NCHP Chapter 38 & 39- Activity and Exercise/ Immobility

What are 2 expected outcomes for a patient with activity intolerance?

1. Patient will be able to ambulate 25 feet in the hall without reports of fatigue or shortness of breath. 2. Patient's pulse oximetry will be at least 90% or above while ambulating within 24 hours.

What is one example of an isometric exercise?

Kegel exercises

Which patient would likely be prone to reduced bone density? A. One with muscular dystrophy B. One with burns C. One who has been physically abused D. One who cannot perform weight-bearing exercises

D (rationale: The patient who cannot perform weight-bearing exercises is prone to reduced bone density by allowing calcium to leak out of the bones.)

dorsal recumbent position

lying supine with knees bent (common position for gynecology exams)

Isotonic exercise examples

walking or ambulating, changing positions in bed, self-grooming

High-Fowler's

Sitting at a 90-degree angle (similar to Fowler's but with head of bed elevated higher)

What are 2 expected outcomes for a patient with paralysis?

1. Patient will maneuver wheelchair within physical limits by the end of rehabilitation. 2. Patient will not lose muscle mass during rehabilitation.

What are 2 expected outcomes for a patient with weakness?

1. Patient will perform one task without assistance by the end of the shift. 2. Patient will exercise muscles at least once a shift.

Which graphic record cue indicates the patient has anorexia? A. Passage of hard, small stools B. Eats less than 50% of meals C. Weight gain D. Presence of a fever

B (rationale: Anorexia is a lack of appetite; thus a graphic record indicating the patient eats less than 50% of meals is a cue for anorexia.)

Which condition would likely result in right-sided hemiplegia? A. Right-sided brain injury B. Left-sided brain injury C. Lower spinal cord trauma D. Upper spinal cord trauma

B (rationale: Left-sided brain injury results in right-sided hemiparesis or hemiplegia because the motor fibers in the brain affect the opposite side of the body.)

Which person is most prone to osteoporosis? A. Adult large-frame male B. Older Asian female C. Middle-age Caucasian female D. Adult black female

B (rationale: Osteoporosis is more prevalent in the older population and in Asian women.)

A patient with redness, warmth, and swelling in the right lower leg is at risk for which complication? A. Joint damage B. Pulmonary embolism C. Orthostatic hypotension D. Pathologic bone fractures

B (rationale: Redness, warmth, and swelling in an extremity is indicative of a deep vein thrombosis, which places the patient at risk for developing a pulmonary embolism.)

In which position would the nurse place the patient to perform coughing and deep breathing? A. Dorsal recumbent B. Fowler's C. Side-lying D. Sim's

B (rationale: The patient must be upright (Fowler's position) to perform coughing and deep breathing to allow full expansion of the lungs.)

In which area would the nurse place a pillow for a patient in the supine position? A. Between the legs B. Under the calves C. Between the arms D. Under the scapula

B (rationale: When a patient is in the supine position a pillow is placed under the calves to alleviate pressure off the heels, preventing pressure injuries.)

Place the steps in the order the nurse would follow to teach a patient how to use a cane. Move the stronger leg Move the cane Move the weaker leg Place cane on the patient's stronger side

1. Place cane on the patient's stronger side 2. Move the cane 3. Move the weaker leg 4. Move the stronger leg (rationale: The cane is placed on patient's stronger side; the patient moves the cane first, then the weaker leg, followed by the stronger leg.)

The nurse would inform unlicensed assistive personnel to turn the patient how often (in hours) to maintain skin integrity? _____ hours

2 (rationale: The patient is turned every 2 hours to maintain skin integrity.)

Match the function to its nervous system component of mobility. Dependent on proprioception A. Posture and gait B. Balance C. Voluntary movement D. Coordination

A

Which area is impaired if a tendon is damaged? A. Bone to muscle attachment B. Bone to cartilage attachment C. Joint cushion D. Joint fluid

A

Which cue is relevant to alterations in the musculoskeletal system? A. Has a shoulder joint that is edematous B. Has a low sodium level C. Has a history of hemorrhoids D. Has five grandchildren

A

Which patient finding would alert the nurse to stop passive range-of-motion exercises? A. Resistance to movement is felt. B. The patient is unable to participate. C. The patient's joints move freely. D. Atrophy occurs.

