300 Sherpath - Activity and Movement: Assess and Recognize Cues

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). Weakness b). Decreased muscle tone c). Decreased muscle mass e). Reduced bone density

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). "Have you noticed any differences in your gait?"

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). A patient with prolonged brain ischemia

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). Back c). Bladder e). Lower abdomen

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). Chills c). Urinary frequency e). Presence of dysuria

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). Eats less than 50% of meals

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). Pulmonary embolism

Which patient situation is a medical emergency? a). Deep vein thrombosis b). Pulmonary embolus c). Stage 3 pressure injury d). Urinary tract infection

b). Pulmonary embolus

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). Redness c). Edema d). Cramping

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). Pressure injuries

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). Skin nonblanches (Skin nonblanching is unexpected because it indicates ischemia)

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). Struggles to complete activities of daily living b). Exhibits dyspnea on exertion c). Has to sit down while doing the dishes

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). Tissue ischemia has occurred.

Match the alteration to its patient cues. a). Unable to move joints because of foot drop b). Decreased muscle size with weak handgrip c). Inability to move, with a loss of sensation d). Irregular patterns of behavior from inadequate coping OPTIONS: 1). Contracture 2). Fracture 3). Altered self-concept 4). Paralysis 5). Isolation 6). Muscle atrophy

a). Unable to move joints because of foot drop = 1). Contracture b). Decreased muscle size with weak handgrip = 6). Muscle atrophy c). Inability to move, with a loss of sensation = 4). Paralysis d). Irregular patterns of behavior from inadequate coping = 3). Altered self-concept

Match the pressure injury stage to its cues. a). Blistering of epidermis or dermis b). Intact skin with reddened area c). Exposure of muscle and bone d). Subcutaneous injury with possible tunneling OPTIONS: 1). Stage 1 2). Stage 2 3). Stage 3 4). Stage 4

a). Blistering of epidermis or dermis = 2). Stage 2 b). Intact skin with reddened area = 1). Stage 1 c). Exposure of muscle and bone = 4). Stage 4 d). Subcutaneous injury with possible tunneling = 3). Stage 3

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). Cyanosis b). Dyspnea e). Diminished breath sounds noted in nurse's notes

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). Flaccidity c). Shuffling gait d). Feeble handgrip

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). Has a shoulder joint that is edematous

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). Hendrich II Fall Risk Model score of 8 (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)

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). Increased venous return b). Decreased lung expansion d). Atelectasis e). Pneumonia

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). Joint crepitus

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). Morse Fall Scale score of 20 (A 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)

Match the musculoskeletal system alteration to its cause. a). Porous, brittle bone b). Deterioration of the muscle itself c). Tissue that is usually easy to move tightness and pulls inward OPTIONS: 1). Amputation 2). Pathologic fracture 3). Muscle atrophy 4). Contracture

a). Porous, brittle bone = 2). Pathologic fracture b). Deterioration of the muscle itself = 3). Muscle atrophy c). Tissue that is usually easy to move tightness and pulls inward = 4). Contracture

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). Resistance to movement is felt.

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). Systolic blood pressure drops from 120 to 100 mm Hg c). Heart rate increases from 65 to 85 beats/min e). Diastolic blood pressure drops from 70 to 60 mm Hg

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). "You have been immobile for several days, which can decrease your metabolism and appetite."

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). Activity intolerance

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). Decreased basal metabolic rate

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). Feelings of isolation

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). Observing the patient

Which complication from immobility causes the alveoli to collapse? a). Pressure injury b). Deep vein thrombosis c). Anorexia d). Atelectasis

d). Atelectasis (is a complete or partial collapse of the entire lung or area (lobe) of the lung)

Which graphic record cue is associated with constipation? a). Fever b). Soft stools c). 90% of meals eaten d). Infrequent stools

d). Infrequent stools

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). One who cannot perform weight-bearing exercises