

Treatment: spine stretching exercises, sleeping without pillows, using bedboard, bracing, and spinal fusion based on cause and severity.

What postural abnormality is this?

Answer 2

Kyphosis

Question 3

In this complication related to immobility there is a proportional decline in the patient’s ability to cough productively. The distribution of mucus in the bronchi increases especially when the patient is in supine, prone, or lateral position. Mucus accumulates in the dependent regions of the airways.

Answer 3

Atelectasis

Question 4

Muscles that attach to bones to provide the needed strength to move an object use which of the following to obtain their objective?

a. Posture
b. Leverage
c. Isometric contraction
d. Muscle tone

Answer 4

ANS: B
Leverage is an inducing or compelling force that occurs when specific bones, such as the humerus, ulna, and radius, and associated joints, such as the elbows, act together as a lever. Posture is the position of the body in relation to the surrounding space. Isometric contraction causes an increase in muscle tension but no active movement. Muscle tone is the normal state of balanced muscle tension.

Question 5

Break in skin integrity.

What body system is this nurse assessing in relation to immobility?

Answer 5

Skin Abnormalities

Question 6

During voluntary movement, impulses descend from the motor strip to the spinal cord. Impulses stimulate muscles by way of

a. Ligaments.
b. Tendons.
c. Neurotransmitters.
d. Cartilage.

Answer 6

ANS: C
Through a complex process, neurotransmitters, or chemicals such as acetylcholine transfer electrical impulses from the nerve across the neuromuscular junction to the muscle. The neurotransmitter reaches a muscle and stimulates it. Ligaments are white, shiny, flexible bands of fibrous tissue that bind joints together and connect bones and cartilages. Tendons connect muscle to bone. Cartilage is nonvascular, supporting connective tissue located chiefly in the joints and in the thorax, trachea, larynx, nose, and ear.

Question 7

Orthostatic hypotension. 
Increased heart rate. 
Third heart sound. 
Weak peripheral pulses. 
Peripheral edema.

What body system is this nurse assessing in relation to immobility?

Answer 7

Cardiovascular Abnormalities

Question 8

Although isometric contractions do not result in muscle shortening, the nurse understands that isometric contractions

a. Result in decreased energy expenditure.
b. Are always desirable regardless of patient condition.
c. Are necessary for the active movement of muscles.
d. Result in increased energy expenditure.

Answer 8

ANS: D
Although isometric contractions do not result in muscle shortening, energy expenditure increases. It is important to understand the energy expenditure associated with isometric exercises because they are sometimes contraindicated in certain illnesses. Isometric contractions increase muscle tension but not active movement of the muscle.

Question 10

Joints are the connections between bones. The joint that is freely movable is known as the _____ joint.

a. Synostotic
b. Cartilaginous
c. Fibrous
d. Synovial

Answer 10

ANS: D
The synovial joint, or true joint, is a freely movable joint in which contiguous bony surfaces are covered by articular cartilage and are connected by ligaments lined with a synovial membrane. The synostotic joint refers to bones jointed by bones. No movement is associated with this type of joint. In the cartilaginous joint, or synchondrosis joint, cartilage unites bony components. When bone growth is complete, the joints ossify. The fibrous joint, or syndesmosis joint, is a joint in which a ligament or membrane unites two bony surfaces, permitting a limited amount of movement only.

Question 11

This is a major threat to physical safety and contributes to a fear of falling and self imposed restrictions on activity.

Answer 11

Impaired balance

Question 12

The term body alignment refers to positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. A term that is similar to body alignment is

a. Weight.
b. Posture.
c. Friction.
d. Body mechanics.

Answer 12

ANS: B
The terms body alignment and posture are similar and refer to positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Weight is the force exerted on a body by gravity. Friction is a force that occurs in a direction to oppose movement. Body mechanics is a term used to describe the coordinated efforts of the musculoskeletal and nervous systems.

Question 13

Without balance control, the center of gravity is displaced, thus creating risk for falls and subsequent injuries. Balance is enhanced by

a. Maintaining a narrow base of support.
b. Creating a high center of gravity.
c. Disregarding body posture.
d. Keeping a low center of gravity.

Answer 13

ANS: D
Without balance control, the center of gravity is displaced, thus creating risk for falls and subsequent injuries. Balance is enhanced by keeping the center of gravity of the body low with a wide base of support and by maintaining correct body posture.

Question 14

Immobilized patients frequently have hypercalcemia, placing them at risk for

a. Osteoporosis.
b. Renal calculi.
c. Pressure ulcers.
d. Thrombus formation.

Answer 14

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. Osteoporosis is caused by accelerated bone loss. 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

Question 15

Patients on bed rest or otherwise immobile are at risk for

a. Increased metabolic rate.
b. Increased diarrhea (peristalsis).
c. Altered metabolic function.
d. Increased appetite.

Answer 15

ANS: C
Immobility disrupts normal metabolic functioning: decreasing the metabolic rate, altering the metabolism of carbohydrates, fats, and proteins (nutritional function); causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.

Question 16

In caring for a patient who is immobile, it is important for the nurse to understand that

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.

Answer 16

ANS: C
The immobilized patient often becomes depressed because of changes in role and self-concept. Every patient responds to immobility differently. Immobility or bed rest frequently affects coping and creates sleep-wake alterations because of changes in routine or in the environment. Because immobilization removes the patient from a daily routine, he or she has more time to worry about disability. Worrying quickly increases the patient’s depression, causing withdrawal. Withdrawn patients often do not want to participate in their own care.

