Immobility Quiz

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

3. Adduction 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.

While assessing a patient for joint mobility, the nurse notices that the patient is unable to dorsiflex the foot. Which condition does the nurse suspect in the patient? 1. Scoliosis 2. Torticollis 3. Joint contracture 4. Disuse osteoporosis

3. Joint contracture A patient with the type of joint contracture known as foot drop is permanently fixed in plantar flexion and is unable to dorsiflex the foot. Disuse osteoporosis refers to atrophy and decreased density of the bone tissue. Torticollis involves inclining the head to the affected side with the sternocleidomastoid muscle is contracted. Scoliosis refers to a lateral S- or C-shaped spinal column with vertebral rotation, and unequal heights of the hips and shoulders.

Which movement is assessed based on the line that divides the body into upper and lower regions when the nurse is observing the mobility of the joint? 1. Flexion 2. Eversion 3. Pronation 4. Abduction

3. Pronation The transverse plane is a horizontal line that divides the body into upper and lower regions. Pronation, supination, and rotation are movements observed in the transverse plane. Flexion is a movement assessed in the sagittal plane. Eversion and abduction are movements assessed in the frontal plane.

A patient has her call bell on and looks frightened when the nurse enters the room. The patient has been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my breath." What should the nurse do first? 1. Call the healthcare provider to report this change in condition. 2. Give the patient a paper bag to breathe into to decrease anxiety. 3. Assess vital signs, perform a respiratory assessment, and be prepared to start oxygen. 4. Explain that this is normal after such trauma and administer the ordered pain medication.

3. Assess vital signs, perform a respiratory assessment, and be prepared to start oxygen. The patient is exhibiting signs of possible pulmonary emboli, which can be life threatening. The nurse must assess the patient, be prepared to start oxygen, and have someone call the surgeon while staying with the patient to continue to monitor the patient's status.

The nurse is preparing a dietary plan for the patient who has osteoporosis. Which foods should the nurse recommend to increase calcium level? Select all that apply. 1. Fruits 2. Legumes 3. Yogurt 4. Cheese 5. Green vegetables

3. Yogurt 4. Cheese 5. Green vegetables The patient with osteoporosis requires a calcium-rich diet to replenish lost calcium. Yogurt, cheese, and green vegetables are rich in calcium and should be added to the dietary plan. Fruits and legumes are good for health but are not good sources of calcium. STUDY TIP: Keep track of your food intake for a few days and check the amount of calcium in various foods as you do so. You will notice how high dairy products and leafy green vegetables are in calcium. There are some online applications that will total various nutrients for you as you enter the foods and quantities you have consumed.

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? 1. "I will massage the legs." 2. "I will instruct the patient to avoid crossing the legs." 3. "I will assist the patient in performing range-of-motion exercises." 4. "I will position the patient without applying pressure on the posterior of knee."

1. "I will massage the legs." Massaging the leg should be avoided in cases of deep vein thrombosis, because it may lead to dislodgement of the thrombus and result in severe complications. Crossing of the legs should be avoided to increase the blood circulation. Performing range-of-motion exercises reduce the risk of contractures and aid in preventing thrombi. Proper positioning without applying pressure on the posterior of knee reduces a patient's risk of thrombus formation, because compression of the leg veins is minimized.

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.

1. Ensure adequate fluid intake. 3. Use elastic stockings on the legs. 4. Perform leg, ankle, and foot exercises regularly. 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. Test-Taking Tip: Staying calm helps you make good choices. Ways to stay calm during the exam include deep breathing, closing your eyes, and picturing a scene that helps you relax, as well as repeating positive affirmations silently to yourself, such as "I have studied; I know this material!"

While assessing a patient, the nurse finds complete elongation of the deltoid muscle even in a normal position. How does the nurse interpret this observation? 1. Normal finding 2. Presence of orthopnea 3. Presence of contracture 4. Limited movement of the arms

1. Normal finding Complete elongation of the deltoid muscle is a normal finding that is used to assess the mobility of the shoulders. Orthopnea may cause a patient to lean on the table in front of his or her chair in an attempt to breathe more easily. A limited range of motion may indicate the presence of contracture. Limited movement of the shoulder may result in decreased movement of the arms.