A

Which solution would the nurse select for a patient who is experiencing anorexia? A. Dietary measures for favorite foods B. Fall risk protocol C. Occupational therapist consult D. Mobility aids for ambulation

A

Which fall risk score would the nurse anticipate in a patient who is weak? A. Hendrich II Fall Risk Model score of 8 B. Morse Fall Scale score of 10 C. Braden Scale score of 22 D. Johns Hopkins Fall Risk Assessment Tool score of 5

A (Rationale: A patient with weakness is at risk for falls. A score of 8, which is in the 5 or above range, indicates the patient is at high risk for falls.)

Which patient finding is expected in a musculoskeletal assessment? A. Morse Fall Scale score of 20 B. Asymmetry of joints C. Slumped posture D. Hendrich II Fall Risk Model score of 7

A (Rationale: Morse Fall Scale score of 20 is within the normal and expected range of 0 to 24, indicating the patient is not a fall risk.)

Which device would be most appropriate for a patient who has had surgery on a fractured femur and needs help repositioning in bed? A. Trapeze bar B. Mechanical lift C. Transfer board D. Friction-reducing sheet

A (rationale: A trapeze bar would allow the patient to assist with repositioning, as the patient can grasp the bar to pull his or her own weight when repositioning.)

Which finding would be unexpected when the nurse is assessing for mobility issues? A. Joint crepitus B. Morse Fall Scale score of 18 C. Braden Scale score of 22 D. Straight posture

A (rationale: Joint crepitus (air trapped under the skin that makes a crackling sound when palpated) is an unexpected finding. A Braden Scale score of 22 is an expected finding; a normal score is 19 or above. A Morse Fall Scale score of 18 is an expected finding; a normal score is 0 to 24.)

Which finding is unexpected when assessing effects of immobility? A. Skin nonblanches B. Braden Scale score of 21 C. 2500 mL intake and 2450 mL output D. Fecal impaction not present

A (rationale: Skin nonblanching is unexpected because it indicates ischemia.)

Which interpretation would the nurse make when observing a darkened or reddened area of skin in an immobile patient? A. Tissue ischemia has occurred. B. Blanching has developed. C. Cyanosis has occurred. D. Deep vein thrombosis has developed.

A (rationale: Skin that appears darkened or reddened is indicative of tissue ischemia. Deep vein thrombosis presents as an area of warmth, redness, swelling, or pain in a lower extremity, not a darkened or reddened area of skin.)

Which action would the nurse take first when assisting a patient who has been in bed for several days after surgery to transfer from the bed to the chair? A. Allow the patient to dangle. B. Stand the patient up with assistance. C. Transfer the patient with a slide board. D. Place the transfer belt after the patient stands.

A (rationale: The first action the nurse would take to assist the patient to transfer is to allow the patient to dangle; sit on the sedge of the bed with their feet hanging off)

Which action would the nurse take for a patient on bed rest who is concerned about developing constipation? A. Increase the patient's dietary fiber and fluid intake. B. Complete the Braden Scale assessment tool. C. Increase the frequency of passive range-of-motion exercises. D. Administer enoxaparin prophylactically.

A (rationale: The patient's dietary fiber and fluid intake would be increased to prevent constipation in the immobile patient.)

Later in the day, John goes back to check on Mr. Parker. He asks John to help him get up and go to the bathroom using his walker. As they are walking to the bathroom, John notices that Mr. Parker is using the walker by putting the two back legs on the floor and then rocking to the front two legs. What should John tell Mr. Parker about his walker usage? A. John should tell Mr. Parker to pick the walker up and set the four legs down together. B. John should tell Mr. Parker that he is doing a good job adjusting to the walker. C. John should tell Mr. Parker to put the right side down first followed by the left side.

A (rationale: The walker provides the patient with a wide base of support by having four points of support each time the walker is advanced.)