Question 17

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

a. Breaks in skin integrity are easy to heal.
b. Preventing a pressure ulcer is more expensive than treating one.
c. Immobilized patients can develop skin breakdown within 3 hours.
d. Pressure ulcers are caused by a sudden influx of oxygen to the tissue.

Answer 17

ANS: C
Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore, preventive nursing interventions are imperative. An older adult who is immobilized can develop skin breakdown within 3 hours. Tissue metabolism depends on the supply of oxygen and nutrients to and the elimination of metabolic wastes from the blood. Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation.

Question 18

Description: exaggeration of anterior convex curve of lumbar spine.

Cause: congenital condition, temporary condition ex. pregnancy.

Treatment: spine stretching exercises based on the cause.

What postural abnormality is this?

Answer 18

Lordosis

Question 19

The nurse is caring for a patient who has been diagnosed with a stroke. As part of her ongoing care, the nurse should

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 owing to a decreased energy need.

Answer 19

ANS: A
Nurses should encourage the 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. Anorexia and insufficient assistance with eating lead to malnutrition.

Question 20

The nurse is assessing the way the patient walks. The manner of walking is known as the patient’s

a. Activity tolerance.
b. Body alignment.
c. Range of motion.
d. Gait.

Answer 20

ANS: D Gait

Question 21

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

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.

Answer 21

ANS: B
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.

Question 22

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

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.

Answer 22

ANS: B
Both feet are supported on the floor, and the ankles are comfortably flexed. With patients of short stature, a footstool is used to ensure that 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.

Question 23

The nurse is assessing body alignment for a patient who is immobilized. To do this, the nurse must

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 23

ANS: D
Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position, not supine. Remove all positioning support from the bed, except for the pillow under the head.

Question 24

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

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.

Answer 24

ANS: C
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.

Question 25

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

Answer 25

ANS: B Measure bilateral calf circumference and record it daily as an assessment for DVT. Homans' sign, or calf pain on dorsiflexion of the foot, is contraindicated in patients when a DVT is suspected. It 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. Bilateral calf circumferences (not ankle) should be measured daily to detect unilateral increases that may be an early indication of thrombosis.

Question 26

When assessing the skin of an immobilized patient, the nurse should a. Assess the skin at least every 4 hours. b. Use a standardized tool such as the Braden Scale. c. Use nursing instinct instead of a standardized tool. d. Have special times for inspection so as to not interrupt routine care.

Answer 26

ANS: B Consistently use a standardized tool, such as the Braden Scale. This identifies patients with high risk of impaired skin integrity. Nursing instinct in this case is not enough. At a minimum, skin assessment occurs every 2 hours. Continually assess the patient's skin for breakdown and color changes such as pallor or redness. Continual assessment reduces the need for the creation of special times for inspection.

Question 27

The nurse is caring for an elderly 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 the elderly is a. Not a normal expectation. b. Purely psychological in origin. c. Not a common manifestation with UTIs. d. Acceptable and needs no further assessment.

Answer 27

ANS: A Acute confusion in older adults is not normal; a thorough nursing assessment is the priority. Abrupt changes in personality often have a physiological cause such as surgery, a medication reaction, a pulmonary embolus, or an acute infection. For example, the primary symptom of compromised older patients with an acute urinary tract infection or fever is confusion. Identifying confusion is an important component of the nurse's assessment.

Question 28

In preparing to create a nursing diagnosis for a patient who is immobile, it is important for the nurse to understand that 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.

Answer 28

ANS: D Often the physiological dimension is the major focus of nursing care for patients with impaired mobility. Thus the psychosocial and developmental dimensions are neglected. Yet all dimensions are important to health.

Question 29

The patient who is experiencing an alteration in mobility often has one or more nursing diagnoses. The nurse would use the diagnosis of Impaired physical mobility for a patient who is a. Not completely immobile. b. Completely immobile. c. At risk for multisystem problems. d. At risk for single-system involvement.

Answer 29

ANS: A The diagnosis of Impaired physical mobility applies to the patient who has some limitation but is not completely immobile. The diagnosis of Risk for disuse syndrome applies to the patient who is immobile and at risk for multisystem problems because of inactivity. Beyond these diagnoses, the list of potential diagnoses is extensive because immobility affects multiple body systems.

Question 30

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. This diagnosis means that the nurse should a. Encourage the patient to do self-care. b. Keep the patient as mobile as possible. c. Encourage the patient to perform ROM. d. Assist the patient with comfort measures.

Answer 30

ANS: D The diagnosis related to pain requires the nurse to assist the patient with comfort measures so that the patient is then willing and better able to move. Pain must be controlled before so that the patient will not be reluctant to initiate movement. The diagnosis of Reluctance to initiate movement requires interventions aimed at keeping the patient as mobile as possible and encouraging the patient to do self-care and ROM. This cannot be accomplished until comfort is achieved.

Question 31

In developing an individualized plan of care for a patient, it is important for the nurse to a. Set goals that are a little beyond the capabilities of the patient. b. Use his or her judgment 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.

Answer 31

ANS: C The nurse must develop an individualized plan of care for each nursing diagnosis and must set goals that are individualized, realistic, and measurable. The nurse should set realistic expectations for care and should include the patient and family when possible. The goals focus on preventing problems or risks to body alignment and mobility.

Question 32

When creating a plan of care for a patient who is experiencing alterations in mobility, the nurse a. Cannot delegate interventions to nursing assistive personnel. b. Is solely responsible for modifying ADLs. c. Consults other health care team members to help plan therapy. d. Consults wound care specialists only when wounds are apparent.