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. Massaging the area may dislodge the thrombus. 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. Test-Taking Tip: Look for answers that promote client safety and client-centered care!

After assessing a patient's range of motion at the ankle joints, the nurse finds increased mobility beyond the normal range. What does the nurse anticipate from this finding? 1. Arthritis 2. Contracture 3. Ligament tear 4. Fluid in the joint

3. Ligament tear Increased mobility of the joints beyond normal may indicate a tear in a ligament or connective tissue disorder. Arthritis is a joint disorder that causes limited mobility. A contracture is a constriction of the joints or muscles in which mobility is limited. Likewise, fluid in the joint would result in decreased mobility.

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. Coffee ground-like aspirate from the feeding tube 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.

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 blood flow 4. Risk for inability to tolerate activity

4. Risk for inability to tolerate activity 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.

The registered nurse is teaching a nursing student about the interventions performed in immobilized patients who are at risk for impaired skin integrity. Which statement made by the nursing student indicates the need for further learning? 1. "I should reposition the patient frequently when he or she is awake." 2. "I should use a device to relieve pressure when the patient is seated." 3. "I should use an objective tool to assess the risk of developing pressure ulcers." 4. "I should teach the patient on how to shift weight at regular intervals while sitting."

1. "I should reposition the patient frequently when he or she is awake." Repositioning should be done every 1 to 2 hours; however, this is not only limited to when the patient is awake. Use of pressure relief devices may reduce the risk of developing pressure ulcers. Using an objective tool to assess the risk of pressure ulcers would help in choosing the appropriate surface devices. Shifting the weight while sitting reduces the risk of developing pressure ulcers. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

The nurse is teaching a patient diagnosed with arthritis of the knees about physical activity and lifestyle changes. Which statement by the patient indicates correct understanding of the teaching? 1. "I will perform exercises in a pool." 2. "I will go for a walk every morning." 3. "I will increase my intake of foods rich in vitamin D." 4. "I will frequently perform weight-bearing exercises."

1. "I will perform exercises in a pool." Aquatic therapy involves performing exercises in a pool, which is an appropriate therapy used to regain joint mobility in severe arthritis of knees. Aquatic therapy would be more beneficial for this patient than walking. Increased intake of foods rich in vitamin D is beneficial to strengthen the bones, but it would not help a patient regain joint mobility. Weight-bearing exercises strengthen the bones and the joints, but there is a risk for fractures in this patient while performing these exercises. Therefore, aquatic therapy is preferred for severe arthritis. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which menus should the nurse recommend? 1. Cream of broccoli soup with whole wheat crackers and tapioca for dessert 2. Hamburger on soft roll with a side salad and an apple for dessert 3. Low-fat turkey chili with sour cream and fresh pears for dessert 4. Chicken salad on toast with tomato and lettuce and honey bun for dessert

1. Cream of broccoli soup with whole wheat crackers and tapioca for dessert The dairy and broccoli in the soup, the whole grain crackers, plus the tapioca are all great sources of calcium.

Which assessment finding may indicate orthostatic hypotension associated with prolonged immobility? 1. Pallor 2. Pain upon breathing 3. Decreased heart rate 4. Increased cardiac output

1. Pallor Pallor may indicate the presence of orthostatic hypotension. The further findings to confirm this condition includes dizziness, light-headedness, nausea, and tachycardia. Pain upon breathing may indicate pneumonia but is not associated with orthostatic hypotension. Increase heart rate is seen in orthostatic hypotension, not decreased heart rate. Decreased cardiac output is seen in orthostatic hypotension, not increased cardiac output.

