Chapter 28 Questions (Activity, Immobility, and Safe Movement)

which one of the following is the best choice of protein for the immobile patient? a. Hot dog b. grilled chicken c. macaroni & cheese d. grilled cheese sandwich

b. grilled chicken

An immobilized patient is suspected as having atelectasis. This is assessed by the nurse, upon auscultation, as: a. harsh crackles b. wheezing on inspiration c. diminished breath sounds d. bronchovesicular whooshing

c. diminished breath sounds

In order to promote respiratory function in the immobilized patient, the nurse should: A. Encourage deep breathing and coughing every hour B. Use oxygen and nebulizer treatments regularly C. Change the patient`s position q 4 to 8 hours D. Suction the patient every hour

A. Encourage deep breathing and coughing every hour

7. When providing home-going instructions for a recently discharged patient, which statement by the patient's son would indicate an understanding of methods to prevent complications from immobility? a. "We'll make sure that Dad eats plenty of lean protein foods." b. "We will limit Dad's fluid intake to prevent bladder incontinence." c. "Dad should sit more and restrict the time he walks around the house." d. "His arm sling should be kept on at all times to prevent an elbow contracture."

ANS: A Adequate protein intake will prevent negative nitrogen balance in sedentary patients. Fluid intake is essential for the promotion of skin integrity, prevention of bladder infections, and regular defecation. Ambulation prevents many of the complications of immobility. Maintaining an extremity in one position for an extended period of time may actually cause a contracture

1. Bones function in what important roles within the body? (Select all that apply.) a. Regulate potassium levels b. Maintain calcium balance c. Protect critical organs d. Produce blood cells e. Control motor activity

ANS: B, C, D Bones assist in the maintenance of both calcium and phosphorus balance within the body. Bones protect vital organs, such as the lungs, that are surrounded by the rib cage. The role of bone marrow is critical to blood cell formation. Potassium levels are regulated by the kidneys. The nervous system controls motor activity.

2. What actions by the nurse are critical to ensure patient safety? (Select all that apply.) a. Place the call light on the patient's nightstand. b. Clean up fluid spills on the floor immediately. c. Instruct the patient to wear socks when ambulating. d. Keep linens and intravenous tubing off the floor. e. Return the bed to low position prior to exiting the room.

ANS: B, D, E Cleaning up spills, keeping items off the floor, and returning the bed to low position are all essential to prevent patient injury. The call light should be placed within reach of the patient on the bed or attached to the patient's gown. Non-skid slippers or shoes should be worn by the patient when ambulating.

3. What nursing intervention would be the first priority to prevent constipation in an immobile patient? a. Administration of a soap suds enema b. Decreased dietary fiber consumption c. Narcotic analgesic pain relief use d. Increased daily oral fluid intake

ANS: D Increased oral intake and ambulation are the highest priority interventions for the prevention of constipation. Promoting dietary fiber intake and administering ordered stool softeners would be the next most important strategies. The use of narcotic analgesia should be minimized in constipated patients since these types of medications actually decrease gastrointestinal (GI) motility. If none of the previous interventions result in the patient having a bowel movement, a soap suds enema may be ordered.

2. What information should the nurse include when teaching a patient about deep vein thrombosis (DVT) prevention? a. Avoid movement of the extremities to prevent potential deep vein thrombosis formation. b. Encourage use of sequential compression devices (SCDs) during ambulation. c. Utilize an ankle foot orthotic (AFO) or pressure relief orthotic (PRAFO) to stretch ligaments. d. Sit with legs uncrossed to promote circulation and venous blood flow to the heart.

ANS: D Instructing patients to sit without crossing their legs and to ambulate as much as possible are important aspects of patient education in DVT prevention. SCDs must be removed prior to ambulation to prevent patient injury. Orthotics may be helpful in preventing heel pressure and footdrop, but have little effect on DVT prevention.

