Foundations Chapter 28 Immobility
3 Muscle abnormalities like muscular dystrophies can cause degeneration of skeletal muscle fibers. Postural abnormalities may affect body alignment. Muscle abnormalities would not affect the central nervous system of the body. Muscle abnormalities are most prevalent for the muscle diseases in childhood.
Which statement is true regarding muscle abnormalities? 1 Muscle abnormalities can affect body alignment. 2 Muscle abnormalities affect the central nervous system of the body. 3 Muscle abnormalities cause degeneration of skeletal muscle fibers. 4 Muscle abnormalities are most prevalent for muscle diseases in adulthood.
2, 4 Isometric contractions involve energy expenditure without any active movement of the muscle; muscle tension increases, but no muscle shortening occurs. Isometric exercises improve activity tolerance, but they have no beneficial effect on preventing orthostatic hypotension. Isometric exercises do not help in increasing muscle mass, because they involve energy expenditure, and they actually increase (rather than decrease) venous return.
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. 1 Isometric exercises increase the muscle mass of the body. 2 Isometric exercises improve activity tolerance. 3 They have a beneficial effect on preventing orthostatic hypotension. 4 Muscle tension increases, but there is no muscle shortening. 5 Isometric exercises decrease venous return.
2, 3, 4, 5 Patients must be repositioned around the clock, not just when they are awake. All other choices are correct. An objective assessment scale allows the nurse to assess for pressure ulcer risk over time. Once the risk is identified, the assessment tool guides the nurse in selecting appropriate pressure-relief devices. Showing the patient how to reduce risk by shifting pressure is also important. Frequent and meaningful position changes that are in concert with the patient's condition and risk factors are necessary to reduce pressure ulcer development.
Immobilized patients are at risk for bedsores. Which interventions would reduce this risk? Select all that apply. 1 Repositioning patient every 1 to 2 hours while awake 2 Using an objective, valid scale to assess patient's risk for pressure ulcer development 3 Using a device to relieve pressure when patient is seated in chair 4 Teaching patient how to shift weight at regular intervals while sitting in a chair 5 Following this good rule: the higher the risk for skin breakdown, the shorter the interval between position changes
3 Knock-knee is the abnormality that curves the legs inward so that knees come together while walking. Patients with bowlegs have legs that bend outward at the knee. Footdrop is the inability to dorsiflex and invert the foot because of perineal nerve damage. Congenital hip dysplasia is an abnormality in which hip instability is seen with the limited abduction of the hips.
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? 1 Bowlegs 2 Footdrop 3 Knock-knee 4 Congenital hip dysplasia
4 When patients are receiving medications such as heparin or enoxaparin, the nurse must assess for signs of bleeding. These include overt signs, such as bleeding from the gums, or covert signs, which can be detected by testing the stool or observing the patient's aspirate from nasogastric (NG) tubes for coffee ground-like matter. These are signs of bleeding in the gastrointestinal tract. Pale yellow urine is not cause for concern, because it may be diluted and pale due to the extra fluids the patient may be given. Unilateral neglect in a cerebrovascular accident (CVA) is common. Slight movement that was not there during the previous neurological check is important and should be documented, but it is not necessary to call the healthcare provider.
A patient had a left-sided cerebrovascular accident (CVA) 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore nasogastric (NG) tube because of dysphagia. Which symptom requires the nurse to call the healthcare provider immediately? 1 Pale yellow urine 2 Unilateral neglect 3 Slight movement noted on the right side 4 Coffee ground-like aspirate from the feeding tube
4 The head of the femur acts as a ball and the pelvic bone as a socket, and together they form a ball-and-socket type of joint , which is a freely movable synovial joint. The elbow and knee joints are examples of hinge joints. The joints in the neck are pivot joints. Cartilaginous joints are found in the sternum where cartilage unites with the bone.
A patient sustained a femur fracture due to a fall in the bathroom. The attending nurse understands that the femur bone forms a hip joint with the pelvic bone. Which type of joint is the hip joint? 1 Hinge joint 2 Pivot joint 3 Cartilaginous joint 4 Ball-and-socket joint
2 Osteoporosis results in decreased bone mass and brittle bones, which make the patient prone to pathological fractures. Joint contractures are a complication of immobility of joints. Footdrop is a type of joint contracture, where the foot is permanently fixed in plantar flexion. Urinary stasis is a complication of immobility, in which the urine gets stagnated in the bladder.
A patient who has attained menopause is diagnosed with osteoporosis. Which consequences of osteoporosis should the nurse consider in the patient? 1 Joint contractures 2 Pathological fractures 3 Footdrop 4 Urinary stasis
3, 5 It is necessary to elevate legs while sitting and before applying stockings to improve venous return. Antiembolic stockings that are free of wrinkles will fit the legs more properly. Massaging the legs may further deteriorate the condition or mobilize a thrombi, so massage should be avoided. Sitting cross-legged and wearing garters promote venous stasis and should be avoided.
