immobility

The nurse is discussing joint mobility exercises with a client who experienced a stroke and now has left-sided weakness. Which of the following statements made by the client reflects the greatest insight regarding the best method for him to maintain mobility of the joints on his left side? 1. "My wife knows how to do those exercises for the joints on my left side." 2. "Physical therapy really exercises my left side when I go there every afternoon." 3. "I'll remind the staff to exercise my left side when they come to help me with my bath and getting dressed." 4. "I will do those passive range of motion exercises you taught me to my left side at least 3 times a day."

"I will do those passive range of motion exercises you taught me to my left side at least 3 times a day."

The nurse recognizes that facilitating correct body alignment for a dependent client may well result in which of the following positive client outcomes? (Select all that apply.) 1. A comfortable night's sleep 2. Minimized activity intolerance 3. Muscle tone that promotes ambulation 4. Reduction of falls caused by general weakness 5. Minimal strain placed on the spinal column 6. Increased socialization, resulting in peace of mind

A comfortable night's sleep Minimized activity intolerance Muscle tone that promotes ambulation Reduction of falls caused by general weakness Minimal strain placed on the spinal column

Which of the following clients is most at risk for losing his or her balance? 1. A woman who is 9 months pregnant walking down a flight of stairs 2. A 16-year-old skate boarding down a 15-degree slope 3. A 45-year-old taking hypertensive medication 4. A 4-year-old riding a tricycle

A woman who is 9 months pregnant walking down a flight of stairs *Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility also affect balance. Impaired balance is a major threat to physical safety and contributes to a fear of falling and self-imposed restrictions on activity. Although all the options represent a risk, the situation of the pregnant woman places her at greatest risk.*

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 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.

Auscultate the entire lung region to assess lung sounds.

Which of the following factors may contribute to an increased risk for thrombus formation, impaired skin integrity, respiratory infection, and constipation in the immobilized client? A. Insufficient passive range of motion B. Emotional depression C. Inadequate fluid intake D. Use of hypnotic medication

Inadequate fluid intake

The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to: a. Measure the calf and thigh diameters b. Attempt to elicit Homan's sign c. Palpate the temperature of the feet d. Observe for a loss of hair and skin turgor in the lower legs

Measure the calf and thigh diameters

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.

immobilized patients can develop skin breakdown within 3 hours

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.

increased muscle contraction results in movement

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.

is about 4.4%

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.

keeping a low center of gravity

The nurse is providing ancillary personnel with instructions regarding the performance of passive range-of-motion (ROM) exercises for a client experiencing paralysis from the waist down (paraplegia) as a result of an automobile accident. Which of the following statements made by the ancillary personnel reflects the greatest insight regarding the frequency with which the intervention should be provided for this client? 1. "I will do a whole body range of motion as I complete her daily bath." 2. "Bath time, bedtime, after lunch, and at least once more; she can pick when." 3. "It works well with her bath and when she is being prepared for bed at night." 4. "I'll ask her when she wants me to exercise her joints in addition to bath time."

"Bath time, bedtime, after lunch, and at least once more; she can pick when."

A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident (stroke). Which of the following is the best intervention for this client? A. Encourage an even gait when walking in place. B. Assess the extremities for unilateral swelling and muscle atrophy. C. Encourage holding the breath frequently to hyperinflate his lungs. D. Teach the use of a two-point crutch technique for ambulation.

Assess the extremities for unilateral swelling and muscle atrophy.

. 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.

Enhance recruitment.

