Essentials Exam 1: chapter 28 Practice Questions

Rotation and supination is a movement assessed in the which plane?

transverse

The registered nurse is teaching a nursing student about the safety guidelines for nursing skills. Which statement by the nursing student indicates the need for further learning?

"I should arrange the positioning equipment as close as possible to the patient's bed."

The nurse reviews discharge instructions with a patient who has osteoporosis. Which statement by the patient indicates that the patient understands the instructions?

"I will stop smoking as soon as possible."

The nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which statements made by a woman in the audience reflect a need for further education?

"I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill."

The nurse is caring for a patient with paralysis. The nurse understands that footdrop is a common but preventable complication in these patients. Which statements are true about footdrop? Select all that apply.

*Footdrop is a type of debilitating contracture. The foot is permanently fixed in dorsiflexion position. *The patient is unable to lift the toes off the ground. *Patients with left- or right-side paralysis are at increased risk of developing footdrop. Footdrop can be treated with regular physiotherapy.

Which physiological changes are observed in a patient when the head of a hospital bed is elevated to 60 degrees? Select all that apply.

*Formation of pressure ulcers *Skin remains against the sheets Increased blood flow in the blood vessels Blood vessels in the underlying tissues are strengthened *Bony skeleton moves forward towards the foot of the bed

The nurse is caring for a patient who has been immobile after a spine surgery. Which urinary changes are likely to occur in the patient? Select all that apply.

*Urinary output decreases. Risk for developing chronic renal failure increases. Urine is more diluted. *Urinary stasis occurs. *Risk for developing urinary tract infection increases.

A patient with left-sided weakness asks the nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." What would be the best therapeutic response?

"By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.

The registered nurse is teaching a nursing student about the skeletal system. Which statements by the nursing student indicate a need for further learning? Select all that apply.

"The skeletal muscle includes three types of bones." "The skeletal system regulates movement and posture."

The effects of immobility on the cardiac system include which of the following? (Select all that apply.)

*Thrombus formation *Increased cardiac workload Weak peripheral pulses Irregular heartbeat *Orthostatic hypotension

What is the correct order in which elastic stockings should be applied? 1. Identify patient using two identifiers. 2. Smooth any creases or wrinkles. 3. Slide the remainder of the stocking over the patient's heel and up the leg 4. Turn the stocking inside out until heel is reached. 5. Assess the condition of the patient's skin and circulation of the legs. 6. Place toes into foot of the stocking. 7. Use tape measure to measure patient's legs to determine proper stocking size.

1, 5, 7, 4, 6, 3, 2

Which patient is at greatest risk for developing multiple adverse effects of immobility?

80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA)

Which movement is assessed in the frontal plane when the nurse is observing the mobility of the joint?

Adduction

The nurse understands that an immobile patient is at high risk of thrombus formation. Which factors may contribute to the risk of thrombus formation? Select all that apply.

Alteration in body weight *Alteration or slowing of blood flow *Damage to the wall of the blood vessels Alteration in the patient's nutritional status *Alteration of the constituents in the blood

To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery?

Ambulate patient to chair in the hall

An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.)

B/P = 128/84 **Respirations 26/min on room air **HR 114 **Crackles over lower lobes heard on auscultation Pain reported as 3 on scale of 0 to 10 after medication

A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility:

Decreased peristalsis

The patient is advised to perform pelvic floor exercises. The nurse explains to the patient that pelvic floor exercise is a type of isometric contraction. Which statements are true about isometric contractions? Select all that apply.

Isometric exercises increase the muscle mass of the body. **Isometric exercises improve activity tolerance. They have a beneficial effect on preventing orthostatic hypotension. **Muscle tension increases, but there is no muscle shortening. Isometric exercises decrease venous return.

What is cartilage?

Nonvascular supporting connective tissue located chiefly in joints

The nurse is assisting a patient in the supported supine position. Which nursing action should the nurse implement to reduce the rotation of the hip?

Placing trochanter rolls parallel to the lateral surface of the thighs

The home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a cane. Which must be corrected or removed for the patient's safety? Select all that apply.

Rubber mat in the walk-in shower *Three-legged stool on wheels in the kitchen *Braided throw rugs in the entry hallway and between the bedroom and bathroom Night-lights in the hallways, bedroom, and bathroom Cordless phone next to the patient's bed

The nurse is teaching a nursing student about various deformities of the spine. Which statements are true about spine deformities? Select all that apply.

Scoliosis is the medial deviation and plantar flexion of the foot. **Kyphosis is the increased convexity in curvature of the thoracic spine. Kyphosis is the internal rotation of forefoot or entire foot. **Lordosis is the exaggeration of the anterior convex curve of lumbar spine. **Scoliosis is the lateral S- or C-shaped spinal column with vertebral rotation.

Which treatment is provided for patients with lordosis?