Which cues would alert the nurse to develop a hypothesis of Risk for Impaired Skin Integrity for a patient? SELECT ALL THAT APPLY. A. Braden Scale score of 16 B. Inability to move or turn C. Braden Scale score of 20 D. Pulse oximetry of 95% E. Dyspnea on exertion

A, B

Which musculoskeletal diseases are more prevalent in the older adult population? Select all that apply. A. Osteoporosis B. Osteoarthritis C. Cerebral palsy D. Spina bifida E. Muscular dystrophy

A, B

Which cues are relevant for activity intolerance? SELECT ALL THAT APPLY. A. Struggles to complete activities of daily living B. Exhibits dyspnea on exertion C. Has to sit down while doing the dishes D. Has an inability to move E. Has no feeling in the lower extremities

A, B, C

Which evaluative cues indicate the patient with a Risk for Deep Vein Thrombosis is deteriorating? Select all that apply. A. Experiences a pulmonary embolus B. Has dusky toes C. Has coagulation laboratory results that indicate the patient is clotting too fast D. States the sequential compression device pressure is maintained at 40 mm Hg E. Experiences intact skin with no abnormalities in the lower leg

A, B, C

When providing care to patients, which safety and body mechanic aspects would the nurse consider to prevent injury to him- or herself and the patient? Select all that apply. A. Leave top side rails up. B. Bend at the knees. C. Carry weight close to the body. D. Use mechanical lift equipment. E. Relax pelvic muscles.

A, B, C, D (rationale for A: Leaving the top side rails up allows patients to self-position and is a safety action the nurse would implement.) (rationale for B: Bending at the knees maintains the center of gravity and lets leg muscles do the lifting; it is a body mechanics action the nurse would implement.) (rationale for C: Carrying weight close to the body places the weight in the same plane as the lifter and near the center of gravity for balance; it is a body mechanics action the nurse would implement.) (rationale for D: Using mechanical lifts is a safe action to implement when moving patients.)

Which actions would the nurse take if the patient falls while ambulating in the hall? Select all that apply. A. Call for help. B. Assess the patient's physical and neurologic status. C. Notify charge nurse and primary health care provider. D. Leave the patient to go get help. E. Complete occurrence report.

A, B, C, E

Which musculoskeletal alterations does immobility predispose a patient to developing? Select all that apply. A. Weakness B. Decreased muscle tone C. Decreased muscle mass D. Increased bone mass E. Reduced bone density

A, B, C, E

Which instructions about respiratory and range-of-motion measures would the nurse share with a patient who has limited mobility? Select all that apply. A. Use the incentive spirometer 5 to 12 times every 1 to 2 hours. B. Deep breathe 10 times every hour. C. Cough two to three times every 2 hours. D. Perform range-of-motion exercises at least five to six times each day. E. Move each joint three to five times during range-of-motion exercises.

A, B, C, E (rationale for why it is not D: ROM exercises are performed at least two to four times each day, not five to six times each day.)

Patients on bed rest are likely at risk for which physiologic effects and conditions? Select all that apply. A. Increased venous return B. Decreased lung expansion C. Decreased cardiac workload D. Atelectasis E. Pneumonia

A, B, D, E (rationale for why it is not C: Patients on bed rest are at risk for increased, not decreased, cardiac workload as a result of increased blood flow to the heart.)

Which cues would likely occur with atelectasis? Select all that apply. A. Cyanosis B. Dyspnea C. Chills D. Graphic record indicates a fever E. Diminished breath sounds noted in nurse's notes

A, B, E

Which cues alert the nurse that the patient with Paralysis is declining? Select all that apply. A. Develops disuse osteoporosis B. Has not lost muscle mass C. Does not participate in physical therapy D. Controls wheelchair according to capabilities E. Avoids muscle atrophy

A, C

Which hypotheses would the nurse develop for a patient post surgery for hip replacement who is receiving opioid pain medication while the patient's spouse is in the room? SELECT ALL THAT APPLY. A. Impaired Mobility B. Social Isolation C. Risk for Deep Vein Thrombosis D. Risk for Constipation E. Activity Intolerance

A, C, D

Which cues are relevant for weakness? SELECT ALL THAT APPLY. A. Flaccidity B. Hypertonicity C. Shuffling gait D. Feeble handgrip E. Score of 5 on Johns Hopkins Fall Risk Assessment Tool

A, C, D (flaccidity: decrease or lack of muscle movement where the affected body part becomes floppy or without muscle tone and with diminished reflexes)

Which interventions would the nurse select for a patient who is on bed rest? Select all that apply. A. Have the patient shift weight every 15 minutes while awake. B. Have the unlicensed assistive personnel teach about the importance of mobility. C. Reduce hallway light at night. D. Apply a pressure-relief ankle-foot orthotic (PRAFO) boot. E. Turn patient every 4 hours.