A 16-year-old has had a full leg cast in place for 2 months, and it is being removed today. Which of the following assessment findings would be expected following the removal of the cast? (Select all that apply.) 1. Popliteal pulse equal in both legs 2. Slight footdrop noted on affected leg 3. Swelling noted at ankle on affected leg 4. Weight bearing less stable on affected leg 5. Calf circumference greater in unaffected leg 6. Greater range of motion of knee of unaffected leg

Popliteal pulse equal in both legs Weight bearing less stable on affected leg Calf circumference greater in unaffected leg Greater range of motion of knee of unaffected leg

The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in an immobile client is to: 1. Keep the skin dry 2. Provide range of motion every shift 3. Use lift equipment when transferring a client 4. Turn the client a minimum of every 2 hours

Turn the client a minimum of every 2 hours

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

Physical therapy Occupational therapy Psychology services

Which of the following factors has an impact on the severity of physical impairment a client will experience from a period of immobility? (Select all that apply.) 1. The client's age 2. Prior overall health 3. Length of immobility 4. The degree of immobility 5. Situation requiring the inactivity 6. Client's mental attitude about the limitations

The client's age Prior overall health Length of immobility The degree of immobility

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.

Tighten abdominal muscles and tuck the pelvis. *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 nurse is caring for a 48-year-old male client who was involved in a motor vehicle accident and had a fractured pelvis, a ruptured spleen, and multiple contusions. The client has been in the hospital for 5 days on bed rest. The nurse knows that this client is at risk for venous thrombus formation because of prolonged bed rest, potential damage to vessel walls during surgery, and the platelets he received in the trauma unit. These three factors are also known as: 1. Trigeminy 2. Virchow's triad 3. Trigone 4. Hutchinson's triad

Virchow's triad *There are three factors that contribute to venous thrombus formation: (1) damage to the vessel wall (e.g., injury during surgical procedures), (2) alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity). These three factors are sometimes referred to as Virchow's triad*

A client recovering from hip surgery tells the nurse that she wants to get better so she can walk down the aisle to her seat at her granddaughter's wedding. Which of the following nursing interventions will have the greatest impact on achieving that goal? 1. Informing physical therapists that the client has expressed that goal 2. Reminding the ancillary staff to offer to walk with the client after her bath 3. Regularly praising the client for the efforts she is making to reach her goal 4. Walking with the client to and from the dining room where she eats her meals

Walking with the client to and from the dining room where she eats her meals *Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. ADLs require muscle action and help maintain muscle tone. When a client is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone decrease. The better the muscle tone, the more stamina the client will experience. Although all the interventions are appropriate, actually walking with the client will have the greatest impact on her ability to achieve the goal.*

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.

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

The nurse caring for a 73-year-old female client who has been hospitalized with a stroke instructs the client's daughter to continue to do passive range-of-motion exercises with her mother on her affected side to prevent contractures. The nurse explains to the daughter that this is very important in an immobile older adult client because contractures can form in as little as: 1. 8 hours 2. 24 hours 3. 1 week 4. 1 month

8 hours *Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. When a contracture occurs, the joint cannot obtain full ROM. Contractures sometimes leave a joint or joints in a nonfunctional position, as seen in clients who are permanently curled in a fetal position. Early prevention of contractures is key; they can begin to form after only 8 hours of immobility in the older adult client.*

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 foot cradle. *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.*

The nurse understands that using metabolic functioning, measures of height, weight, and skinfold thickness, to evaluate muscle atrophy in an immobilized client is known as: 1. Anthropometric measurements 2. Anhydrous measurements 3. Balke test 4. Calorimetry

Anthropometric measurements *When assessing metabolic functioning, use anthropometric measurements (measures of height, weight, and skinfold thickness) to evaluate muscle atrophy. Anhydrous means without water, the Balke test determines maximum oxygen utilization, and calorimetry is the determination of heat loss or gain.*

Antiembolytic stockings (TEDs) are ordered for the client on bed rest after surgery. The nurse explains to the client that the primary purpose for the elastic stockings is to: a. Keep the skin warm and dry b. Prevent abnormal joint flexion c. Apply external pressure d. Prevent bleeding

Apply external pressure

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.