Nursing assistive personnel (NAP) are applying antiembolic elastic stockings to the patient. Which instructions should the NAP give to the patient? Select all that apply. 1 Massage the legs if they ache. 2 Wear garters regularly. 3 Elevate the legs while sitting. 4 Make a habit of sitting cross-legged. 5 Avoid wrinkles in stockings
2 In osteoporosis the bones lack calcium due to demineralization. Therefore, calcium supplements are added to the prescription to improve bone strength. Zinc is useful in cellular metabolism but has no role in bone health. Sodium is important for cells to function but has no role in promoting bone health. Iron is needed for hemoglobin production. It does not help in managing osteoporosis related to bone changes.
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? 1 Zinc 2 Calcium 3 Sodium 4 Iron
2 A patient who is immobile with limited movement of the lower limbs may develop deep vein thrombosis due to stagnation of blood. This thrombus may get dislodged if the affected calf muscles are massaged. A dislodged thrombus may block any blood vessel and lead to complications. Therefore, in the patient who has developed thrombosis, massage should be avoided. Massaging may not be painful and may not cause skin breakdown or an ulcer.
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? 1 Massaging the area may be painful for the patient. 2 Massaging the area may dislodge the thrombus. 3 Massaging the area may cause skin breakdown. 4 Massaging the area may promote ulcer formation
2 Genu varum , or bowlegs, is an abnormality where one or both of the legs are bent outward at the child's knee. This is a congenital condition and is considered normal until 2 to 3 years of age. If the legs are bent inward and the knees come together as the person walks, it is called knock-knee or genu valgum. S- and C-shaped spines are seen in scoliosis.
When reviewing the medical record of a 3-year-old child, the nurse finds that the child has genu varum. What finding should the nurse expect in the child? 1 The legs are bent inward. 2 The legs are bent outward. 3 The spine is S-shaped. 4 The spine is C-shaped.
1 The patient with a below-the-knee amputation has restricted mobility. The patient should be advised to exercise the rest of the body. Lifting soup cans helps to improve the patient's strength and abilities. Increase in calcium intake and vitamin C may help to increase bone strength but may not be helpful in increasing muscle strength. Performing range-of-motion exercises is helpful for the patient to build up muscle strength and mass.
A patient has undergone a below-the-knee amputation. Which nursing intervention should the nurse suggest to the patient to promote mobility? 1 Lift soup cans. 2 Increase calcium intake. 3 Increase vitamin C intake. 4 Avoid performing range-of-motion exercises.
1, 3, 5 Shear injuries result from improper positioning, usually when the patient slides down in the bed. In the supported Fowler's position, the pressure points at the sacrum and heel are unprotected, increasing the risk of pressure ulcers. Pressure on the posterior aspect of the knees may decrease the circulation to the feet. Therefore, the knees should be kept slightly elevated without pressure. In the supine position, the thumb is not in opposition to the fingers, and the shoulders remain unsupported and internally rotated.
A patient is advised to be in supported Fowler's position. Which trouble areas can cause patient discomfort in this position? Select all that apply. 1 Increased shearing force on the back and heels 2 Thumb not in opposition to the fingers 3 Unprotected pressure points at the sacrum and heels 4 Shoulders unsupported and internally rotated 5 Pressure on the posterior aspect of the knees decreasing circulation to the feet
3 A pressure ulcer is an impairment of the skin as a result of prolonged ischemia in the tissues, and the prevalence of pressure ulcers is highest in long-term care facilities due to decreased blood supply to the tissues. Patients who have suffered cerebrovascular accident with resulting left- or right-sided paralysis are at high risk for footdrop. Patients who are immobilized are at high risk for developing a pulmonary complication such as atelectasis, but it may not be observed in patients who are in long-term health care facilities. Patients with disuse osteoporosis are at high risk for pathological fractures.
A patient is undergoing treatment in a long-term health care facility. Which type of immobility complication is likely to develop in the immobilized patient? 1 Footdrop 2 Atelectasis 3 Pressure ulcers 4 Pathological fractures
4 Patients on bed rest are at risk for inability to tolerate activity, which increases patients' risk for falling. The patient is in acute pain, not chronic pain. The patient could have some skin breakdown, but this is not relevant to getting the patient out of bed. The patient's cerebral tissue bloodflow is not an issue in this situation.
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? 1 Chronic pain 2 Impaired skin condition 3 Risk for ineffective cerebral tissue bloodflow 4 Risk for inability to tolerate activity
3 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. Internal rotation of the entire foot is a postural abnormality called pigeon toes. Bowleg is a condition in which the patient has both the legs bent outward at the knee. Knock-knee is the postural abnormality in which legs curve inward so the knees come together as the person walks.