A, C, D (rational: Teaching patients with some mobility to shift their position every 15 minutes while awake is recommended. The hallway light should be reduced at night for patients on bed rest to assist with restful sleep and maintain a normal sleep-wake cycle. A PRAFO boot keeps heels protected by relieving pressure off heels.)

Which disorders decrease the body's ability to deliver oxygen and nutrients to the muscles and bones? Select all that apply. A. Heart failure B. Renal failure C. Spina bifida D. Peripheral vascular disease E. Chronic obstructive pulmonary disease

A, D, E

Which conditions would likely cause paralysis on one side of the body? Select all that apply. A. Right-sided stroke B. Paresis C. Cervical spinal cord injury D. Traumatic brain injury E. Left-sided cerebrovascular accident

A, D, E (rationale for A: A right-sided stroke would likely cause paralysis on one side of the body (the left side).) (rationale for B: Paresis is weakness, not paralysis on one side of the body.) (rationale for C: A cervical spinal cord injury would likely cause paralysis on the upper and lower extremities but not on one side of the body.) (rationale for D: A traumatic brain injury would likely cause paralysis on one side of the body, either the right or the left depending on the location of the injury.) (rationale for E: A left-sided cerebrovascular accident would likely cause paralysis on one side of the body (the right side).)

Which safety measures would the nurse implement for a patient who is a fall risk? Select all that apply. A. Use a low bed. B. Place in a room away from the nurses' station for quietness. C. Raise all four side rails. D. Frequently orient the patient. E. Place floor mats beside the bed.

A, D, E (rationale for A: The nurse would use a low bed to decrease the distance if a patient falls.) (rationale for D: The nurse would frequently orient the patient who is at risk for falls to promote safety by familiarizing the patient to the environment, date, and time.) (rationale for E: The nurse would place floor mats beside the bed to cushion a possible fall.)

Which effects can occur with cerebellar damage related to traumatic brain injury? Select all that apply. A. Poor balance B. Abnormal formation of the spinal cord B. Ability to move joints D. Lack of sensors in the inner ear E. Uncoordinated movement

A, E

Match the function to its nervous system component of mobility. Dependent on cerebellum and inner ear A. Posture and gait B. Balance C. Voluntary movement D. Coordination

B

Which hypothesis would the nurse select for a patient who experiences increased heart rate and increased oxygen requirements when eating? A. Fall B. Activity Intolerance C. Risk for Deep Vein Thrombosis D. Risk for Impaired Skin Integrity

B

Which instruction would the nurse share with the patient about coughing techniques? A. Fully inhale between coughs. B. Take two deep breaths in and out to start. C. Inhale through the nose as deeply as possible. D. Exhale slowly through the spirometer's mouthpiece.

B

Which mineral is stored in bones? A. Sodium B. Calcium C. Chloride D. Potassium

B

Which patient is prone to paralysis? A. A patient on bed rest B. A patient with prolonged brain ischemia C. A patient with a fracture D. A patient on a low-calcium diet

B

Which patient situation is a medical emergency? A. Deep vein thrombosis B. Pulmonary embolus C. Stage 3 pressure injury D. Urinary tract infection

B

Which question would the nurse ask a patient to determine symptom-related issues with the musculoskeletal system? A. "Do any of your family members have osteoporosis?" B. "Have you noticed any differences in your gait?" C. "Do you have an active lifestyle or sedentary lifestyle?" D. "Have you ever found yourself on the floor and don't know how you got there?"

B

Which ambulation aid would the nurse suggest for a patient who has a history of falls, is displaying generalized weakness, and requires some assistance with ambulation? A. Cane B. Walker C. Crutches D. Trochanter roll

B (rationale: A walker would provide the patient with support to prevent falls and provides a wide base of support.)