As soon as the ability to move is lost *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.*

The nurse recognizes that a client who is inactive is at a risk for decreased muscle mass as a result of increased muscle atrophy and: 1. Decrease metabolic rate 2. Catabolic tissue breakdown 3. Inactivity-induced depression 4. Anorexia caused by decreased peristalsis

Catabolic tissue breakdown *Weight loss, decreased muscle mass, and weakness result from tissue catabolism (tissue breakdown).*

The nurse caring for a 78-year-old male client recovering from hip replacement surgery is assessing for signs of improvement of the client's activity tolerance. The nurse determined a baseline for ongoing assessments by: 1. Determining how much time it takes the client to recover from an activity 2. Assessing how much the client can do at one time 3. Determining the level of pain experienced by the client during the activity 4. Asking the client how much the client feels like doing

Determining how much time it takes the client to recover from an activity

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.

Further assessment of the patient is needed. *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.*

To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse should implement the use of a: a. Footboard b. Trochanter roll c. Trapeze bar d. Bed board

Trochanter roll *A trochanter roll prevents external rotation of the hips when the client is in a supine position. The footboard prevents footdrop by maintaining the feet in dorsiflexion. The trapeze bar allows the client 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. A bed board is used to increase back support and alignment, especially with a soft mattress.*

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

renal calculi

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.

results in increase energy expenditure

Which of the following statements made by ancillary staff reflects the most informed knowledge regarding the benefit of having a client assist with his or her own activities of daily living (ADLs) to that client's activity tolerance? 1. "The more he does for himself, the more he will be able to do for himself." 2. "He doesn't like washing and dressing himself, but it makes him stronger." 3. "Doing for himself makes him tired, but in the long run he has more energy and strength when he does." 4. "By washing and dressing himself he is building muscle strength that lets him actually walk a little better."

"By washing and dressing himself he is building muscle strength that lets him actually walk a little better." *Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. ADLs require muscle action and help maintain muscle tone. When a client is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone decrease. The remaining options do not explain the reason for the additional activity tolerance as does the answer.*

Which of the following statements regarding physical activity and its effect on activity tolerance made by a client shows the most informed knowledge regarding the connection between the two? 1. "I know I need to walk more if I want to get stronger." 2. "I don't like walking, but I do it because I know it will make me stronger." 3. "I try to walk a little farther each afternoon so I can dance at my grandson's wedding." 4. "I walk with my son three evenings a week because it's good for his weight and for my bones."

"I try to walk a little farther each afternoon so I can dance at my grandson's wedding." *Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. The better the muscle tone, the more stamina the client will experience. The remaining options do not state the connection between activity and stamina as well as the answer.*

Which of the following statements made by a nurse caring for a client who experienced a myocardial infarction 8 hours ago shows the greatest insight as to the purpose for keeping the client on bed rest? 1. "This has been exhausting; she needs a period of uninterrupted rest." 2. "The pain she experienced is exhausting; it's imperative that she rest." 3. "Keeping her on bed rest decreases the need her body has for oxygen" 4. "She needs complete rest; she is really very ill, especially her heart."

"Keeping her on bed rest decreases the need her body has for oxygen" *Although all of the options are correct, the primary reason for bed rest in this scenario is to minimize the need for oxygen to both the heart and the body in general.*

Prevention of plantar flexion (footdrop) through the application of high-topped shoes is a primary intervention for which of the following mobility-impaired clients? 1. A 54-year-old diagnosed with osteoarthritis in all lower extremity joints 2. A 25-year-old with a fractured pelvis as a result of a motorcycle accident 3. A 78-year-old who has experienced left-sided paralysis resulting from a cerebral vascular accident (CVA) 4. A 15-year-old who has been comatose for 2 years as a result of a head injury sustained from a fall off a roof

A 25-year-old with a fractured pelvis as a result of a motorcycle accident

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.

Assistive devices or additional nurses should be used.