The nurse assesses a patient's condition and suspects that the patient has footdrop. Which assessment finding supports the nurse's suspicion? 1 Internal rotation of entire foot 2 Both the legs bent outward at knee 3 The foot is permanently fixed in plantar flexion 4 Legs curved inward, so knees come together as person walks
2, 3, 5 Antiembolitic elastic stockings may hamper circulation of blood to the legs if they are too tight. The temperature of the skin is important to confirm adequacy of blood supply. The skin may be cold to the touch if the stockings are constrictive. The pedal pulse may be absent if the stockings are too tight and the circulation is hampered. The color of the skin may also indicate whether sufficient blood supply is reaching the legs. Bluish skin indicates pooling of blood due to constrictive stockings. Radial pulse is palpated on the wrist, and femoral pulse is found in the groin area. Neither pulse may be affected with elastic stockings.
The nurse has put antiembolitic elastic stockings on the legs of a patient. What parameters should the nurse check after applying the stockings? Select all that apply. 1 Radial pulse 2 Temperature of the skin 3 Pedal pulse 4 Femoral pulse 5 Color of the skin
4 The nurse should ask the patient to move the leg back toward the medial position and beyond if possible to assess adduction in the hip joint. To assess flexion in the hip joint, the leg should be moved forward and up. To assess extension in the hip joint, the leg should be moved behind the other leg. To assess abduction in the hip joint, the leg should be moved laterally away from the body.
The nurse is assessing a patient for the movement of the hip ball and socket joint. Which range-of-motion (ROM) exercise should the nurse ask the patient to perform to assess adduction? 1 Move the leg forward and up. 2 Move the leg behind the other leg. 3 Move the leg laterally away from body. 4 Move the leg back toward the medial position.
1, 3, 5 A thrombus formed due to deep vein thrombosis may be dislodged and impair circulation and oxygenation, resulting in tachycardia and shortness of breath. A unilateral increase in the calf region is an early indication for thrombus formation in the lower extremities. Dehydration may indicate the impairment of the metabolic system. Orthostatic hypotension may be caused by standing, especially after periods of immobilization.
The nurse is assessing a postoperative patient and suspects deep vein thrombosis. Which other assessment findings will help the nurse confirm the suspicion? Select all that apply. 1 Tachycardia 2 Dehydration 3 Shortness of breath 4 Orthostatic hypotension 5 Increased calf circumference
3 For Patient 3, the flexion of the neck that brings the chin to rest on the chest should be 45 degrees. Flexion of only 10 degrees indicates disability in the pivotal joint. In Patient 1, the extension of the elbow to 90 degrees indicates normal function. In Patient 2, the wrist with the hand in slight dorsiflexion is a normal finding. In Patient 4, a slight flexion of the thumb in opposition to the fingers is a normal finding.
The nurse is assessing four patients by asking them to perform range-of-motion exercises. Which patient does the nurse identify as having limited mobility? 1 Patient 1 2 Patient 2 3 Patient 3 4 Patient 4
2 Increased calf circumference may indicate deep vein thrombosis, which may further result in pulmonary embolism. A patient with dehydration is at increased risk of impaired skin integrity due to immobility. Decreased blood pressure may indicate orthostatic hypotension due to immobility. Increased serum calcium levels may result from increased bone resorption, resulting in osteoporosis due to immobility.
The nurse is assessing four patients. Which patient does the nurse suspect to be at increased risk of pulmonary embolism due to immobility? 1 Patient with dehydration 2 Patient with enlarged calf circumference 3 Patient with decreased blood pressure 4 Patient with increased serum calcium levels
2 Most functions of the hand are best carried out with the forearm in moderate pronation. When the forearm is fixed in a position of full supination, the patient's use of the hand is limited. When the wrist is fixed in even a slightly flexed position, the grasp is weakened. When the patient has limited movement in the shoulder, he/she may have difficulty moving the arms. When there is impaired range of motion in the fingers and thumbs, the patient is less able to perform fine-motor skills such as carpentry and painting.
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? 1 The patient's grasp is weakened. 2 The patient's use of hand is limited. 3 The patient has difficulty moving the arms. 4 The patient cannot perform fine motor skills, like painting.
1, 3, 4, 5 Pressure ulcers develop in people who are immobile for a long duration. Repositioning helps to relieve pressure from the bony prominences and promote circulation. If the patient can lie down in lateral position, a 30-degree lateral position is preferred. In this position, the body weight rests on hip and shoulder. Pulling the patient when repositioning may increase the shearing force, leading to the development of pressure ulcers. Well-hydrated skin is less likely to break down. In supine position, the risk of pressure ulcer is highest.
The nurse is attending to a patient who is immobilized due to stroke. Which measures should the nurse take to prevent development of pressure ulcers in the patient? Select all that apply. 1 Reposition the patient every 1 to 2 hours. 2 Place the patient in supine position. 3 Place the patient in a 30-degree lateral position. 4 Avoid pulling the patient when repositioning. 5 Keep the patient well hydrated.