Which action would the nurse take for a newly admitted patient who is unsteady when transferring from the wheelchair to the bed? A. Place the patient on complete bed rest. B. Initiate a fall prevention plan for the patient. C. Start passive range-of-motion exercises twice a day. D. Make sure the patient only ambulates with a walker.

B (rationale: An unsteady gait places the patient at risk for falling, and the nurse would initiate fall prevention measures to ensure the patient's safety.)

Which cues are relevant for a deep vein thrombosis (DVT)? SELECT ALL THAT APPLY. A. Tunneling B. Redness C. Edema D. Cramping E. Chest pain

B, C, D

Which actions would the nurse take for a patient who is immobile? Select all that apply. A. Encourage at least 1500 mL of fluid daily. B. Suggest drinking at least 2000 mL during a 24-hour period. C. Encourage passive range-of-motion exercises. D. Place high-top tennis shoes on feet. E. Reposition at least once every 8 hours.

B, C, D (rationale for B: The nurse would encourage the patient to drink at least 2000 mL in a 24-hour period.) (rationale for C: Range-of-motion exercises must be done to prevent complications from being stationary for a long period of time.) (rationale for D: High-top tennis shoes can be used to prevent foot drop.)

Which actions by the nurse caring for patients with mobility problems would require correction by the charge nurse? Select all that apply. A. Refuses to massage a patient's leg with deep vein thrombosis B. Places a gait belt on a patient with osteoporosis to assist with ambulation C. Allows the patient's elbows to be bent at a 45-degree angle when using a cane D. Tells the patient with a four-point crutch gait to move one crutch forward simultaneously with the opposite leg E. Has the patient cough two times after using an incentive spirometer

B, C, D (rationale for B: the nurse does not use a gait belt on a patient with osteoporosis because it can cause vertebral compression fractures. (rationale for C: This action would cause the charge nurse to correct the nurse. The angle is 30 degrees, not 45 degrees.) (rationale for D: A four-point walking gait moves one crutch forward, followed by opposite leg, and then repeats with the opposite crutch and leg. The two-point walking gait moves one crutch forward simultaneously with the opposite leg.)

In which areas would the patient experience pain if a urinary tract infection is present? SELECT ALL THAT APPLY. A. Calf B. Back C. Bladder D. Upper chest E. Lower abdomen

B, C, E

Which cues prompt the nurse to determine the patient with impaired mobility who needs a one-person assist is improving? Select all that apply. A. Needs a one-person assist to ambulate B. Needs no assistance to transfer C. Ambulates unassisted down the corridor and back D. Needs a two-person assist to walk to the bathroom E. Ambulates with no slips on the floor

B, C, E

Which interventions would the nurse implement for a patient with lower extremity Paralysis? Select all that apply. A. Apply oxygen. B. Turn every 2 hours. C. Arrange for a special bed. D. Use a gait belt for transfers and ambulation. E. Perform range-of-motion (ROM) exercises at least two times per day.

B, C, E

Which changes in vital signs are indicative of postural hypotension when a patient stands up? Select all that apply. A. Heart rate increases from 60 to 70 beats/min B. Systolic blood pressure drops from 120 to 100 mm Hg C. Heart rate increases from 65 to 85 beats/min D. Systolic blood pressure drops from 110 to 100 mm Hg E. Diastolic blood pressure drops from 70 to 60 mm Hg

B, C, E (Rationale: Postural hypertension = A drop in systolic blood pressure of 20 mm Hg when patient stands, A drop of diastolic blood pressure of 10 mm Hg when a patient stands, & An increase in heart rate of 20 beats/min when a patient stands)

Which parameters would the nurse assess to determine if a urinary tract infection (UTI) has developed? Select all that apply. A. Peripheral pulses B. Chills C. Urinary frequency D. Serum albumin levels E. Presence of dysuria

B, C, E (rationale for why it is not D: Serum albumin levels relate to anorexia and nutritional issues, not a UTI.)