4. Which patient care activity can be delegated by the registered nurse (RN) to unlicensed assistive personnel (UAP)? a. Completing an admission skin assessment b. Administering an ordered stool softener c. Teaching deep vein thrombosis prophylaxis d. Range of motion exercises

ANS: D Range of motion exercises is the only intervention on this list that legally can be delegated to unlicensed assistive personnel. Completing an initial patient assessment, administering medications, and patient teaching are all roles and responsibilities of the registered nurse.

A nurse is providing patient education on the prevention of osteoporosis. Which important fact should the nurse include in the teaching care plan? a. Calcium should be taken with vitamin D to increase calcium absorption b. African American women are more prone to developing osteoporosis than are Asian American women c. Increased phosophorus metabolism may lead to bone fragillity d. Aerobic exercise is more advantageous than weight-bearing exercise in preventing osteoporosis

Answer: a Vitamin D is required for calcium metabolism. Asian American women are more prone to osteoporosis than African American women. Phosphorus deficiency may lead to malformation of bones. Weight-bearing exercise is more beneficial than aerobic exercise in the prevention of osteoporosis.

Which nursing diagnosis label is most appropriate for a patient who is experiencing sensory deprivation due to a lack of interaction with others? a. Impaired Verbal Communication b. Sedentary Lifestyle c. Social Isolation d. Disturbed Personal Identity

Answer: c Social isolation is experienced by patients who are unable to be in contact with other people. Patients with impaired verbal communication have difficulty speaking. A sedentary lifestyle may constitute an appropriate nursing diagnosis for patients who have a low physical activity level. Patients who exhibit serious psychological issues concerning identity may suffer from disturbed personal identity.

A patient is getting up for the first time after a period of bed rest. The nurse should first: A. Assess respiratory function B. Obtain a baseline blood pressure C. Assist the patient to sit at the edge of the bed D. Ask the patient if he or she feels lightheaded

B. Obtain a baseline blood pressure

What is the purpose of dangling?

Dangling can prevent postural hypotension and syncope by allowing patients to sit with their legs in a dependent position for a few minutes before standing.

During ROM, how many times should the joints be put through their motions?

Each joint is moved 3 to 5 times

Provide three examples of special mattresses that may be used for immobile patients

Examples of special mattresses include surface redesign, foam, gatch, gel, low air-loss, and air-fluidized

What are two recommendation and goals for logrolling a patient with a halo brace?

For logrolling, three people are recommended and the use of a mechanical or assistive device should be determined. The goals are to prevent injury to the patient and nurse

Identify some general safety measures to implement for a patient using an asisstive device for ambulation.

General safety measures for use of assistive devices for ambulation include checking if they are sturdy and intact, correclty fitted for the patient, able to fit through doors, appropriate for the need of the patient. Patients should have nonskid and well-fitting shoes, and the route for ambulation should be free of clutter. There should be sufficient personnel for assitance to prevent patient injury.

While performing passive ROM, the patient starts to grimace, moan, and become tense. The nurse should:

In the presence of resistance or pain during ROM, the activity should be stopped.

How many times a day is ROM usually performed?

ROM is usually performed twice a day

What can the nurse do to prevent friction against the immobile patient's skin?

Reducing friction includes slighlty lifting rather than pulling patient's using a trapeze bar, transfer/slide board, or friction-reducing sheets. The patient may also benefit from the use of heel and elbow protectors.

The nurse observes that the patient is extremely uncomfortable during position changes. What can the nurse do to avoid discomfort for the patient?

The nurse can obtain an order for an analgesic and premedicate the patient before the activity

What criteria should be used to determine if the patient is strong enough to ambulate?