2, 3, 4 A patient confined to bed may have a negative nitrogen balance, because the body excretes more nitrogen than it ingests through proteins. The basal metabolic rate (BMR) may decrease as a result of reduced food intake. A patient confined to bed experiences decreased appetite and slowing of peristalsis in response to the low BMR. Immobility also results in calcium resorption from bones, in which the calcium is released into circulation, resulting in hypercalcemia. The muscle mass may decrease due to tissue catabolism.
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. 1 Low calcium levels in the blood 2 Negative nitrogen balance 3 Decrease in the basal metabolic rate 4 Decreased appetite and slowing of peristalsis 5 Increased muscle mass due to tissue anabolism
3, 4, 5 The duty of a physical therapist is to assist patients in activities that enhance mobility such as ambulation, prescribing exercises to improve strength, and addressing any postural abnormalities that could further hamper mobility. A person with T7-level spinal cord injury does not require ventilator support. Physical therapists could assist in bed mobility to prevent bed sores, and they are knowledgeable about wound care, but managing bed sores is the duty of the nurse.
The nurse is caring for a patient diagnosed with a spinal cord injury at T7 level. For which areas of care should the nurse seek out a physical therapist for assistance? Select all that apply. 1 Assisting with management of bed sores 2 Managing the controls of the ventilator 3 Preventing the development of any postural abnormalities 4 Assisting the patient in ambulation 5 Prescribing exercises to strengthen trunk musculature
2, 3 Bedridden patients are at risk such as atelectasis and hypostatic pneumonia. Atelectasis, or lung collapse, occurs when secretions block the bronchus or the bronchiole, and the distal alveoli collapse due to hypoventilation. Due to immobility, the secretions may pool in the lungs, which promotes bacterial growth. The resultant infection is called hypostatic pneumonia. Asthma is due to hypersensitivity of the airways to specific allergens and is not due to immobility. Allergic rhinitis is caused by inflammation of the nasal passage due to allergic reactions. Tuberculosis is caused by infection with Mycobacterium tuberculosis.
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. 1 Asthma 2 Atelectasis 3 Hypostatic pneumonia 4 Allergic rhinitis 5 Tuberculosis
4 Anticoagulant therapy is based on the premise that the initiation or extension of thrombi can be prevented by inhibiting the synthesis of clotting factors or by accelerating their inactivation. The anticoagulants heparin and warfarin do not induce thrombolysis but effectively prevent clot extension. These drugs do not decrease the blood viscosity or prevent absorption of vitamin K.
The nurse is caring for a patient who receives anticoagulant treatment for thromboembolic disease. What is the action of anticoagulant drugs? 1 Dissolve the thrombi 2 Decrease blood viscosity 3 Prevent absorption of vitamin K 4 Inhibits the synthesis of clotting factors
1, 3, 4 Footdrop is the most common type of debilitating contracture. The patient is unable to lift the toes from the ground, making it difficult to ambulate. Patients who have suffered a right- or left-sided paralysis are at increased risk of developing footdrop due to immobility. The foot is permanently fixed in plantar flexion. Once footdrop occurs, it cannot be treated. However, it can be prevented through regular physiotherapy.
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. 1 Footdrop is a type of debilitating contracture. 2 The foot is permanently fixed in dorsiflexion position. 3 The patient is unable to lift the toes off the ground. 4 Patients with left- or right-side paralysis are at increased risk of developing footdrop. 5 Footdrop can be treated with regular physiotherapy
2, 3, 4 The physical therapist may collaborate to help the patient rehabilitate by giving the patient gait training. The physical therapist is the head of the rehabilitation team and should be able to guide the family members for rehabilitation. The occupational therapist may help the patient with activities of daily living (ADLs), such as dressing, bathing and toileting, or household chores. The prosthetist's role is to make prosthesis for amputees. The patient has not had an amputation and does not require prosthesis. The social worker focuses on assessment and evaluation of the patient's social situation. The patient's needs are related to the physical mobility; a social worker may not be of help.
The nurse is caring for a retired patient who has had a stroke. The nurse needs to assist the family in adapting to the condition and also help in rehabilitating the patient. Which interdisciplinary team members should the nurse collaborate with? Select all that apply. 1 Social worker 2 Speech therapist 3 Occupational therapist 4 Physical therapist 5 Prosthetist
2, 3, 4 Using a cane to walk is a safety measure that reduces the risk of falls. Reducing the intake of caffeinated products such as coffee indicates effective teaching, as it will improve bone strength by enhancing calcium absorption. Spinach is a calcium rich food that also improves the bone strength. Smoking should be stopped completely. The patient should be able to perform normal daily activities independently.
The nurse is evaluating a patient who was diagnosed with osteoporosis 3 months ago. The patient has limited mobility and has been taught measures to limit risks associated with osteoporosis. Which statements made by the patient indicate effective outcomes of the teaching? Select all that apply. 1 "I have reduced smoking to three cigarettes per day." 2 "I am using a cane to walk when I am alone." 3 "I reduced drinking coffee to 1 cup per day." 4 "I added spinach to my daily diet because I am lactose intolerant." 5 "I can perform normal daily activities with the support of my son."