Which functions are the primary responsibilities of the cardiopulmonary system in relation to movement? Select all that apply. A. Control posture and gait B. Circulate blood throughout the body C. Provide framework for movement D. Supply tissues with oxygen and nutrients E. Provide essential fluids for the body

B, D, E

Which types of impairments are expected with a cerebrovascular accident that occurred on the right side of the brain? Select all that apply. A. Right-sided paralysis B. Left-sided hemiparesis C. Lower body paralysis D. Inability to move all four extremities E. Left-sided hemiplegia

B, E (rationale: Right-sided brain affects left-sided functioning; motor fibers in the brain affect the opposite side of the body)

An infection of which structure would likely be the source for balance problems? A. Eye B. Cornea C. Inner ear D. Tonsils

C

Match the function to its nervous system component of mobility. Regulated by the cerebral cortex A. Posture and gait B. Balance C. Voluntary movement D. Coordination

C

Patient reports of shortness of breath and fatigue while performing activities of daily living are indicative of which alteration? A. Orthostatic hypotension B. Deep vein thrombosis C. Activity intolerance D. Cerebellar problems

C

Which action by the nurse initiates the physical assessment of a patient's mobility? A.Inquiring about the patient's health history B. Asking the patient questions C. Observing the patient D. Palpating the patient's joints

C

Which action would the nurse take for an immobile patient who needs help maintaining a normal sleep-wake cycle? A. Encourage contact with family and friends. B. Provide a clock in the patient's room. C. Open the window blinds during the day. D. Allow access to the radio.

C

Which cue would the nurse rank as priority for a patient who suffered multiple fractures after a motor vehicle accident? A. Pain B. Elevated heart rate C. Respiratory distress D. Decreased mobility

C

Which finding is a psychological consequence of bed rest and manifests in the patient becoming lonely or depressed? A. Faulty equilibrium B. Sensory deprivation C. Feelings of isolation D. Alteration in self-concept

C

Which nutritional alteration is associated with immobility? A. Enhanced appetite B. Positive nitrogen balance C. Decreased basal metabolic rate D. Increased serum albumin levels

C

Which response would the nurse make to an immobile patient who says, "I am just not hungry. I don't understand it. I am always hungry"? A. "Don't worry about it, every patient gets that way in the hospital." B. "Your loss of appetite is unusual; I will let your health care provider know." C. "You have been immobile for several days, which can decrease your metabolism and appetite." D. "Your lack of appetite is your body's way of telling you that bed rest interferes with your body's ability to digest food and not to eat too much."

C

Which term is used to describe a slightly movable joint? A. Patellar B. Fibrous C. Cartilaginous D. Synovial

C (rationale: A cartilaginous joint is slightly movable. A fibrous joint is immobile, not slightly movable. A synovial joint is freely movable, not slightly movable.)

Which exercise benefit would the nurse likely emphasize to a patient who has limited mobility to help facilitate normal movement? A. Improves mood B. Minimizes joint flexibility C. Promotes muscle strength D. Stimulates bone reabsorption

C (rationale: Exercise promotes muscle strength and helps prevent the negative impacts of immobility. This is the most important aspect to emphasize in the discussion.)

On the day after Mrs. Simmons' surgery, Dana notices that Mrs. Simmons has scooted down in the bed and appears uncomfortable. How many staff members should she get to help her reposition Mrs. Simmons if she is obese? A. None B. One more staff member C. Three to four staff members

C (rationale: Mrs. Simmons is obese, so Dana should get enough help so that no one is likely to get injured when pulling Mrs. Simmons up in bed.)

Which characteristic is typical of paresis? A. Lower body paralysis B. Complete loss of movement C. Impaired mobility and movement D. Weakness on one side of the body

C (rationale: Paresis is impaired mobility and movement. Weakness on one side of the body is characteristic of hemiparesis, not paresis.)

Which action would the nurse take to improve an immobile patient's nutritional intake? A. Monitor the patient's serum albumin. B. Assess the patient's nutritional intake. C. Allow the patient to make food choices. D. Weigh the patient at routine intervals.

C (rationale: Allowing the patient to make food choices will enable the patient to select foods that are likely to be consumed, improving nutritional intake.)