Answer 32

ANS: C The nurse should collaborate with other health care team members such as physical or occupational therapists when considering mobility needs. Nurses often delegate some interventions to nursing assistive personnel. Nursing assistive personnel may turn and position patients, apply elastic stockings, help patient use the incentive spirometer, etc. Occupational therapists are a resource for planning ADLs that patients need to modify or relearn. It is especially important in priority setting to make sure not to overlook potential complications. Many times, actual problems such as pressure ulcers are addressed only after they develop. They should be addressed before they develop.

Question 33

The patient is being admitted to the neurological unit with the diagnosis of stroke. 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.

Answer 33

ANS: A Discharge planning begins when a patient enters the health care system. In anticipation of the patient's discharge from an institution, the nurse makes appropriate referrals or consults a case manager or a discharge planner to ensure that the patient's needs will be met at home. Referrals to home care or outpatient therapy are often needed.

Question 34

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 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.

Answer 34

ANS: A "The patient will walk 1000 feet using her walker by the time of discharge" is individualized, realistic, and measurable. "The patient will ambulate by the time of discharge" is not measurable because it does not specify the distance. Even though we can see that the patient will ambulate, this does not quantify how far. "Ambulating briskly on a treadmill" is not realistic for this patient. The last option focuses on the nurse, not the patient, and is not measurable.

Question 35

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. The nurse is aware that the rate of occupational injury and illness in the hospital setting a. Is the same as in the private industry sector. b. Is higher than in the nursing home setting. c. Is about 4.4%. d. Has decreased in recent years.

Answer 35

ANS: C The rate of work-related injury in health care settings has increased in recent years. In 2006, 4.4 cases per 100 full-time workers who experienced occupational injury and illness were reported compared with 5 cases per 100 for private industry overall. The rate for nursing homes was 10.1 per 100 workers.

Question 36

In caring for immobile patients, the nurse understands that back injuries occur a. Only when lifting patients. b. Only when transferring patients. c. Only when providing direct patient care. d. With many clinical activities.

Answer 36

ANS: D Musculoskeletal injuries among health care workers are related not only to lifting and transferring patients. Nurses spend time in many activities involving bending and twisting, which also cause injury. Examples of such activities include lifting objects, pushing beds, and providing direct patient care such as bathing, feeding, dressing, and undressing patients

Question 37

To prevent injury, the nurse should not begin a task (e.g., moving a bed from one room to another, lifting heavy objects) until the task can be completed safely. To prevent injury a. Keep the weight as far from the body as possible. b. Keep the knees still to prevent loss of balance. c. Tighten abdominal muscles and tuck the pelvis. d. Bend at the waist to move weight forward.

Answer 37

ANS: C Follow these steps to prevent injury: (1) tighten abdominal muscles and tuck the pelvis to provide balance and help protect the back; (2) keep the weight to be lifted as close to the body as possible; (3) bend at the knees to maintain the center of gravity, and use the stronger leg muscles; and (4) maintain the trunk erect and the knees bent so that multiple muscle groups work together in a coordinated manner. The patient is immobilized after undergoing hip replacement surgery.

Question 38

90% of all _______ begin in the deep veins of the lower extremities. A dislodged _______ is called emboli and it can travel to the circulatory system to the lungs and impair ____ and ______, resulting in tachycardia and shortness of breath. If these travel to the lungs they can be _____.

Answer 38

DVT Venous Thrombus circulation and oxygenation life-threatening

Question 39

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. SCDs wrapped around the legs to prevent DVT formation d. Elastic stockings (TED hose) to promote venous return

Answer 39

ANS: B Heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of DVT. Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding. Pulmonary secretions that become thick and tenacious are difficult to remove and are a sign of inadequate hydration, but not of bleeding. SCDs consist of sleeves or stockings made of fabric or plastic that are wrapped around the leg and are secured with Velcro. They decrease venous stasis by increasing venous return through the deep veins of the legs. They do not usually cause bleeding. Elastic stockings also aid in maintaining external pressure on the muscles of the lower extremities and in promoting venous return. They do not usually cause bleeding.

Question 41

The nurse needs to transfer the patient from the bed to the chair. The nurse should a. Avoid using a transfer or gait belt around the patient's waist prior to transfer. b. Not allow the patient to help in any way because resistance can lead to injury. c. Assess for the need of a mechanical lift and help. d. Ensure that the patient has stockings on his feet for transfer.

Answer 41

ANS: C Careful assessment of your patient's ability to assist in the positioning technique to be used is extremely important. Consider the use of a mechanical lift. Your role in assisting your patient to a sitting position is to guide and instruct. If the patient can bear weight and move to a sitting position independently, allow him or her to do so and offer assistance. A transfer belt maintains stability of the patient during transfer and reduces risk for falls. Ensure that the patient has stable nonskid shoes on his feet.

Question 42

The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair. The nurse opts to use a mechanical lift (Hoyer lift). The nurse understands that when this lift is used, the a. Straps need to be removed before lowering the patient to the chair. b. Horseshoe-shaped base should be on the opposite side from the chair. c. Longer straps hook to the bottom of the sling. d. Short straps are hooked to the bottom of the sling.

Answer 42

ANS: C The nurse should attach the hooks on the strap to the holes in the sling. Short straps hook to top holes of the sling; longer straps hook to the bottom of the sling. This prevents the sling from flipping upside down. The horseshoe-shaped base goes under the side of the bed on the side with the chair. Position the patient and lower slowly into the chair in accordance with manufacturer guidelines to safely guide the patient into the back of the chair as the seat descends; then remove the straps and the mechanical/hydraulic lift.