2, 4, 5 Kyphosis is the increased convexity in the curvature of the thoracic spine, which may be caused by rickets, osteoporosis, or tuberculosis of the spine. Lordosis is the exaggeration of the anterior convex curve of the lumbar spine. This can be a congenital condition or a temporary condition as in the case of pregnancy. Scoliosis is the lateral S- or C-shaped spinal column with vertebral rotation. This can be a consequence of numerous congenital, connective tissue, and neuromuscular disorders. The medial deviation and plantar flexion of the foot is called clubfoot and is not a spinal deformity. The internal rotation of forefoot or entire foot is called pigeon toes, and it is not a spine deformity.
The nurse is teaching a nursing student about various deformities of the spine. Which statements are true about spine deformities? Select all that apply. 1 Scoliosis is the medial deviation and plantar flexion of the foot. 2 Kyphosis is the increased convexity in curvature of the thoracic spine. 3 Kyphosis is the internal rotation of forefoot or entire foot. 4 Lordosis is the exaggeration of the anterior convex curve of lumbar spine. 5 Scoliosis is the lateral S- or C-shaped spinal column with vertebral rotation.
4 Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces the risk for deep vein thrombosis (DVT) formation in the lower extremities. The stockings are not used to prevent varicose veins, muscular atrophy, and contractures, or to promote joint mobility.
The nurse puts elastic stockings on a patient following major abdominal surgery. Why are elastic stockings used after a surgical procedure? 1 To prevent varicose veins 2 To prevent muscular atrophy 3 To ensure joint mobility and prevent contractures 4 To promote venous return to the heart
1, 3, 4, 5 Bending at the knees helps to maintain the center of gravity and thus keeps the body aligned. Bending at the knees uses the stronger leg muscles to do the lifting, preventing exhaustion of other small muscles. Maintaining the trunk erect with knees bent helps multiple muscle groups work together and prevents overworking a single muscle. Getting assistance when shifting patients promotes patient safety and prevents musculoskeletal injury. The risk of injury is less if the object is in the same plane as the person lifting it and is close to the center of gravity for balance. Therefore, the object should be kept as close to the body as possible. The abdominal muscles should be tightened and the pelvis should be tucked. This position provides balance and prevents the back from injury.
The nurse understands the increased risk of musculoskeletal injuries due to activities such as lifting objects, pushing beds, and bathing and feeding patients. Which measures should the nurse adopt to prevent injury? Select all that apply. 1 Bend at the knees. 2 Relax the abdominal muscles. 3 Maintain an erect trunk and bent knees. 4 Get assistance when moving patients. 5 Keep the weight to be lifted as close to the body as possible.
1, 2 Prolonged immobilization in infants, toddlers, and preschoolers may lead to delayed development of gross motor skills. Immobilization in older adults can be caused by degenerative disease, neurological trauma, or chronic illness. Decreased physical activity and hormonal changes can lead to loss of bone mass in older adults. Older adults may experience functional status changes secondary to hospitalization and altered mobility status. Prescribed medications may alter blood pressure when older adults change position too quickly, increasing their risk for falls.
The registered nurse is teaching a nursing student about developmental changes in older adults. Which statements made by the nursing student indicate the need for further learning? Select all that apply. 1 "Prolonged immobilization in older adults delays gross motor skills." 2 "Immobilization in older adults is only caused by degenerative disease." 3 "Decreased physical activity can lead to loss of bone mass in older adults." 4 "Older adults experience functional status changes secondary to hospitalization." 5 "Medications may alter blood pressure when older adults change position too quickly."
2, 5 Postural abnormalities can cause pain and impair alignment or mobility. Muscle abnormalities are more prevalent for muscle diseases in childhood. The nurse should observe body alignment in patients with postural abnormalities. The nurse should ask the patient to perform range of motion exercises to identify postural abnormalities. Lifting, transfer, and positioning are necessary for patients with postural abnormalities.
The registered nurse is teaching a nursing student about postural abnormalities. Which statements made by the nursing student indicate the need for further learning? Select all that apply. 1 "Body alignment should be observed regularly." 2 "Postural abnormalities will only impair alignment." 3 "Patients should perform range of motion exercises." 4 "Positioning is necessary for patients with postural abnormalities." 5 "Postural abnormalities are more prevalent for muscle diseases in childhood."
1, 5 Every patient responds to immobility in a different way. Withdrawn patients often do not want to participate in their own care. Patients with restricted mobility may experience depression. Impaired mobility can cause social isolation and loneliness. Immobilization often leads to emotional and behavioral responses, sensory alterations, and changes in coping.
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. 1 "Every patient responds to immobility in a same way." 2 "Patients with restricted mobility may have depression." 3 "Impaired mobility can cause social isolation and loneliness." 4 "Immobilization leads to emotional and behavioral responses." 5 "Withdrawn patients often want to participate in their own care."