The patient needs to be able to raise the legs 1 inch off the bed in order to have strength for ambulation

Select which of the following are correct for the use of antiembolism hose. Select all that apply. a. knee-length hose should end 1 to 2 inches below the knww b. application is after the patient is out of bed for at least 15 minutes c. DVT is checked with the Homan sigh if there is calf redness or pain d. draining wounds are covered with bandages e. hose is applied over damp skin to facilitate application f. hose should be washed at least every 3 days

a, d, f The appropriate use of antiembolism hose includes: Knee-length hose should end 1 to 2 inches below the knee Draining wounds are covered with bandages Hose should be washed at least every 3 days

A patient has sequential compression stockings in place. Which of the following indicates that they are being implemented correctly? a. The ankle pressure is set at 40 mm Hg b. Stockings are removed every hour during application c. There is no space between the sleeve and the leg when the sleeve is not inflated d. If there is an order for only one leg, the other sleeve is disconnected from the machine.

a. The ankle pressure is set at 40 mm Hg

The best approach for the nurse to use to assess the presence of DVT in an immobilized patient is to: a. measure the calf and thigh diameters b. attempt to elicit the Homan sign c. palpate the temperature of the feet d. observe for a loss of hair and skin turgor in the lower legs

a. measure the calf and thigh diameters

Provide examples of alterations in the following body systems that can lead to impaired mobility. a. musculoskeletal b. neurologic c. cardiopulmonary

a. musculoskeletal-- Impairment or injury, inadequate dietary intake of calcium and vitamin D, decreased physical exercise, rheumatoid arthritis and osteoarthritis, genetic disorders b. neurologic-- damage to cerebrum or cerebellum of the brain and spinal cord injury, cerebrovascular accidents, spinal cord injury c. cardiopulmonary-- compromised cardiac function, decreased tissue perfusion, and diminished respiratory capacity, CHF, Peripheral vascular disease, and COPD

which of the following patients is expected to use a four point crutch walking technique? the patient who can bear weight: a. on both feet b. partially on both feet c. on both feet but has weak upper body strength and lower leg paralysis d. on both feet but has strong upper body strength and lower body paralysis

a. on both feet

A patient has been on bed rest for a prolonged period of time. To specifically promote the use of isotonic exercise, the nurse will instruct the patient to: a. turn side to side in bed b. perform pelvic floor exercises c. repeatedly tighten the thigh muscle d. use a trapeze to lift and hold the upper body off the bed

a. turn side to side in bed

What bony prominences are at greatest risk for skin breakdown on a patient who is restricted to bed rest and placed in the side-lying position? (Select All That Apply) a. Sternum b. Ears c. Elbows d. Hips e. Coccyx

b, c, d ears, elbows, hips The patient's ears, elbows, and hips are in contact with the bed surface in the side-lying position. Breakdown on the sternum would be a potential risk if the patient were in prone position. The coccyx experiences the most pressure when a patient is sitting or in the supine position.

Two nurses are standing on opposite sides of the bed to move the patient up in bed with a draw sheet. Where should the nurses be standing in relation tothe patient'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

b. even with the shoulders

A patient has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the patient, the nurse is alert to a(n): a. increased blood pressure b. decreased heart rate c. increased urinary output d. decreased peristalsis

d. decreased peristalsis

which of the following observations by the nurse indicates the correct use by the patient of a walker without wheels? a. moving forward with both feet and then advancing the Walker b. moving one foot forward, advancing the Walker, and then moving the other foot c. sliding the Walker while shuffling both feet forward d. lifting the Walker forward one step, placing it on the ground, and then stepping forward into the walker

d. lifting the Walker forward one step, placing it on the ground, and the stepping forward into the walker

A patient is admitted to the medical unit following a cerebrovascular accident (stroke). There is evidence of left sided hemiparesis, and the nurse will be following up on ROM and other exercises performed in physical therapy. The nurse correctly teaches the patient and family members which one of the following principles of ROM exercises? a. move the joints quickly b. work from the lower to upper body c. flex the joint to the point of resistance d. provide support above and below joints

d. provide support above and below joints

An average-size male patient has right-sided hemiparesis, requiring minimal assistance with ambulation. The nurse helps this patient to walk by standing at his: a. left side and holding his arm b. left side and holding one arm around his waist c. right side and holding his arm d. right side and holding the gait belt at the patient's back