Question 43

Description: internal rotation of forefoot or entire foot common in infants. Cause: congenital condition, habit. Treatment: growth, wearing reversed shoes. What postural abnormality is this?

Answer 43

Pigeon Toes

Question 44

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, the nurse can use a. A trochanter roll. b. The trapeze bar. c. Hand rolls. d. Hand-wrist splints.

Answer 44

B. Trochanter Roll A trochanter roll prevents external rotation of the hips when the patient is in a supine position.

Question 45

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

Answer 45

ANS: D This is not a one-person task. Helping a patient move up in bed without help from other coworkers or without the aid of an assistive device (e.g., friction-reducing pad) is not recommended and is not considered safe for the patient or the nurse. When pulling a patient up in bed, the bed should be flat or in a Trendelenburg position (when tolerated) to gain gravity assistance, and the side rails should be down. Remove the pillow from under head and shoulders and place it at the head of the bed to prevent striking the patient's head against the head of the bed.

Question 47

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. One strategy that the nurse could use is a. A foot cradle. b. A trochanter roll. c. The trapeze bar. d. Hand rolls.

Answer 47

ANS: A A foot cradle may be used in patients with poor peripheral circulation as a means of reducing pressure on the tips of a patient's toes. A trochanter roll prevents external rotation of the hips when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bed frame. It allows the patient to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises.

Question 48

In applying for a job on a nursing unit that requires frequent patient positioning, the nurse should be aware that nurses a. Are at low risk for back injury. b. Are especially at risk for high back injuries. c. Should be aware of agency policies. d. Should not need to use assistive devices.

Answer 48

ANS: C Nurses and other health care staff are especially at risk for injury to lumbar muscles when lifting, transferring, or positioning immobilized patients. Therefore, the nurse should be aware of agency policies and protocols that protect staff and patients from injury. Current evidence supports that using mechanical or other ergonomic assistive devices is the safest way to reposition and lift patients who are unable to do these activities themselves.

Question 49

The _______ protects vital organs and aids in calcium regulation. _____ store calcium and release it into the circulation as needed. Patient's with decreased calcium regulation and metabolism are at risk for developing this?

Answer 49

Skeletal System Bones Osteoporosis & Pathological Fractures

Question 50

When preparing a plan of care for an immobilized patient, the nurse should a. Use established expected outcomes to evaluate the patient's response to care. b. Display an air of professional superiority when interventions are not successful. c. Never vary from interventions that have been successful for other patients. d. Use objective data only in determining whether interventions have been successful.

Answer 50

ANS: A The nurse should use established expected outcomes to evaluate the patient's response to care. The nurse should use creativity when designing new interventions to improve the patient's mobility status and should display humility when identifying those interventions that were not successful. Ask if the patient's expectations of care are being met and use objective data to determine the success of interventions.

Question 51

The director of a nursing home has decided to institute ergonomic programs in the facility because these programs increase employee satisfaction and have been shown to a. Be ineffective in reducing injury. b. Be cost neutral in budgeting. c. Enhance recruitment. d. Decrease retention rates.

Answer 51

ANS: C Research has demonstrated that ergonomic programs in health care facilities reduce costs, injuries to employees, and missed workdays. These programs also enhance recruitment, retention, and satisfaction of employees.

Question 52

The nurse needs to reposition a 300-lb 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 Trendelenburg 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.

Answer 52

ANS: C Assess and determine the number of people needed; to prevent injury, do not start until the task can be completed safely. Assess the situation and do not turn the patient alone if this cannot be done safely. The trunk should be erect and the knees bent, so that multiple muscle groups (not just the arms) work together in a coordinated manner. This is not a one-person task: DO NOT PULL FROM THE HEAD OF THE BED.

Question 53

The nurse is caring for a patient who has had a stroke causing total paralysis of the right side. To help maintain joint function and to prevent contractures, passive ROM 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 rehab unit d. No ROM is needed.

Answer 53

ANS: B Passive ROM exercises should begin as soon as the patient's ability to move the extremity or joint is lost. The nurse should not wait for the acute phase to end. It may be some time before the patient enters the rehab unit, and contractures could form by then. ROM is certainly needed in this patient.

Question 54

The nurse is admitting a patient who has been diagnosed as having had a stroke. The physician writes orders for "ROM as needed." The nurse understands that 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.

Answer 54

ANS: C Further assessment of the patient is needed. Some patients are able to move some joints actively, whereas the nurse passively moves others. With a weak patient, the nurse may have to support an extremity while the patient performs the movement. In general, exercises need to be as active as health and mobility allow.

Question 55

While performing passive ROM exercises, the nurse stands at the side of the bed closest to the joint being exercised and 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.

Answer 55

ANS: D The nurse carries 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 five times during the session.

Question 56

Describe any changes you've noticed in your ability to walk and take care of yourself and a daily basis? Have you ever experienced any stiffness and swelling pain or difficulty with moving? If so describe how you felt. Have you noticed any shortness of breath? What part of the nursing process is this?

Answer 56

Mobility Assessment

Question 57

The patient is admitted to a skilled care unit for rehabilitation 10 days after the surgical procedure of fixation of a fractured left hip and has a nursing diagnosis of Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which of the following nursing interventions is most appropriate for this patient? a. Obtain assistance and physically transfer the patient to the chair. b. Assist the patient with ambulation and measure how far she walks. c. Withhold pain medication so that she can ambulate with a clear mind. d. Bring the patient to the cafeteria for group instruction on ambulation.