The nurse assesses that the client has torticollis and that this may adversely influence the client's mobility. This individual has a(n): 1. Exaggeration of the lumbar spine curvature 2. Increased convexity of the thoracic spine 3. Abnormal anteroposterior and lateral curvature of the spine 4. Contracture of the sternocleidomastoid muscle with a head incline

Contracture of the sternocleidomastoid muscle with a head incline *Torticollis is inclining of the head to the affected side, in which the sternocleidomastoid muscle is contracted. Lordosis is an exaggeration of the lumbar spine curvature. Kyphosis is an increased convexity in the curvature of the thoracic spine. Kyphoscoliosis is an abnormal anteroposterior and lateral curvature of the spine.*

An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as: 1. Harsh crackles 2. Wheezing on inspiration 3. Diminished breath sounds 4. Bronchovesicular whooshing

Diminished breath sounds *Harsh crackles indicate excessive airway secretion. Wheezing on inspiration indicates narrowing of the lumen of a respiratory passageway. Bronchovesicular sounds are a mixture of bronchial and vesicular sounds. Bronchovesicular whooshing would not be an expected sound indicating atelectasis.*

Two nurses are standing on opposite sides of the bed to move the client up in bed with a drawsheet. Where should the nurses be standing in relation to the client's body as they prepare for the move? A. Even with the thorax B. Even with the shoulders C. Even with the hips D. Even with the knees

Even with the shoulders

A staff member experienced a shoulder injury while assisting with a client transfer. The nurse manager's most therapeutic response to this situation is to: 1. Thoroughly review the accident report filed by the injured personnel to determine the factors that contributed to the injury 2. Have a nonpunitive meeting with all the involved staff to discuss correcting the factors that resulted in the injury 3. Require that mechanical lifts be used in the transfer of all clients incapable of assisting with the transfer 4. Implement new policies and procedures to correct the factors that resulted in the injury

Have a nonpunitive meeting with all the involved staff to discuss correcting the factors that resulted in the injury *An "after-action review" allows the health care team to apply knowledge about safe client moving to the situation to identify safety factors contributing to the problem and make suggestions for the implementation of strategies to minimize risk to both client and staff.*

To reduce the chance of plantar flexion (foot drop) in a client on prolonged bed rest, the nurse should implement the use of: a. Trapeze bars b. High-top sneakers c. Trochanter rolls d. 30-degree lateral positioning

High-top sneakers *High-top tennis shoes or an ankle/foot orthotic may be used to help maintain dorsiflexion and prevent footdrop. A trapeze bar is not used to keep the foot in dorsiflexion. A trapeze bar is used to assist the client in mobility. A trochanter roll prevents external rotation of the hips when the client is in a supine position. It is not used to prevent footdrop. Thirty-degree lateral positioning does not prevent plantar flexion. It may be used for clients at risk for pressure ulcers.*

The nurse caring for a 38-year-old female client with multiple fractures in the trauma intensive care unit knows that this client is at high risk for pulmonary complications such as atelectasis from her immobility. One of the interventions that the nurse can do to help prevent this from occurring is to: 1. Keep the PaO2 level at or above 94% 2. Instruct the client to deep breathe and cough every hour while awake 3. Turn the client every 2 hours 4. Keep the client on the ventilator as long as possible

Instruct the client to deep breathe and cough every hour while awake

A client has sequential compression stockings in place. The nurse evaluates that they are implemented appropriately by the new staff nurse when the: 1. Initial measurement is made around the client's calves 2. Intermittent pressure is set at 40 mm Hg 3. Stockings are wrapped directly over the leg from ankle to knee 4. Stockings are removed every hour during application

Intermittent pressure is set at 40 mm Hg *Inflation pressures average 40 mm Hg. Initial measurement is made around the largest part of the client's thigh. A protective stockinette is placed over the client's leg; then the stocking is wrapped around the leg, starting at the ankle, with the opening over the patella. For optimal results, sequential compression devices (SCDs) or intermittent pneumatic compression (IPC) are used as soon as possible and maintained until the client becomes fully ambulatory. Stockings are not removed every hour but should be removed periodically to assess the condition of the client's skin.*