1 Immobility can lead to developmental changes in all age groups. Immobilization leads to social isolation in adolescents. Immobilization can delay a child's gross motor skills, intellectual development, and musculoskeletal development. Immobilization can affect self-concept and self-confidence in adults who have an impact on the job status of adults and their family. Immobilization can result in the risk of physiological systems in older adults.
The registered nurse is teaching a nursing student about the developmental changes that occur due to immobility. Which statement by the nursing student indicates the need for further learning? 1 "Immobilization can lead to social isolation in infants." 2 "Immobilization can delay development of a child's gross motor skills." 3 "Immobilization can affect self-concept in older adults." 4 "Immobilization can result in risk for all physiological systems in older adults."
3 Direct trauma to the musculoskeletal system results in bruises, sprains, and contusions. Damage to the cerebellum causes problems with balance and motor impairment. A person with right-sided cerebral hemorrhage with necrosis has destruction of the right motor strip that results in left-sided hemiplegia. A complete transection of spinal cord results in bilateral loss of voluntary motor control below the level of trauma because motor fibers are cut.
The registered nurse is teaching a nursing student about the pathological influence on mobility. Which statement made by the nursing student indicates a need for further learning? 1 "Damage to the cerebellum causes problems with balance." 2 "Right-sided cerebral hemorrhage causes left-sided hemiplegia." 3 "Direct trauma to the central nervous system results in bruises and contusions." 4 "Complete transection of spinal cord causes bilateral loss of voluntary motor control below the level of the trauma."
1, 4 Mobility of the knee joint is assessed by flexion of 120 degrees to 130 degrees. Flexion of 90 degrees of knee joint may indicate disability. The thumb is a saddle joint and should extend up to 90 degrees. Extension of 50 degrees may indicate disability. Extension of the elbow joint up to 150 degrees would be a normal finding. The food is a gliding joint and should exhibit inversion up to 10 degrees. Abduction of the condyloid joint of the wrist is up to 30 degrees.
The registered nurse is teaching a nursing student about the range-of-motion exercises used to assess mobility. Which statement made by the nursing student indicates the need for further teaching? Select all that apply. 1 "I will assess the knee joint by flexion of 90 degrees." 2 "I will assess the elbow joint by flexion of 150 degrees." 3 "I will assess the foot joint by inversion of 10 degrees." 4 "I will assess the thumb joint by extension of 50 degrees." 5 "I will assess the condyloid joint of wrist by abduction of 30 degrees."
3, 4 The skeletal system is the supporting framework of the body and is made up of four types of bones: long, short, flat, and irregular. The skeletal muscle provides attachments for muscles and ligaments and the nervous system regulates movement and posture. The skeletal muscles protect vital organs and aids in calcium regulation. The skeletal muscle enables the bones to withstand weight bearing.
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. 1 "The skeletal system protects the vital organs." 2 "The skeletal system aids in calcium regulation." 3 "The skeletal muscle includes three types of bones." 4 "The skeletal system regulates movement and posture." 5 "The skeletal system enables the bones to withstand weight bearing."
1, 2, 4 The frontal plane divides the body into front and back. Inversion, abduction, eversion, and adduction are the movements that occur along the frontal plane. Sagittal plane divides the body into left and right sides. Extension and flexion are the movements assessed in sagittal plane. Rotation is assessed in transverse plane. It is a line that divides the body into upper and lower body. Plantar flexion is assessed in sagittal plane.
The registered nurse is teaching a nursing student how to assess range of motion based on planes of the body. Which statements made by the nursing student indicate effective learning? Select all that apply. 1 "Inversion of the foot takes place in a line that divides the body into front and back." 2 "Abduction of the arm takes place in a line that divides the body into front and back." 3 "Rotation of the hip takes place in a line that divides the body into left and right sides." 4 "Extension of the elbow takes place in a line that divides the body into left and right sides." 5 "Plantar flexion of the foot takes place in a line that divides the body into upper and lower body."
1, 2, 5 The functions of the skeletal system include providing joint flexibility and support, regulating calcium, and protecting vital organs. The nervous system regulates movement and posture. Body alignment contributes to balance of the body.
What are the functions of the skeletal system? Select all that apply. 1 Provide support 2 Regulate calcium 3 Regulate posture 4 Contribute balance 5 Protect vital organs
2, 4, 3, 1 Assessment of mobility focuses on range of motion, gait, exercise, and activity tolerance. Generally, the nurse performs the assessment of movement starting with the patient in a lying position, proceeding to assessing sitting positions in bed, then transferring to a chair, and finally walking.
What is the correct order of assessments of patient mobility performed by the nurse? 1. Walking 2. Lying position 3. Transferring to chair 4. Sitting position in bed
2 Hypoventilation may occur due to atelectasis resulting from blockage of bronchioles by secretions and the collapse of distal lung tissue. Tachypnea is seen in atelectasis and not bradypnea. Crackle sounds are heard with pneumonia. Asymmetrical chest wall is observed due to lung collapse.