Answer 57

B. To determine her baseline level of activity to measures future outcomes.

Question 58

The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique to keep the spinal column in straight alignment. Which of the following is the proper technique for logrolling? a. Obtain assistance from at least two or three other people. b. Have the patient reach for the opposite side rail when turning. c. Move the top part of the patient's torso, then the bottom part. d. Do not use pillows after turning because the softness causes misalignment.

Answer 58

ANS: A At least three to four people are needed to perform this skill safely. Have the patient cross arms on chest to prevent injury to the arms. Move the patient as one unit in a smooth, continuous motion on the count of three. Gently lean the patient as a unit back toward pillows for support.

Question 59

``` Decreased urine output. Cloudy or concentrated urine. Decreased frequency of bowel movements. Distended bladder and abdomen. Decreased bowel sounds. ``` What body system is this nurse assessing in relation to immobility?

Answer 59

Elimination Abnormalities

Question 60

Correct body alignment reduces strain on musculoskeletal structures and contributes to balance. Balance control is attained by (Select all that apply.) a. Keeping the body's center of gravity high. b. Maintaining a wide base of support. c. Keeping the body's center of gravity low. d. Maintaining correct body posture. e. Maintaining immobility to prevent falls.

Answer 60

ANS: B, C, D Without balance control, the center of gravity is displaced, thus creating risk for falls and injuries. Balance is enhanced by keeping the body's center of gravity low (not high) with a wide base of support and by maintaining correct body posture. Prolonged immobility leads to impaired balance.

Question 61

The nurse is caring for a patient with the 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

Answer 61

ANS: A, B, C, D

Question 62

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 2 lbs. 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. Physical therapy b. Occupational therapy c. Respiratory therapy d. Cardiac rehabilitation e. Psychology services

Answer 62

ANS: A, B, E Physical therapists are a resource for planning ROM or strengthening exercises, and occupational therapists are a resource for planning ADLs that patients need to modify or re-learn. Referral to a mental health advanced practice nurse, a licensed social worker, or a physiologist to assist with coping or other psychosocial issues is also wise. Because the patient exhibits good cardiac and respiratory function, respiratory therapy and cardiac rehabilitation probably are not needed at this time.

Question 63

Nurses use information about body alignment, balance, gravity, and friction, when implementing nursing interventions such as?

Answer 63

Positioning Fall risk Transferrability

Question 64

Medications that cause dizziness and prolonged immobility also affect this?

Answer 64

Balance

Question 65

A normal person center of gravity is usually at _____ to ____ of standing height and at the midline

Answer 65

55% - 57%

Question 66

As a result of this blood vessels in the underlying tissue are stretched and damaged, resulting in impeded blood flow to the deep tissues.

Answer 66

Shearing Force

Question 67

Patients with altered _________function also experience diminished red blood cell production and fatigue easily because of reduced ________ which results in the bloods decreased oxygen-carrying ability. This fatigue decreases their ________ and increases the ________.

Answer 67

Bone Marrow Hemoglobin Mobility Risk for Falls

Question 68

This is the biggest and strongest tendon in the body?

Answer 68

Achilles Tendon aka | Tendo Calcaneus

Question 69

Anatomical structure and attachment to the skeleton enhance contractile elements of the _______ because of their ability to contract and relax they are there working elements of movement.

Answer 69

Skeletal Muscle

Question 70

Although isometric contractions do not result in muscle shortening _______ increases.

Answer 70

energy expenditure

Question 71

Energy expenditure is an ______ respiratory rate and __________ heart rate associated with _________ exercises.

Answer 71

Increased Increased Isometric

Question 72

___________ exercises are sometimes contraindicated in certain patient illnesses. Two examples of illnesses?

Answer 72

Isometric myocardial infarction chronic obstructive pulmonary disease

Question 73

This can be a reflection of a person's personality, discomfort, and mood?

Answer 73

Posture

Question 74

______ require muscle action maintain muscle tone. When a patient is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone ________.

Answer 74

ADLs | Decrease

Question 75

What body system regulates movement and posture? The _______ or motor strip is the major voluntary motor area and is in the ________.

Answer 75

Nervous System Precentral Gyrus cerebral cortex

Question 76

This is a chemical that transfers electric impulses from the nerve across the neuromuscular junction to the muscle. What is the name of this chemical? When it reaches the muscle it stimulates it causing _______?

Answer 76

Acetylcholine movement

Question 77

Movement is impaired by disorders that alter ___________ production, which is the transfer of impulses from the nerve to the muscle, or activation of muscle activity. Ex. Parkinson's.

Answer 77

neurotransmitter

Question 78

``` Decreased range of motion. Erythema. Increased diameter and calf or thigh. Joint contracture. Activity intolerance. Muscle atrophy. Joint contracture. ``` What body system is this nurse assessing in relation to immobility?

Answer 78

Musculoskeletal Abnormalities

Question 79

If ROM is limited in an affected joints nurses must maintain maximum ROM in unaffected joints and then design _______ to strengthen affected a muscle and joints to improve the patient's _______ and adequately use both affected and unaffected muscle groups.

Answer 79

interventions | posture

Question 80

This is the most prevalent of muscle disorder in childhood? Patients experience progressive __________ weakness and ______ of skeletal muscle groups, with _______ disability and deformity.

Answer 80

Muscular Dystrophy symmetrical wasting increasing

Question 81

This body system regulates voluntary movement and trauma would result in impaired body alignment, balance, and mobility. What system is this?

