Chapter 47: Mobility and Immobility

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.

c. Immobilized patients can develop skin breakdown within 3 hours.

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.

c. Is about 4.4%.

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.

c. Longer straps hook to the bottom of the sling.

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.

c. Neurotransmitters.

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.

c. Should be aware of agency policies.

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.

a. Increased muscle contraction results in movement.

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.

a. Not a normal expectation.

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.

a. The patient will walk 1000 feet using her walker by the time of discharge.

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.

b. Posture.

Immobilized patients frequently have hypercalcemia, placing them at risk for a. Osteoporosis. b. Renal calculi. c. Pressure ulcers. d. Thrombus formation.

b. Renal calculi.

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.

b. Use a standardized tool such as the Braden Scale.

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.

d. Result in increased energy expenditure.

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

d. Synovial

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.

d. With many clinical activities.

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

b. Leverage

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.

a. A foot cradle.

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.

d. Gait.

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

a, b, e

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

a, b, c

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.

a. A trochanter roll.

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.

a. At the time of admission.

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.

a. Encourage the patient to perform as many self-care activities as possible.

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.

a. Not completely immobile.

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.

a. Obtain assistance from at least two or three other people.

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.

a. Use established expected outcomes to evaluate the patient's response to care.

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.

b. When observed laterally, the spinal curves align in a reversed "S" pattern.

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.

b, c, d

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.

b. As soon as the ability to move is lost

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.

b. Assist the patient with ambulation and measure how far she walks.

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.

b. Both feet are supported on the floor with ankles flexed.

The patient is immobilized after undergoing hip replacement surgery. Which of the following would place the patient at risk for hemorrhage? a. Thick, tenacious pulmonary secretions b. Low-molecular-weight heparin doses to prevent DVT c. SCDs wrapped around the legs to prevent DVT formation d. Elastic stockings (TED hose) to promote venous return

b. Low-molecular-weight heparin doses to prevent DVT

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.

b. Measure the calf circumference of both legs.

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.

c. Altered metabolic function.

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.

c. Assess and obtain the number of people needed to help.

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.

c. Assess for the need of a mechanical lift and help.

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.

c. Auscultate the entire lung region to assess lung sounds.

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.

c. Changes in role and self-concept may lead to depression.

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.

c. Consults other health care team members to help plan therapy.

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.

c. Enhance recruitment.

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.

c. Establish goals that are measurable and realistic.

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.

c. Further assessment of the patient is needed.

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.

c. Tighten abdominal muscles and tuck the pelvis.

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.

d. All dimensions are important to health.

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.

d. Assist the patient with comfort measures.

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.

d. Assistive devices or additional nurses should be used.

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.

d. Carries out movements slowly and smoothly.

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.

d. Keeping a low center of gravity.

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.

d. Place the patient in a lateral position.