Which outcomes would the nurse develop for a patient experiencing weakness, cerebellum injury, and orthostatic hypotension? SELECT ALL THAT APPLY. A. Patient will not lose muscle mass during hospital stay. B. Patient will ambulate with no assistance. C. Patient will not fall during hospitalization. D. Patient will not injure self during hospital stay. E. Patient will not experience a pulmonary embolus during hospitalization.

C, D

Which effects are typical of decreased physical activity? Select all that apply. A. Spasticity B. Hypertonicity C. Deterioration D. Bone fragility E. Loss of strength

C, D, E

Which solutions would the nurse choose for a patient experiencing dyspnea on exertion, oxygen saturation level of 86%, and pulse of 112 beats/min when grooming? SELECT ALL THAT APPLY. A. Sequential compression devices B. Turning C. Physical therapist consult D. Special equipment for hygiene needs E. Exercises for strengthening

C, D, E

Which evaluative findings will alert the nurse an immobile patient with a left hip stage 1 pressure injury is declining? Select all that apply. A. Has a reddened area on hip that will not blanch B. Has dry, warm, intact skin C. Has a Braden Scale score that indicates a high risk for skin breakdown D. Develops a Stage 1 pressure injury on the buttocks E. Develops a Stage 2 pressure injury on the left hip

C, D, E (rationale for why it is not A: This finding indicates the patient is unchanged, not declining. A stage 1 pressure injury is redness on a bony prominence that will not blanch.)

Match the function to its nervous system component of mobility. Regulated by the cerebellum A. Posture and gait B. Balance C. Voluntary movement D. Coordination

D

Tissue ischemia related to immobility can directly lead to the development of which complication? A. Atelectasis B. Contractures C. Pulmonary embolus D. Pressure injuries

D

Which complication from immobility causes the alveoli to collapse? A. Pressure injury B. Deep vein thrombosis C. Anorexia D. Atelectasis

D

Which graphic record cue is associated with constipation? A. Fever B. Soft stools C. 90% of meals eaten D. Infrequent stools

D

Which hypothesis would the nurse select for a patient who develops redness, warmth, and slight swelling in the right lower leg from bed rest? A. Paralysis B. Weakness C. Activity Intolerance D. Risk for Deep Vein Thrombosis

D

Which hypothesis would the nurse select for a patient who refuses to turn on their side and lies supine most of the time? A. Impaired Mobility B. Weakness C. Risk for Fall D. Risk for Impaired Skin Integrity

D

Which solution would the nurse select for an immobile patient who appears withdrawn and reports not having any visitors in the past week? A. Removal of cell phone B. Laxative administration C. Rest periods D. Spiritual consult

D

Which anatomic structure serves the purpose of connecting bones to cartilage? A. Muscles B. Tendons C. Joints D. Ligaments

D (Rationale: Ligaments connect bones to cartilage. Tendons connect muscles to bones, not bones to cartilage.)

Which movement is the nurse assessing in this image? A. Rotation B. Extension C. Hyperextension D. Lateral flexion

D (Rationale: The nurse is assessing lateral flexion, bending the head and neck to each side.)

Which characteristic is typical of lower extremity flaccidity? A. Bone fragility B. Muscle spasms C. Joint inflammation D. Lack of muscle tone

D (rationale for why it is not ABC: Bone fragility is typical of osteoporosis, Muscle spasms are characteristic of spasticity, Joint inflammation is typical of rheumatoid arthritis and osteoarthritis)

Which evaluative cue alerts the nurse that a patient with Activity Intolerance is improving? A. Ambulates 15 feet with shortness of breath B. Has a heart rate of 110 beats/min when ambulating C. Brushes hair while sitting in chair with assistance D. Has a pulse oximetry reading of 94% when standing to brush teeth

D (rationale: A pulse oximetry reading above 90% when brushing teeth indicates the patient with Activity Intolerance is improving because the patient is performing activities of daily living without adverse effects.)

Which action would the nurse take when caring for a patient with sequential compression devices (SCDs)? A. Ensure the fit of the sleeves is tight. B. Roll the sleeves inside out to apply them. C. Activate the heating feature once a shift. D. Monitor the patient's toes for impaired circulation.