Which assessment findings indicate atelectasis that may result from immobility? 1 Bradypnea 2 Hypoventilation 3 Presence of crackles 4 Symmetrical chest wall
1, 4, 5 Immobility causes many complications, and patients with comorbid conditions are at a higher risk of developing one of these complications. The patients with arthritis, diabetes, and spinal cord injury are at high risk for complications when lying down. The patient with arthritis may have impaired joint mobility, which may aggravate complications. Diabetes may cause impaired circulation and increase the risk of skin breakdown. In case of spinal cord injury, there may be a lack of voluntary muscle control, making the patient susceptible to complications like pressure ulcers. The patient who has anemia or back pain is not at high risk for damage when immobile.
Which conditions put the patient at high risk for complications when bedridden and immobile? Select all that apply. 1 Arthritis 2 Anemia 3 Back pain 4 Diabetes 5 Spinal cord injury
1 When the patient is in the supine position, the nurse should use a trochanter roll to prevent external rotation of the hips. When the hips are correctly aligned, the patella faces directly upward. The positioning boots help in preventing footdrop. Patients use trapeze bars to lift themselves during repositioning. Pillows may not be helpful in preventing the external rotation of the hips.
Which device should the nurse use to prevent external rotation of the hips when the patient is in a supine position? 1 Trochanter roll 2 Positioning boots 3 Trapeze bars 4 Pillows
2 The patient with hemiplegia due to limited mobility is at risk of increased calcium resorption from the bones, resulting in hypercalcemia. Immobility may lead to loss of appetite and decreased peristalsis. Immobilized patients often have an increased basal metabolic rate due to an increase in cellular oxygen requirements. Immobility may lead to impairment of gastrointestinal functioning, which may further lead to increased intraluminal pressure.
Which finding does the nurse anticipate while assessing a patient who has had limited mobility for the past month and is diagnosed with hemiplegia? 1 Increased peristalsis 2 Increased calcium resorption 3 Decreased basal metabolic rate 4 Decreased intraluminal pressure
1, 3, 4 Adequate fluid intake prevents dehydration and ensures an adequate intravascular volume. Elastic stockings help maintain external pressure on the muscles of the leg, thus promoting venous return and preventing thrombus formation. Performing leg, ankle, and foot exercises regularly prevents blood stasis. Repositioning also prevents stasis of blood, thus preventing formation of thrombus. Exercises of the hand, arm, and neck do not contribute to prevention of thrombus formation. These muscles are not large enough to promote blood flow from periphery to the heart.
Which interventions should the nurse perform to reduce the risk of thrombus formation in a bedridden patient? Select all that apply. 1 Ensure adequate fluid intake. 2 Do not move or reposition the patient. 3 Use elastic stockings on the legs. 4 Perform leg, ankle, and foot exercises regularly. 5 Perform hand, arm, and neck exercises regularly.
2 Once osteoporosis is diagnosed, the main goal is to maintain independence in activities of daily living (ADLs). It is best to identify individuals at risk and work toward preventing the disease. The patient should be taught the current recommended dietary allowances for calcium and vitamin D. Bone loss cannot be totally reversed, but measures can be taken to prevent further bone loss and pathological fractures.
Which is a desired outcome for a patient diagnosed with osteoporosis? 1 Maintain serum level of calcium. 2 Maintain independence with activities of daily living (ADLs). 3 Reduce supplemental sources of vitamin D. 4 Reverse bone loss through dietary manipulation.
4 In an immobile patient, his or her body often excretes more nitrogen that in ingests, resulting in negative nitrogen balance. Immobility disrupts normal metabolic functioning, and causes gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. The metabolic rate decreases in patients with immobility.
Which metabolic changes are observed in immobile patients? 1 Increased appetite 2 Increased peristalsis 3 Increased metabolic rate 4 Increased nitrogen levels
3 Adduction, abduction, eversion, and inversion are the movements assessed in the frontal plane. Rotation is a movement assessed in the transverse plane. Extension is a movement in the sagittal plane. Supination is also the movement assessed in the transverse plane.
Which movement is assessed in the frontal plane when the nurse is observing the mobility of the joint? 1 Rotation 2 Extension 3 Adduction 4 Supination
1, 2, 3 Antiembolic stockings are used to maintain external pressure on the muscles of the lower extremities and promote venous return. These stockings are not used if there are skin lesions, gangrene, or recent vein ligation. Application of these stockings would compromise circulation and worsen these conditions. Venous insufficiency is an indication for application of elastic stockings; it helps to prevent muscle atrophy.