Spine-stretching exercises

Which nursing intervention would increase the risk for joint dislocation in a patient with hemiplegia who is immobile for an extended period?

Supporting the patient by holding the arm

The nurse assesses a patient's condition and suspects that the patient has footdrop. Which assessment finding supports the nurse's suspicion?

The foot is permanently fixed in plantar flexion

The supine position would be beneficial for?

a postoperative patient to prevent footdrop

Patients with pressure ulcers would benefit from?

being placed in a 30-degree lateral position

A 60-year-old female patient sustained a femur fracture due to a fall in the bathroom. The patient complains of severe pain. Which mineral supplement is likely to be added to the patient's prescription to manage osteoporosis?

calcium

Which of the following are physiological outcomes of immobility?

decreased lung expansion

The trochanter roll prevents?

external rotation of the hips when a patient is in a supine position

A patient who has hemiplegia is unable to dorsiflex and invert the feet. Which condition does the patient likely have?

foot drop

Adduction, abduction, eversion, and inversion are the movements assessed in which plane?

frontal

Which assistive device would the nurse use to reduce surface area and friction when patients are unable to assist with moving up in bed?

full body sling

The trouble points of the supported Fowler's position are

increased cervical flexion and pressure on the posterior aspects of the knee.

Which urinary elimination changes are often observed as the period of immobility continues for a patient? Select all that apply.

increased fluid intake Increased urinary output **Increased risk of renal calculi **Increased urinary concentration **Increased risk for urinary tract infections

Torticollis

involves inclination of the head to the affected side and contraction of the sternocleidomastoid muscle.

Scoliosis

is a lateral S- or C-shaped spinal column with vertebral rotation and unequal heights of hips and shoulders

When assessing a patient, the nurse observes that the patient's legs are curved inward while walking. Which abnormality should the nurse anticipate in the patient?

knock-knee

Atelectasis

or lung collapse occurs when secretions block the bronchus or the bronchiole, and the distal alveoli collapse due to hypoventilation

A child has rickets. The health care provider suggests an increase of calcium, vitamin D, and phosphorus in the patient's diet. Which food items are good sources of calcium? Select all that apply.

veggies yogurt cheese

A 3-year-old child has rickets. Which vitamin should be supplemented to the child's diet?

vitamin D

The registered nurse is teaching a nursing student about the interventions performed to prevent deep vein thrombosis in an immobilized patient. Which statement made by the nursing student indicates a need for correction?

"I will massage the legs"

What are the functions of the skeletal system? Select all that apply.

**Provide support **Regulate calcium Regulate posture Contribute balance **Protect vital organs

How many nurses would be required to place a patient in the semi-prone position(SIMS position)?

1

A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient?

Encouraging use of an overhead trapeze for positioning and transfer.

Which is a common debilitating contracture?

Footdrop

Which metabolic changes are observed in immobile patients?

Increased nitrogen levels

Which intervention should the nurse perform while positioning a patient in the supported Fowler's position to decrease flexion of vertebrae?

Place a small pillow at the lower back

The nurse puts elastic stockings on a patient following major abdominal surgery. Why are elastic stockings used after a surgical procedure?

To promote venous return to the heart

The nurse places the patient in prone position. Which nursing action reduces the flexion or hyperextension of the cervical vertebrae?

Turning the patient's head to one side and supporting it with a small pillow

The nurse is caring for a patient who is bedridden due to surgery on the spine. Which respiratory complications may occur if the patient is bedridden for a long duration? Select all that apply.

Asthma *Atelectasis *Hypostatic pneumonia Allergic rhinitis Tuberculosis

The nurse is caring for a child with clubfoot. Which should the nurse advise the caregiver to apply on the child?

Denis Browne splint

A patient sustained a severe injury in a motor vehicle accident. The patient is unable to perform any movement. Which metabolic changes would be found in the patient due to immobility? Select all that apply.

Increase in appetite **Calcium imbalance Increase in peristalsis **Gastrointestinal disturbances **Alteration in the metabolism of protein

Following surgery, a patient has become bedridden and has developed a thrombus in the left leg. The nurse instructs the patient, caregiver, and staff members to avoid massaging the affected area. What is the most likely reason for this instruction?

Massaging the area may dislodge the thrombus.

Which statement is true regarding muscle abnormalities?

Muscle abnormalities cause degeneration of skeletal muscle fibers.

Which can cause contracture of a joint?

The muscle fibers become shortened because of disuse.

An elderly patient has undergone hip replacement surgery. On the second postoperative day, the nurse finds that the pedal pulses are absent and the lower extremities are cold to the touch. What should the nurse interpret from this finding?

The patient has venous thrombus formation.

The nurse is assessing range of motion of a patient. Which condition does the nurse observe when the forearm of the patient is fixed in a position of full supination?

The patient's use of hand is limited.

Which positioning aid decreases the shearing action from sliding across up and down in bed?