Answer 81

central nervous system

Question 82

Trauma from a head injury, ischemia from a stroke or brain attack or cerebrovascular accident, or bacterial infection such as meningitis can damage the _______in the cerebral cortex.

Answer 82

cerebellum or the motor strip

Question 83

Damage to the ______ causes problems with balance and motor impairment directly related to the amount of destruction of the area.

Answer 83

cerebellum

Question 84

Description: Inclining of head to affect his side in which sternocleidomastoid muscle is contracted. Cause: congenital or acquired condition. Treatments: surgery, heat, support, or immobilization depending on cause and severity, gentle ROM. What postural abnormality is this?

Answer 84

Torticollis

Question 85

Description: Lateral S or C shaped spinal column with vertebral rotation, unequal heights of hips and shoulders. Cause: sometimes a consequence of numerous connective tissue you, congenital, and neuromuscular disorders. Treatment: approximately half of children with this require surgery. Nonsurgical treatment is with the braces and exercises. What postural abnormality is this?

Answer 85

Scoliosis

Question 86

Description: hip instability with limited abduction of hips and occasionally addduction contractures because the head of the femur does not articulate with acetabulum because of abnormal shallowness of acetabulum. Cause: congenital condition more common in breach deliveries. Treatment: maintenance of continuous abduction of thigh so head of femur presses into center of acetabulum. Abduction splints, casting, and surgery. What postural abnormality is this?

Answer 86

Congenital Hip Dysplasia

Question 87

Description: legs curved inward so knees come together as a person walks. Cause: congenital condition. Rickets. Treatment: knee braces, surgery if not corrected by growth. What postural abnormality is this?

Answer 87

Genu Valgum | Knock Knee'd

Question 88

Description: one or both legs bend outward at me which is normal and till 2 to 3 years of age. Cause: congenital condition. Rickets. Treatment: slowing rate of curving if not corrected by growth. With rickets increase of vitamin D, calcium, and phosphorus intake until WNL. What postural abnormality is this?

Answer 88

Genu Varum | Bow-Legged

Question 89

Description 95% medial deviation and plantarflexion of foot also known as _____. 5% lateral deviation and dorsiflexion also known as ________. Cause: congenital condition. Treatment: Casts, splints such as Denis Browne splint, and surgery based on degree and rigidity of deformity. What postural abnormality is this?

Answer 89

Equinovarus Calcaneovalgus Clubfoot

Question 90

Description: inability to dorsiflex and invert foot because of peroneal nerve damage. Cause: congenital condition. Trauma. And proper positioning of immobilized patient. Treatment: none cannot be corrected. Prevention through physical therapy. Bracing with ankle foot orthotic. What postural abnormality is this?

Answer 90

Footdrop

Question 91

Treatment of a fracture often includes positioning the fractured a bone in ______ and _______ it to promote healing and restore function.

Answer 91

proper alignment immobilizing

Question 92

Implementing evidence-based interventions and programs ______ the number of work-related injuries which improve the health of the nurse and ______ indirect costs to the health care agency.

Answer 92

Reduce | reduce

Question 93

Comprehensive safe patient handling programs include the following elements an ________ assessment protocol for healthcare environments, _______ assessment criteria, _______ for patient handling and movement, special equipment kept in ______ locations to help transfer patients, back injury _______ nurses, and an ____ review that allows the healthcare team to apply knowledge about moving patient safely in different settings, and a _____ policy.