d. right side and holding the gait belt at the patient's back

for the patient who is standing erect, which of the following indicates correct use of crutches? a. axillary padding removed b. crutches placed 10-12 inches to either side of each foot c. elbow flexion of 60 degrees for the handbar d. three finger widths between the axilla and axillary piece of the crutch

d. three finger widths between the axilla and axillary piece of the crutch

in order to reduce the chance of external hip rotation in a patient on prolonged bed rest, the nurse should implement the use of a: a. footboard b. trapeze bar c. bed board d. trochanter roll

d. trochanter roll

A patient is leaving for surgery and, because of preoperative sedation, needs complete assistance to transfer from the bed to the stretcher. Which of the following should the nurse do first? a. elevate the head of the bed b. explain the procedure to the patient c. place the patient in the prone position d. assess the situation for any potentially unsafe complications

d. assess the situation for any potentially unsafe complications

Which area of the central nervous system has most likely sustained damage if a patient exhibits a lack of coordination and an unsteady gait after a traumatic head injury? a. medulla oblongata b. articular disk c. brainstem d. cerebellum

d. cerebellum Injury to the cerebellum directly affects a patient's ability to ambulate and control movement. The medulla oblongata regulates heart rate, breathing, blood pressure, and reflexive actions such as vomitting. The articular disk is fibrous connective tissue in the temporomandibular joint, which facilitates jaw movement. The brainstem connects the spinal cord to the hemispheres of the brain.

When using a mechanical lift, which of the following techniques are appropriate? Select all that apply. a. Use the device only in life-threatening situations b. at least two health care workers should carry out the procedure c. Determine the operational status before using d.Check the manufacter's weight limit for the device before using e. use a transfer chair for confused or uncooperative patients f. instruct the patient in how the device will work

b, c, d, e, f At least two health care workers should carry out the procedure Determine the operational status before using Check the manufacterer's weight limit for the device before using use a transfer chair for confused or uncooperative patients instruct the patient in how the device will work

in order to reduce the chance of plantar flexion (drop foot) in a patient 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

b. high top sneakers

The nurse assesses that the patient has right-sided hemiparesis following a stroke. This individual most likely had ischemia to the: a. right side of the brain b. left side of the brain c. cerebellum d. medulla oblongata

b. left side of the brain

After instruction, which action by a patient who can bear weight on both feet indicates an understanding of the proper use of crutches? a. Adjusting the crutches so that they rest directly b. Moving the opposing crutch and leg together for a two-point crutch walk c. Using a four-point crutch walk when not weight bearing on the left leg d. Placing the crutches 28inches forward and then swinging both legs forward when using a three-point crutch walk

b. moving the opposing crutch and leg together for a two-point crutch walk Moving the opposing crutch and leg together provides needed stability for patients who can bear partial weight on each foot. Crutches must rest at minimum of two to three finger widths below the axilla to prevent brachial nerve damage. The four point crutch walk is used by only patients who can bear weight on both legs. Crutches should be advanced no more than 6 to 8 inches, and a three point crutch walk is not a swing through gait.

The nurse is working with a patient who has left-sided weakness. After instruction, the nurse observes the patient ambulate in order to evaluate the use of the cane. Which action indicates that the patient knows how to use the cane properly? a. The patient keeps the cane on the left side b. Two points of support are kept on the floor at all times. c. There is a slight lean to the right when the patient is walking. d. After advancing the cane, the patient moves the right leg forward.

b. two points of support are kept on the floor at all times

A patient with a fractured left femur has been using crutches for the past 4 weeks. The physician tells the patient to begin putting a little weight on the left foot when walking. Which of the following gaits should the patient be taught to use? a. two-point b. three-point c. four-point d. swing-through

c. four-point

Place the steps in the correct order for a patient arising from a chair with crutches: a. move the crutches to a tripod position b. hands are holding the hand bar of the crutches and armrest of the chair c. move to front edge of the chair d. push off the chair and balance

c, b, d, a 1. move to the front edge of the chair 2. hands are holding the hand bar of the crutches and armres of the chair 3. push off the chair and balane 4. move the crutches to a tripod position