The nurse chooses to use a mechanical lift to move an obese immobile client. The nurse recognizes that the positive outcomes for both the client and the staff resulting from this intervention will be: (Select all that apply.) 1. Less of the client's body will be dragged along the sheets during the transfer 2. There will be less chance of injuring the skin on the client's elbows and buttocks 3. The staff involved in the transfer will have less likelihood of self-injury 4. The staff will have a greater degree of control over the move 5. The client will feel physically safer during the transfer 6. The move will be accomplished more quickly

Less of the client's body will be dragged along the sheets during the transfer There will be less chance of injuring the skin on the client's elbows and buttocks The staff involved in the transfer will have less likelihood of self-injury The staff will have a greater degree of control over the move

A client who experienced a myocardial infarction has been placed on bed rest. The nurse caring for the client recognizes that the inactivity will result in certain assessment findings that include: (Select all that apply.) 1. Lethargy 2. Confusion 3. Depression 4. Poor appetite 5. Hypoactive bowel sounds 6. Decrease in baseline respiratory rate

Lethargy Poor appetite Hypoactive bowel sounds Decrease in baseline respiratory rate

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.

Maintaining a wide base of support. Keeping the body's center of gravity low Maintaining correct body posture.

An infant born via cesarean section because of a breech presentation is diagnosed with bilateral congenital hip dysplasia. The primary nursing intervention directed toward this diagnosis is: 1. Assessing the infant frequently to determine abduction of the thighs 2. Maintaining the infant in the position of continuous abduction of both hips 3. Educating the parents about the importance of positioning the infant so that the head of the femurs are in alignment with the hip sockets 4. Providing pain management so that the infant is comfortable in the therapeutic position required

Maintaining the infant in the position of continuous abduction of both hips *Maintenance of continuous abduction of the thigh so that the head of the femur presses into the center of the acetabulum is critical in the care and treatment of this infant. Although the other options are appropriate, they are not primary interventions in this scenario.*

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.

Not a normal expectation.

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.

Obtain assistance from at least two or three other people.

A 78-year-old inactive client diagnosed with acute renal failure is at risk for which of the following skeletal maladies? 1. Rickets 2. Osteomyelitis 3. Pathological fractures of long bones 4. Compression fractures of the spinal column

Pathological fractures of long bones *Immobility causes the release of calcium into the circulation, where normally the kidneys excrete the excess calcium. If the kidneys are unable to respond appropriately, hypercalcemia results. Pathological fractures occur if calcium reabsorption continues as the client remains on bed rest or continues to be immobile. Bed rest is not a direct causative factor for the other options.*

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.

Place the patient in a lateral position. *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.*

A client is admitted to the medical unit following a cerebrovascular accident (CVA). There is evidence of left-sided hemiparesis and the nurse will be following up on range of motion and other exercises performed in physical therapy. The nurse correctly teaches the client and family members which one of the following principles of range-of-motion exercises? a. Flex the joint to the point of discomfort b. Work from proximal to distal joints c. Move the joints quickly d. Provide support for distal joints

Provide support for distal joints

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.

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

The nurse and a nursing assistive personnel (NAP) are going to move an older adult client up in bed. Before moving the client, the nurse explains to the NAP that they will need to lift the client off the bed with an assistive device instead of using the drawsheet. The most important reason for using the assistive device is: 1. To avoid frightening the client 2. To avoid shearing the client's skin 3. To avoid getting "written up" for not following lift procedures 4. Because the nurse is tired

To avoid shearing the client's skin

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.

both feet are supported on the floor with ankles flexed. *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.*

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

leverage

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.

longer straps hook to the bottom of the sling *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.

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

low-molecular-weight heparin doses to prevent dvt *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.

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.

neurotransmitter

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.

not completely immobile. *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.

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.

trochanter roll *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. Hand-wrist splints are individually molded for the patient to maintain proper alignment of the thumb and the wrist. 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.*