D (rationale: Because SCDs can impair circulation if too tight, it is important for the nurse to check the patient's circulation to the toes.) (rationale for A: SCDs should fit snugly, not tightly, and allow two fingers between the leg and the sleeve when not inflated.) (rationale for B: Antiembolism stocking are rolled inside out to apply them; SCDs are wrapped around the patient's leg and secured with Velcro.) (rationale for C: SCDs have a cooling feature but not a heating feature.)

Which nervous system factor is likely associated with difficulty breathing? A. Right-sided brain injury B. Left-sided brain injury C. Lower spinal cord trauma D. Cervical spinal cord trauma

D (rationale: Breathing difficulties are associated with cervical (neck) spinal cord trauma.)

Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills? A. Place the patient flat in bed. B. Encourage the patient to take deep breaths. C. Assess the patient for signs of deep vein thrombosis. D. Notify the health care provider that the patient may have pneumonia.

D (rationale: The nurse would notify the health care provider that the patient may have pneumonia as a consequence of prolonged immobility, decreased lung expansion, and pooling of secretions in the lungs.)

Which action would the nurse take when using a mechanical lift for a patient who is experiencing limited mobility? A. Ensures that no more than 35 lb (15.9 kg) is placed in the lift B. Has the patient grab the bars for stability C. Transfers the patient toward the weaker side D. Obtains two unlicensed assistive personnel to help

D (rationale: The total personnel are three: the nurse and two other personnel (in this case, two unlicensed assistive personnel). To use a mechanical lift, two personnel are needed but three are better.)

To which other member of a multidisciplinary team would the nurse delegate the task of moving an immobile patient to maintain skin integrity? A. Dietitian B. Primary health care provider C. Occupational therapist D. Unlicensed assistive personnel

D (rationale: Unlicensed assistive personnel provide hands-on care for patients as directed by the nurse. Nurses delegate turning to unlicensed assistive personnel.)

Which SMART (specific, measurable, assignable, relevant, time-based) outcomes would the nurse develop for a patient who is light-headed and fatigued and has feeble handgrip with reduced bone density? SELECT ALL THAT APPLY. A. Patient's pulse oximetry will be above 90% during an activity. B. Patient will have intact skin throughout hospital stay. C. Patient will exercise arm and leg muscles. D. Patient will brush teeth after breakfast with one person assisting. E. Patient will exercise joints at least twice per shift.

D, E

Sequential Compression Devices (SCDs)

Device that sequentially compress veins in the legs to promote venous return

Isotonic exercise

Requires muscle contractions for active movement

Isometric exercise

Requires muscles to tense and relax but involves no joint movement (ex: Kegel exercises)

Anaerobic exercise

Requires no oxygen to produce energy to build strength and body mass (ex: heavy weight lifting)

Aerobic exercise

Requires oxygen to produce energy (ex: rigorous walking, repetitive stair climbing, running)

Semi-Fowler's

Semi-sitting with head of bed slightly lower than in Fowler's

Dana reviews Mrs. Simmons' orders and sees that she is to have elastic stockings and a sequential compression device (SCD) on her lower extremities. Mrs. Simmons asks Dana why she must put those on. How should Dana reply?

These devices will help prevent blood clots from forming in your legs until you are more mobile.

John begins walking Mr. Parker to the bathroom. Mr. Parker tells John that he feels like he is going to faint. What should John do?

Use a wide base of support, hold onto the gait belt, extend one leg and let the patient slide against it, and bend your knees as you lower the patient to the floor.

antiembolism stockings (TED hose)

elastic stockings that compress superficial leg veins and promote venous return

supine position

lying on the back

Active ROM exercises are performed by

person

Sim's position

semi-prone position on left side with right knee pulled up towards chest

Fowler's position

sitting position

Passive ROM exercises are performed by

someone else

Which pressure injury stage is characterized as "intact skin with reddened area"

stage 1

Which pressure injury stage is characterized as "blistering of epidermis or dermis"

stage 2

Which pressure injury stage is characterized as "Subcutaneous injury with possible tunneling"

stage 3

Which pressure injury stage is characterized as "Exposure of muscle and bone"

stage 4