Which patient conditions are contraindications for antiembolic stockings? 1. Skin lesions 2. Gangrene 3. Recent vein ligation 4. Venous insufficiency 5. Muscle wasting

1. Skin lesions 2. Gangrene 3. Recent vein ligation 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 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

1. Trochanter roll 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 condition is associated with increased risk of footdrop? 1. Kyphosis 2. Hemiplegia 3. Osteoporosis 4. Disuse syndrome

2. Hemiplegia In foot drop, the foot is permanently fixed in plantar flexion, resulting limited mobility. Patients with hemiplegia are at increased risk of developing footdrop. Kyphosis refers to increased convexity in curvature of the thoracic spine. Osteoporosis may result from decreased bone density. Disuse syndrome refers to impaired physical mobility.

Which assessment finding is contraindicated in a patient who is suspected to have a deep vein thrombosis due to restricted mobility? 1. Edema 2. Homans' sign 3. Absence of peripheral pulse 4. Increased calf circumference

2. Homans' sign Homans' sign, or calf pain on dorsiflexion of the foot, is no longer considered a reliable indicator to assess deep vein thrombosis (DVT), and it is contraindicated in diagnosing patients who are suspected to have DVT. The nurse should assess for edema and peripheral pulse in a patient who is suspected to have DVT. Daily measurement of calf circumference is the recommended assessment for DVT, because an increase in calf circumference may indicate DVT.

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

2. Increased calcium resorption 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.

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? 1. Assessing the feet for temperature 2. Measuring the calf and thigh circumference 3. Assessing for calf pain on dorsiflexion of the foot 4. Observing for loss of skin integrity in the lower extremities

2. Measuring the calf and thigh circumference A unilateral increase in calf circumference is an early indicator for deep vein thrombosis. Therefore, circumferences of the thigh and calf should be measured to assess for DVT. The temperature of the feet is not a reliable assessment in determining a DVT. Assessing for calf pain on dorsiflexion of the foot is contraindicated for a patient who is suspected to have developed DVT. Loss of skin integrity is a sign of increased risk of DVT; therefore, skin assessment in the lower extremities is a correct action.

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

2. Temperature of the skin 3. Pedal pulse 5. Color of the skin 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. STUDY TIP: Memorize the locations of all the pulses by quizzing with a fellow student or in a study group. Have one person call out the name of the pulse and another demonstrate the pulse. Or make it a contest and award a point for each correct demonstration. Continue until each person has correctly demonstrated the location of each pulse.

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. 1. Rubber mat in the walk-in shower 2. Three-legged stool on wheels in the kitchen 3. Braided throw rugs in the entry hallway and between the bedroom and bathroom 4. Night-lights in the hallways, bedroom, and bathroom 5. Cordless phone next to the patient's bed

2. Three-legged stool on wheels in the kitchen 3. Braided throw rugs in the entry hallway and between the bedroom and bathroom The three-legged stool on wheels and throw rugs are hazards that put the patient at risk for falls. The rubber mat in the shower, night-lights, and cordless phone are all safety measures that should be put in place to prevent fall or injury. By planning ahead and collaborating, the home care nurse can provide a safe home environment for the patient after discharge.

Which finding may indicate metabolic change as a result of immobility? 1. Muscle atrophy 2. Peripheral edema 3. Delayed wound healing 4. Orthostatic hypotension

3. Delayed wound healing Delayed wound healing is a metabolic change, because the rate of healing is affected by nutritional intake and nutrient absorption. Muscle atrophy is a musculoskeletal change due to immobility. Peripheral edema and orthostatic hypotension are cardiovascular changes due to immobility.

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.

3. Elevate the legs while sitting. 5. Avoid wrinkles in stockings. 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. Test-Taking Tip: Monitor questions you answered with an educated guess or those in which you changed your answer from the first option you selected. This will help you to analyze your ability to think critically. Usually your first response is correct and should not be changed without reason.

The nurse is reviewing the data of patients who have undergone surgery. Which patient would be at the highest risk of orthostatic hypotension based on the given data? 1. Patient A: appendectomy 2. Patient B: lobotomy 3. Patient C: hip replacement 4. Patient D: bypass surgery

3. Patient C: hip replacement The longer the duration of a patient's immobility, the higher the risk is for orthostatic hypotension. Therefore, the patient who underwent hip replacement and required bed rest for 90 days would be at the highest risk of orthostatic hypotension. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and assistant/patient interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.