Trapeze bar

Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?

Use of incentive spirometer every 2 hours while awake

What are ligaments?

White, shiny, flexible bands of fibrous tissue

footdrop

is the leg contracture in which the foot is permanently fixed in plantar flexion, and the patient is unable to lift the toes off the ground.

Extension is a movement in the which plane?

sagittal plane

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend?

Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert

After assessing a patient with immobility, the nurse observes that the patient has acute respiratory distress syndrome. Which positioning of the patient would be appropriate to improve oxygenation?

Prone position

The nurse is caring for a patient with acute respiratory distress syndrome. While positioning the patient, the nurse observes hyperextension of the lumbar spine. Which patient positioning would likely have caused this condition?

Prone position

Kyphosis

s the increased convexity in the curvature of thoracic spine.

The registered nurse is teaching a nursing student about psychosocial effects on patients with immobility. Which statements made by the nursing student indicate a need for further learning? Select all that apply.

**"Every patient responds to immobility in a same way." "Patients with restricted mobility may have depression." "Impaired mobility can cause social isolation and loneliness." "Immobilization leads to emotional and behavioral responses." **"Withdrawn patients often want to participate in their own care."

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply.)

**"I usually go swimming with my family at the YMCA 3 times a week." ** "I need to ask my doctor if I should have a bone mineral density check this year." ** "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." "My lactose intolerance should not be a concern when considering my calcium intake."

The nurse is caring for a patient who has been immobile for a month due to quadriplegia. Which risks should the nurse be prepared for? Select all that apply.

**Risk of developing atelectasis Risk of developing tension pneumothorax **Risk of developing hypostatic pneumonia Risk of developing pulmonary tuberculosis **Risk of ineffective coughing

A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply.)

*Bruising Pale yellow urine *Bleeding gums *Coffee ground-like vomitus Light brown stool

What are the risk factors for developing pathological fractures in patients with immobility? Select all that apply.

*Decreased metabolism Decreased urinary output Decreased tissue catabolism *Decreased calcium regulation Decreased urine concentration

Which type of joint is the hip joint?

Ball-and-socket joint

Which primary muscles are used for the abduction of the wrist joint? Select all that apply.

Flexor carpi ulnaris **Flexor carpi radialis Extensor carpi ulnaris Extensor carpi radialis brevis **Extensor carpi radialis longus

The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.)

Initial patient measurement is made around the calves *Inflation pressure averages 40 mm Hg *Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve. Stockings are removed every 2 hours during application. Yellow light indicates SCD device is functioning.

Which postural abnormality indicates an exaggeration of the anterior convex curve of the lumbar spine?

Lordosis

The nurse is caring for a bedridden patient. The nurse understands that immobility results in many metabolic changes. Which metabolic changes may be found in this patient? Select all that apply.

Low calcium levels in the blood **Negative nitrogen balance **Decrease in the basal metabolic rate **Decreased appetite and slowing of peristalsis Increased muscle mass due to tissue anabolism

The nurse is caring for a postoperative patient. Which nursing action should be avoided if deep vein thrombosis (DVT) is suspected in an immobilized patient?

Measuring the calf and thigh circumference A unilateral increase in calf circumference is an early indicator for deep vein thrombosis.

A 60-year-old female patient sustained a femur fracture due to a fall in the bathroom. The patient complains of severe pain and expresses that she did not expect a fracture as the fall was not very severe. The nurse tells the patient that fracture is common for people her age. Which condition should the nurse cite as the most common cause of fracture in postmenopausal patients?

Osteoporosis

A patient was diagnosed with left-sided neglect after suffering a cerebrovascular accident. Which nursing intervention would be most effective to ensure the patient's safety?

Reminding the patient to scan the environment while walking

While assessing a patient with impaired mobility, the nurse observes that the patient is unable to perform range of motion exercises. Which complications are most likely to occur in the patient?

Respiratory

An older adult who was in a car accident and fractured the femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time?

Risk for inability to tolerate activity

Which indicates that additional assistance is needed to transfer a patient from the bed to the stretcher?

The patient received an injection of morphine 30 minutes ago for pain.

Which device should the nurse use to prevent external rotation of the hips when the patient is in a supine position?

Trochanter roll

Which positioning aid prevents external rotation of the hips when the patient is in the supine position?

Trochanter roll

The nurse is positioning a hemiplegic patient in the supine position. The nurse places a folded towel under the hip of the patient. What is the reason behind this intervention?

control hip postion

The trouble points of the Sims' position and the side-lying position are?

lateral flexion of the neck and lack of foot support

An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility?

left ankle joint stiffness

venous thrombus formation.

occurs because of stagnation or alteration in the blood flow as a result of immobility or injury to the vessel wall during surgery.

A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken:

pressure ulcers

Patients with a head injury would benefit from?

semi-Fowler's position