Which patient conditions are contraindications for antiembolic stockings? 1 Skin lesions 2 Gangrene 3 Recent vein ligation 4 Venous insufficiency 5 Muscle wasting
1, 2, 5 When the head of the hospital bed is elevated, pressure ulcers often develop within the undermined tissue. When the bed is elevated to 60 degrees, gravity pulls a patient so that bony skeleton moves towards the foot of the bed while the skin remains against the sheet. The blood vessels in the underlying tissue are not strengthened; instead they are stretched and damaged, resulting in the impeded blood flow to the deeper tissues and blood vessels.
Which physiological changes are observed in a patient when the head of a hospital bed is elevated to 60 degrees? Select all that apply. 1 Formation of pressure ulcers 2 Skin remains against the sheets 3 Increased blood flow in the blood vessels 4 Blood vessels in the underlying tissues are strengthened 5 Bony skeleton moves forward towards the foot of the bed
1 Lordosis is a postural abnormality that involves an exaggeration of the anterior convex curve of the lumbar spine. Kyphosis is the increased convexity in the curvature of thoracic spine. Scoliosis is a lateral S- or C-shaped spinal column with vertebral rotation and unequal heights of hips and shoulders. Torticollis involves inclination of the head to the affected side and contraction of the sternocleidomastoid muscle.
Which postural abnormality indicates an exaggeration of the anterior convex curve of the lumbar spine? 1 Lordosis 2 Kyphosis 3 Scoliosis 4 Torticollis
2 At some point in the development of respiratory complications, there is proportional decline in the patient's ability to cough productively. In patients with respiratory complications, mucus accumulates in dependent regions of the airways. Hypostatic pneumonia frequently results because mucus is an excellent place for bacteria to grow. Distribution of the mucus in the bronchi increases, particularly when the patient is in the supine or lateral position.
Which statement by a nursing student regarding the respiratory changes in immobile patients needs correction? 1 "Mucus accumulates in dependent regions of the airways." 2 "There is increased cough productivity in immobile patients." 3 "Hypostatic pneumonia may develop in patients with immobility." 4 "Distribution of mucus in the bronchi increases when the patient is in the supine position."
3 In the sagittal plane, movements are flexion and extension of fingers and elbows. Ligaments, muscles, and the nature of the joint limit mobility in each of the planes, but some joint movements are specific to each plane. In the frontal plane, movements are abduction and adduction of arms and legs. In the transverse plane, the movements are internal and external rotation of hips, pronation, and supination.
Which statement made by a nursing student regarding the three planes of the body involved in maximum movement requires correction? 1 "Some joint movements are specific to each plane." 2 "In the frontal plane, movements are abduction of arms." 3 "In the sagittal plane, movements are pronation and supination." 4 "In the transverse plane, movements are internal and external rotation of hips."
3, 4, 5 The urinary elimination changes that are often observed as the period of immobility continues are increased renal calculi, as immobilized patients may have hypercalcemia that causes calcium stones. As the immobility continues, the fluid intake decreases and the concentration of urine increases. As the concentration of urine increases, urinary tract infections also increase. As the period of immobility continues, fluid intake often diminishes and, therefore, urinary output also decreases.
Which urinary elimination changes are often observed as the period of immobility continues for a patient? Select all that apply. 1 Increased fluid intake 2 Increased urinary output 3 Increased risk of renal calculi 4 Increased urinary concentration 5 Increased risk for urinary tract infections
2 Lack of movement and exercise places patients at risk for respiratory complications. The metabolic changes seen in patients with impaired mobility are altered endocrine metabolism and calcium resorption. An ulcer is characterized by inflammation and usually forms over a bony prominence. It is seen due to integumentary changes in patients with impaired mobility. The musculoskeletal changes seen in patients with impaired mobility are temporary impairment and permanent disability.
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? 1 Metabolic 2 Respiratory 3 Integumentary 4 Musculoskeletal
4 The normal respiratory rate is 12 to 18 breaths/minute. Patients with limited mobility may be at risk of pooling pulmonary secretions, which may result in increased respiratory rate. A heart rate of 60 beats/minute, blood pressure of 120/90, and pain reported as 2 on a scale of 1 to 10 are normal findings.
While assessing a postoperative patient, the nurse observes that the patient is unable to sleep in the lateral position. Which assessment finding indicates an increased risk of developing complications due to immobility? 1 Heart rate 60 beats/minute 2 Blood pressure 120/90 mm Hg 3 Pain reported as 2 on pain scale 4 Respiratory rate 28 breaths/minute
3 Alterations in blood constituents, such as a change in clotting factors and increased platelet activity, may result in deep vein thrombosis. Increased serum calcium may indicate osteoporosis due to increased bone resorption. A decrease in blood glucose might not indicate deep vein thrombosis. A decreased red blood cell count is not associated with deep vein thrombosis.
While caring for a patient, the nurse suspects deep vein thrombosis. Which factor of Virchow's triad may lead to this condition? 1 Increased serum calcium 2 Decreased blood glucose 3 Increased platelet activity 4 Decreased red blood cell count