The nurse is teaching the aide about correct body mechanics. Which of the following principles are accurate andd should be included in the teaching? Select all that apply. a. Elevate work surfaces to approximately neck height b. never liftmore than 75 lbs independently c. push rather than pull patients or objects d. bend from the waist when lifting e. keep patients or objects close to the body to minimize reach f. keep the feet apart to provide a stable base

c, e, & f push rather than pull patients or objects, keep patients or objects close to the body to minimize reach, keep the feet apart to provide a stable base

to provide for the psychosocial needs of an immobilized patient, an appropriate statement by the nurse is: a. "the staff will limit your visitors so that you will not be bothered" b. "a roommate can be a real bother. you'd probably rather have a private room." c. "let's discuss the routine to see if there are any changes we can make" d. "I think you should have your hair done and put on some make up"

c. "let's discuss the routine to see if there are any changes we can make"

An uncooperative 70-year-old male with right-sided paralysis from a recent cerebrovascular accident (CVA) has to be transferred from the bed to a wheelchair. Which action indicates the best method to transfer this patient? a. A two-person lift is performed, with one person on each side of the patient b. The patient is steadied under the arms and pivoted on his left leg c. A full-body sling lift is used with help of unlicensed assistive personnel d. A stand assist lift is used with the help of another nurse

c. A full-body sling lift is used with the help of unlicensed assistive personal According to safe patient handling algorithms, a full body sling with the assistance of the nurse and UAP is indicated because the patient is uncooperative and able to bear only partial weight. Lifting a patient manually has the potential to injure the patient and the care providers. The stand and pivot technique is not indicated because the patient is uncooperative. The stand assist lift is not indicated because the patient is uncooperative.

Antiembolism hose (stockings) are ordered for the patient on bed rest following surgery. The nurse explains to the patient that the primary purpose for the elastic stocking is to: a. keep the skin warm and dry b. prevent abnormal joint flexion c. apply external pressure d. prevent bleeding

c. apply external pressure

6. To prevent injury to a patient during logrolling, which action by the nurse is most important? a. Place an ankle foot orthotic on the patient prior to movement. b. Remove the patient's drawsheet to avoid lower extremity entanglement. c. Position a pillow between the patient's legs to maintain body alignment. d. Raise all four side rails prior to initiating logrolling independently.

ANS: C A pillow is positioned between a patient's legs during logrolling to maintain spinal alignment. Ankle foot orthotics are used to prevent footdrop and would not be indicated during logrolling. A drawsheet is critical during logrolling to prevent potential injury to both caregivers and patients in most cases. Side rails are lowered when a caregiver is positioned next to the side of the bed so that the patient can be reached without back strain to the nurse.

5. Following hip surgery, a trochanter roll is used to prevent what type of movement? a. Supination b. Pronation c. Internal rotation d. External rotation

ANS: D A trochanter roll is placed along the greater trochanter of the femur (the outer aspect of the leg) to prevent external rotation of the hip when a patient is lying in supine position. A pillow is placed between a patient's legs when logrolling or in the side-lying position to prevent internal rotation. Supination and pronation refer to body positions of face up and face down.

1. Which assessment finding would indicate that a patient has hemiparesis? a. Bilateral lack of movement in the patient's lower extremities b. Complaint of pain when the patient attempts to ambulate c. Loss of sensation in both of the patient's legs d. Weakness of the patient's right arm and leg

ANS: D Hemiparesis results from a neurological brain injury that causes weakness on one side of the body. Bilateral muscle and sensory loss may be due to a spinal cord injury, the level of which determines whether the patient is paraplegic or quadriplegic. Pain with ambulation may be a neurological or musculoskeletal response to a variety of concerns or disorders.