Answer 93

``` ergonomic patient algorithms convenient resource after-action no lift ```

Question 94

Patient's of average weight and height without a chronic illness on bed rest lose muscle strength from baseline levels at a rate of ____ a day.

Answer 94

3%

Question 95

Older adults with chronic illnesses develop pronounced effects of immobility ______ than younger patients with the same immobility problem.

Answer 95

Faster

Question 96

This body system is made up of hormone secreting glands, maintains and regulates: Response to stress and injury. Growth and development. Reproduction. Maintenance of the internal environment. Energy production, use, and storage. What system is this?

Answer 96

Endocrine System

Question 97

This body system helps regulate the tissue and cell internal environment through maintenance of sodium, potassium, water, acid-base balance, and energy metabolism. What body system is this?

Answer 97

The Endocrine System

Question 98

This hormone increases the body's basal metabolic rate and energy becomes available to cells through the integrated action of _______ and ______ hormones. What hormone is this?

Answer 98

Thyroid Hormone gastrointestinal pancreatic

Question 99

Immobility decreases the metabolic rate which alters the metabolism of _____, _____, and _____, causing fluid, electrolytes, and calcium ______. This causes gastrointestinal disturbances such a decreased ______ and slowing of ________.

Answer 99

carbohydrates fats proteins imbalances appetite peristalsis

Question 100

During infection immobilized patient will have an increased ____ as a result of fever or wound healing because these increase ______ requirements.

Answer 100

Basal Metabolic Rate cellular oxygen

Question 101

A deficiency in ______ and ______ is a characteristic of patient with decreased appetite secondary to immobility.

Answer 101

Calories | Proteins

Question 102

Weight-loss, decreased muscle mass, and weakness are caused by tissue _____.

Answer 102

catabolism

Question 103

_______ causes the release of calcium into blood circulation from inside the bone marrow. Normally the kidneys excrete the excess calcium. However if kidneys are unable to respond appropriately ________ results. ______ occur if Calcium reabsorption continues and the patient remains on bed rest or continues to be immobile.

Answer 103

Immobility hypercalcemia Pathological fractures

Question 103

Difficulty in passing stools (constipation) is a common symptom although pseudo-diarrhea often results from fecal impaction. This is related to?

Answer 103

Immobility

Question 104

As a result of immobility, with fecal impaction, the resulting fluid in the intestine produces distention and increases intraluminal pressure. Overtime intestinal function becomes _____, _______ occurs, _______ ceases, and ______ disturbances worsen.

Answer 104

depressed dehydration absorption fluid and electrolyte

Question 105

Lack of movement and exercise places patients at risk for ________ collapse of alveoli and ______ inflammation of the lung from stasis or poolling of secretions.

Answer 105

atelectasis | hypostatic pneumonia

Question 106

In this complication with immobility secretions block a bronchiole or a bronchus and the alveoli collapses as the air existing is absorbed producing hypoventilation. Site of blockage affects severity.

Answer 106

atelectasis

Question 107

This frequently results because mucus is an excellent place for bacteria to grow in the lungs in an immobile patient.

Answer 107

Hypostatic pneumonia

Question 108

The three major ways that immobilization negatively affects the cardiovascular system?

Answer 108

Orthostatic hypertension, increases cardiac workload, Increases thrombus formation.

Question 109

This complication of immobility is an increase in heart rate of more than 15% in a drop of 15 mm/Hg or more and systolic blood pressure or a drop of 10 mm/Hg or more and diastolic pressure when the patient changes from the supine to standing position?

Answer 109

Orthostatic Hypotension

Question 110

In the immobilize patient decrease circulating fluid volume pooling of blood in the lower extremities and decreased autonomic response occur and causes this complication of immobility?

Answer 110

Orthostatic Hypotension

Question 111

As cardiac workload increases so does _________. Therefore the heart works harder and less efficiently during periods of prolonged rest. As immobilization increases cardiac output _______, further decreasing cardiac efficiency, and ________ workload. What is this complication of immobilization called?

Answer 111

Oxygen consumption decreases Increasing Orthostatic hypotension

Question 112

Patients who are immobile are at an increased risk for _______ formation.

Answer 112

Thrombus

Question 113

What three factors contribute to venous thrombus formation? What is this referred too?

Answer 113

Damage to the vessel wall Ex. injury during surgical procedure bloodflow changed Ex. slow blood flow in Calf is R/T Bedrest alterations in blood constituents ex. Change in clotting factors and Increased platelet activity VirchowsTriad

Question 114

_________ results in loss of endurance, strength, muscle mass, decreased stability, balance, impaired calcium, metabolism, and joint mobility.

Answer 114

Restricted mobility

Question 115

Loss of endurance, decreased muscle mass and strength, and joint instability puts patients at risk for what?

Answer 115

Falls

Question 117

_______ is a common response to illness, decreased ADLs, and immobilization.

Answer 117

Muscle atrophy

Question 118

When assessing for _________ monitor patient for symptoms such as dyspnea, fatigue, chest pain, and/or a change in vital signs.

Answer 118

exercise and activity tolerance

Question 119

Immobilization causes what two skeletal changes?

Answer 119

Impaired calcium metabolism | joint abnormalities

Question 120

Disuse, atrophy, and shortening of the muscle fibers cause this complication of immobility?

Answer 120

Joint contractures

Question 121

_________ muscles for joints are stronger than ________ muscles and therefore contribute largely to the formation of contractures.

Answer 121

Flexor | extensor

Question 122

When a contraction occurs the joint cannot achieve full ____?

Answer 122

ROM

Question 123

Contractures can begin to form after only ___ hours of immobility in the older adult when this occurs the joints cannot achieve full ROM.

Answer 123

8 Contractures sometimes leave a joint in a non-functional position such as patients who are permanently curled in a fetal position.

Question 124

What type of patient is at risk for developing foot drop?

Answer 124

CVA's or brain attacks with resulting right or left sided paralysis hemiplegia

Question 125

These are stones that lodge in the renal pelvis or pass through the ureters. Immobilize patients are at risk for these because they frequently have hypercalcemia.

Answer 125

Renal Calculi

Question 126

After a long period of ________ the patient will stop drinking fluids when you combine this with other problems like a fever a risk for ________ increases as a result urinary output declines after the ___ or ____day of immobilization and the urine becomes concentrated.

Answer 126

immobility dehydration fifth or sixth

Question 127

This increases the risk for renal calculi formation an infection.

Answer 127

Concentrated urine

Question 128

What is the most important risk factor related to immobility?

Answer 128

Pressure ulcers

Question 129

_______ depends on the supply of oxygen, nutrients to and the elimination of _______ from the blood. Pressure affects cellular metabolism by _____ or ______ tissue circulation.

Answer 129

Tissue metabolism metabolic waste decreasing or totally eliminating

Question 130

What population is at the highest risk for skin breakdown ?

Answer 130

Elderly

Question 131

An older patient can develop skin breakdown within ____ hours?

Answer 131

3

Question 132

_________ often leads to emotional and behavioral responses, ________ alterations, and changes in _______.

Answer 132

Immobilization sensory coping

Question 133

This is an affective disorder characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion to reality.

Answer 133

Depression

Question 134

Asymmetrical chest wall movement. Dyspnea. Increased respiratory rate. Crackles. Wheezes. What body system is this nurse assessing in relation to immobility?

Answer 134

Respiratory Abnormalities

Question 135

_________ removes the patient from a daily routine, in turn they will have more time to worry about the disability. Worrying increases the patients ______ causing withdrawal. Withdrawn patients often ______ want to participate in their own care.

Answer 135

Immobilization depression do not

Question 136

Social isolation is a concern for this population when immobilization occurs?

Answer 136

Adolescents Adolescence who experience immobility often are behind peers in gaining independence and accomplishing certain skills such as obtaining a drivers license.

Question 137

When immobility occurs some adults lose their jobs which can affect what psychological aspect?

Answer 137

Self concept

Question 138

The elderly experience progressive loss of ________ some possible causes include decreased physical activity, ______ changes, and bone calcium _______. The effect of bone loss is _____ bones.

Answer 138

total bone mass hormonal reabsorption weaker

Question 139

This can alter the elderly sense of balance and affect the blood pressure when they change positions too quickly, increasing the risk for falls and injuries?

Answer 139

Prescribed medications

Question 140

Immobilization of some older adults results from ______ disease, _____ trauma, or chronic illness. Can occur gradually or suddenly. when performing care for this patient encourage the patient to perform as many ______ activities as possible maintaining their highest level of mobility.

Answer 140

degenerative neurological self-care

Question 141

Design a care plan that improves the patients ______ status, promote _____, maintain ________ well-being, and reduces the ______ of immobility.

Answer 141

functional self-care psychological hazards

Question 142

Assessment of patient mobility focuses on what 5 assessments?

Answer 142