Which indicates that additional assistance is needed to transfer a patient from the bed to the stretcher? 1. The patient is 5 feet 6 inches and weighs 120 lbs. 2. The patient speaks and understands English. 3. The patient received an injection of morphine 30 minutes ago for pain. 4. The nurse feels comfortable handling a patient of this size and with this level of cooperation.

3. The patient received an injection of morphine 30 minutes ago for pain. The morphine injection would change the patient's ability to safely follow directions and participate in the transfer; therefore, additional help would be needed to safely transfer the patient from the bed to the stretcher. The patient's height and weight, ability to speak English, and the nurse's comfort level in handling the patient do not change the patient's ability to participate in the transfer.

The nurse reviews discharge instructions with a patient who has osteoporosis. Which statement by the patient indicates that the patient understands the instructions? 1. "I will avoid intake of leafy green vegetables." 2. "I will avoid exercises, because they may cause bone fracture." 3. "I will reduce consumption of food containing calcium." 4. "I will stop smoking as soon as possible."

4. "I will stop smoking as soon as possible." Patients with osteoporosis should make lifestyle changes to prevent the disease from becoming worse. Smoking poses a major risk for osteoporosis, but this risk can be drastically reduced if the patient stops smoking. Intake of leafy green vegetables is helpful for the patient who has osteoporosis and should not be avoided. Exercise is helpful in keeping the bones strong. The patient should increase intake of calcium to maintain bone health. Test-Taking Tip: If you did not know the answer to this question, your best guess would be to pick the statement that is consistent with good health practices. Read the choices again while thinking, "Would this statement support health?" Only one response meets that goal, so the answer is clear.

Healthcare professionals have an increased risk of musculoskeletal injuries, because their occupation involves lifting and transferring patients. How can the nurse reduce the risk of musculoskeletal injuries when lifting any person or object? 1. Keep the object away from the body. 2. Bend at the hips and not at the knees. 3. Relax the abdominal muscles. 4. Keep trunk erect and bend the knees.

4. Keep trunk erect and bend the knees. When lifting an object or person, the trunk should be kept erect and the knees should be bent so that multiple muscle groups are used in a coordinated manner, which prevents strain on single muscles. When lifting, the object should be as close to the body as possible. This helps place the object in the same plane as the lifter and close to the center of gravity for balance. The body should be bent at the knees to maintain the center of gravity and promote use of the stronger leg muscles to do the lifting. The abdominal muscles should be tightened, and the pelvis should be tucked, to provide balance and help protect the back. STUDY TIP: Practice lifting large empty boxes in your study group and critiquing each other on your lifting form to prepare for lifting heavier objects or a patient. Aim for these factors: (1) position object close to body; (2) bend at the knees and not at the hips; (3) tighten your abdominal muscles (think: tummy tight!); and (4) keep the trunk erect with the pelvis tucked. Be sure everyone actually practices, as this is a psychomotor skill.

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

4. To promote venous return to the heart 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 is caring for multiple patients in a health care setting. Which patient would the nurse anticipate to be at a higher risk of osteoporosis? Select all that apply. Patient A: Torticollis Patient B: Immobility Patient C: Cerebrovascular accident D: Lactose intolerance Patient A Patient B Patient C Patient D

Patient D Osteoporosis is a condition in which bone density decreases and which results in increased risk of fractures. Osteoporosis occurs due to calcium deficiency. A patient with lactose intolerance has a higher risk of calcium deficiency and is at a higher risk for osteoporosis. Torticollis is a condition where the patient's neck is tilted in an abnormal position. Torticollis is congenital or acquired and is not associated with osteoporosis. A patient who has had a cerebrovascular accident or stroke may develop paralysis resulting in footdrop but would not have an increased risk of osteoporosis. Although primary osteoporosis is different in origin from the osteoporosis that results from immobility, it is imperative that nurses recognize that immobilized patients are at high risk for accelerated bone loss if they have primary osteoporosis.