What nursing intervention would be most effective in preventing flaccidity in a hospitalized patient? a. Early ambulation after surgery b. Adminstering calcium with vitamin D c. Coughing and deep breathing exercises d. Referring the patient to occupational therapy

Answer: a Ambulation is the most effective intervention to promote maintenance of muscle tone and prevent flaccidity. Calcium with vitamin D helps prevent osteoporosis. Coughing and deep breathing is important for the prevention of pneumonia associated with immobility, and occupational therapy is typically ordered to help patients regain their ability to complete activities of daily living (ADLs) independently.

Which discovery found during an admission assessment of a patient transferred from a long-term care facility does the nurse recognize as the result of immobility? a. Bilateral elbow contractures b. Increased muscle tone c. Decreased cardiac workload d. Orthostatic hypertension

Answer: a Joint contractures may begin within hours of immobility and cause irreparable damage to joint flexibility. Muscle tone decreases, and cardiac workload increases with immobility. Pooling of blood in the lower extremities and quickly changing position may cause a rapid drop, rather than increase, in blood pressure, known as orthostatic hypotension

After application of sequential compression devices (SCDs) on a patient, what assessment finding is essential for the nurse to include in documentation? a. Warmth of bilateral upper extremities b. Lower extremity circulatory status c. Circumoral cyanosis d. Bowel sounds

Answer: b The nurse must document the date and time of initiating SCD placement and the results of a skin, circulatory, and neurologic assessment of the lower extremities. SCDs do not affect the upper extremities, cardiac or respiratory status leading to circumoral cyanosis, or bowel sounds.

Identify all nursing interventions that are necessary when caring for a quadriplegic patient injured 2 years earlier in a motor vehicle accident. (Select all that apply) a. Monitoring respiratory status and breathing difficulties b. Assisting with feeding and activites of daily living (ADLs) c. Developing a care plan with the patient's power of attorney d. Using mechanical lifts to assist with transferring the patient e. Placing a gait belt around the patient's waist before ambulation

Answers: a, b, d Quadriplegia is the result of a high spinal cord injury that affects a patient's ability to breathe without mechanical assistance and severely limits the patient's ability to move all extremities. Most quadriplegics are confined to a wheelchair and unable to ambulate even with assistance. Mechanical lifts should be used to safely transfer this type of patient. Quadriplegic patients should be given the opportunity to direct their care and fully participate in setting care plan goals.

Which assessment questions will help the nurse determine if a patient is experiencing difficulty with mobility?

Are you experiencing any stiffness, joint discomfort, or pain with movement? Have you noticed any difficulty with dizziness or balance? Do you become SOB or easily fatigued when completing your activities of daily living? How is your appetite? What is your typical dietary intake in a day? What is the frequency of your bowel movements? Describe your normal sleep pattern Do you exercise?

Nurses need to implement appropriate body mechanics in order to prevent injury to themselves and patients. Which principle of body mechanics should the nurse incorporate into patient care? a. Flex the knees and keep the feet wide apart b. Assume a position far enough away from the patient c. Twist the body in the direction of movement d. Use the strong back muscles for lifting or moving

a. flex the knees and keep the feet wide apart

Following an assessment of a patient, the nurse identifies the nursing diagnosis Activity Intolerance Related to Increased Weight Gain and Inactivity. The physician wants the patient to improve her endurance and increase activity. Which of the following is an outcome identified by the nurse? a. Resting heart rate will be 90-100/minute b. Blood pressure will be maintained between 140/80 and 160/90 c. exercise will be performed 3 times per day over the next 2 weeks d. accommodation will be made for excess weight and fatigue

c. exercise will be performed 3 times per day over the next 2 weeks

While ambulating in the hallway of a hospital, the patient complains of extreme dizziness. The nurse, alert to a syncopal episode, should first: a. support the patient and walk quietly back to the room b. lean the patient against the wall until the episode passes c. lower the patient gently to the floor d. go for help

c. lower the patient gently to the floor