``` ROM Gait Exercise Activity Intolerance Body Alignment ```

Question 143

What order should the assessment of movement go in? 1. Patient sitting in bed. 2. Patient lying down in bed. 3. Patient walking. 4. Patient transfers to chair. This helps to protect the patient safety.

Answer 143

2 1 4 3

Question 144

Range of motion is the maximum amount of movement available at a joint in one of the three planes of the body? Name the three planes

Answer 144

sagittal divides arms/legs transverse divides top/bottom Frontal divides front back

Question 145

Does your days seem very long? Are you sleeping well at night? Have you noticed any places on your skin that a reddened or have any open sores? Describe any changes you have noticed in urinating and/or bowel movements? What part of the nursing process is this?

Answer 145

Immobility Assessment

Question 146

People who are depressed, worried, anxious or frequently unable to tolerate _______.

Answer 146

Exercise

Question 147

_____ changes and ____ affect exercise and activity tolerance.

Answer 147

Developmental | age

Question 148

Assess _________ to identify trauma, muscle damage, or nerve dysfunction. It is important to assess alignment one sitting if the patient has muscle weakness, muscle paralysis, or nerve damage. what are you assessing for?

Answer 148

body alignment | Decreased sensation

Question 149

When a patient with severe respiratory disease assumes a posture of leaning on the table in front of the chair and attempt to breathe more easily this is called what?

Answer 149

Orthopnea

Question 150

``` Patients with impaired mobility Ex. traction or arthritis Decrease in sensation Ex. hemiparesis after CVA Impaired Circulation Ex. diabetes involuntary muscle control Ex. spinal cord injury Are at risk for damage when _____? ```

Answer 150

lying down

Question 151

Use anthropometric measurements to evaluate what complication of immobility?

Answer 151

muscle atrophy

Question 152

__________ and ________ increased the rate of skin breakdown in a patient who is immobilized monitoring the laboratory levels of ________, serum proteins (__________ and ________), and ______ aid the nurse in determining metabolic functioning.

Answer 152

Dehydration and Edema electrolytes albumin and total protein blood urea nitrogen BUN

Question 153

Monitoring _________ and _________ patterns and assessing ______ helps to determine altered G.I. functioning and potential metabolic problems.

Answer 153

food intake elimination Wound healing

Question 153

If a patient has a wound the ______ indicates how well nutrients are being delivered to the damaged tissue.

Answer 153

Rate of healing

Question 153

This complication commonly occurs in patients who are immobilized. Assess the patient's food intake before the food tray is removed to determine the actual amount of food eaten.

Answer 153

Anorexia

Question 154

``` Slowed wound healing. Abnormal laboratory data. Muscle atrophy. Decreased amount of subcutaneous fat. Generalized Edema ``` What body system is this nurse assessing in relation to immobility?

Answer 154

Metabolic Abnormalities

Question 155

Perform a respiratory assessment at least every __ hours for patients with restricted activity. Inspect chest wall movement during the full ________ cycle if patient has atelectic area chest movement is _______.

Answer 155

2 inspiratory-expiratory asymmetrical

Question 156

Assessment of the cardiovascular system of a patient who is immobilized includes?

Answer 156

Check blood pressure. Evaluate apical and peripheral pulses. Observe for signs of Venus stasis. Ex. Edema and Delayed Wound Healing

Question 157

The longer the period of immobility, the greater the risk of _____ when the patient stands. Although not all patients experience this nurses monitor their vital signs during the first few attempts at sitting or standing.

Answer 157

Orthostatic hypotension

Question 158

A third heart sound hurt at the apex is an early indication of?

Answer 158

Congestive heart failure

Question 159

If the heart is unable to tolerate the increased workload. A body region such as the hands, feet, nose, and earlobes are ______ then central body regions.

Answer 159

Colder

Question 160

To assess for DVT remove embolic stockings every ____ hours or according to policy and observe the calves for what three skin abnormalities?

Answer 160

eight | Redness warmth tenderness

Question 161

_____ or calf pain on dorsiflexion of the foot is contraindicated in patients when a DVT is suspected. It is ____ a reliable indicator in assessing for DVT as it is present in other conditions.

Answer 161

Homan's sign Not

Question 162

Measure bilateral calf and thigh circumference and record it daily as an alternative assessment for ___.

Answer 162

DVT