Mobility/Immobility

The nurse is reviewing the data of a patient with severe joint pain. Which questions asked by the nurse help assess joint mobility?

"Does your joint pain worsen if you walk?" "Have you noticed any swelling of the joints?"

The registered nurse is teaching a nursing student about positioning techniques. Which statement made by the nursing student indicates effective learning?

"I can use folded sheets when additional pillows are unavailable."

The registered nurse is teaching a student nurse about restorative and continuing care for a patient who underwent hip replacement. Which statements by the nursing student indicate effective learning?

"I will ensure that the patient can eat by him- or herself." "I will ensure that the patient can take medication by him- or herself."

The registered nurse is teaching a nursing student about postural abnormalities. Which statements made by the nursing student indicate the need for further learning?

"Postural abnormalities will only impair alignment." "Postural abnormalities are more prevalent for muscle diseases in childhood."

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

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

The nurse is caring for patients on a medical-surgical unit. The nurse plans the patients' care and instructs the nursing assistant to assist in repositioning patients every 2 hours. Which patients are at the greatest risk for complications if not repositioned properly?

A 20-year-old unconscious patient A 90-year-old frail patient A 40-year-old patient who has paraplegia

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?

Atelectasis Hypostatic pneumonia

The nurse has placed a patient in the Sims' position. Which areas would bear the maximum weight of the body?

Clavicle

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?

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

While positioning a patient in the 30-degree lateral position, the nurse rolls the patient towards his or her side. What is the rationale behind this nursing action?

Decrease trauma to tissues

hypostatic pneumonia

Due to immobility, the secretions may pool in the lungs, which promotes bacterial growth.

Nursing assistive personnel (NAP) are applying antiembolic elastic stockings to the patient. Which instructions should the NAP give to the patient?

Elevate the legs while sitting. Avoid wrinkles in stockings.

What are the common trouble areas for patients in the supine position?

Extended elbows Unsupported feet Externally rotated hips

The nurse is assessing a patient who complains of joint pain. Which types of range of motion assessed by the nurse involve sagittal plane movement?

Extension Dorsiflexion

The nurse is assessing a patient who is experiencing complications due to restricted activity after surgery. Which findings assessed by the nurse would indicate that the patient has pneumonia?

Fever Crackles Pain on breathing

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

Footdrop

Which is a common debilitating contracture?

Footdrop

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?

Footdrop is a type of debilitating contracture. 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.

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?

Green leafy vegetables Yogurt Cheese

Which areas of the patient would bear weight when placed in the side-lying position?

Hip Shoulder

What is the desired outcome when the head of the bed is elevated to 60 degrees in supported Fowler's position?

Improves ventilation

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?

Ligament tear

Atelectasis

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

While positioning a patient in the supported supine position, the nurse places a pillow under the upper shoulders. What is the rationale behind this intervention?

Maintain correct alignment

Which is a desired outcome for a patient diagnosed with osteoporosis?

Maintain independence with activities of daily living (ADLs).

Which assessment finding may indicate orthostatic hypotension associated with prolonged immobility?

Pallor

The nurse is caring for four different patients with immobility. Which patient should the nurse place in the supine position?

Patient with musculoskeletal complications

While positioning a hemiplegic patient in the supported Fowler's position, the nurse positions the head of the patient against a small pillow with the chin slightly forward. What is the rationale behind this nursing action?

Prevent flexion contractures

While placing a patient in the prone position, the nurse supports the lower legs with pillows to elevate the toes. What could be the reason for this nursing action?

Prevent footdrop Reduce external rotation of the hips Eliminate mattress pressure on the toes

While assessing a patient with impaired mobility, the nurse prioritizes which type of related complication?

Respiratory

The nurse is positioning a patient in supported Fowler's position. Which action should the nurse perform to prevent flexion contractures of the cervical spine?

Rest the head of the patient against the mattress

The nurse is caring for different patients. Which patient's condition may benefit from logrolling?

Spinal cord injury

The nurse has put antiembolitic elastic stockings on the legs of a patient. What parameters should the nurse check after applying the stockings?

Temperature of the skin Pedal pulse Color of the skin

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.

Which positioning aid increases cervical flexion?

Thick pillow

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

Trapeze bar

Which site is at risk for skin breakdown when the patient is in the side-lying position?

Trochanter

Immobilized patients are at risk for bedsores. Which interventions would reduce this risk?

Using an objective, valid scale to assess patient's risk for pressure ulcer development Using a device to relieve pressure when patient is seated in chair Teaching patient how to shift weight at regular intervals while sitting in a chair Following this good rule: the higher the risk for skin breakdown, the shorter the interval between position changes

The nurse is preparing a dietary plan for the patient who has osteoporosis. Which foods should the nurse recommend to increase calcium level?

Yogurt Cheese Green vegetables

Which metabolic changes are observed in immobile patients?

Increased nitrogen levels

The nurse is assessing a postoperative patient and suspects deep vein thrombosis. Which other assessment findings will help the nurse confirm the suspicion?

Tachycardia Shortness of breath Increased calf circumference

The registered nurse is providing instructions to a nursing student about the interventions performed while moving the patient. Which instruction given by the registered nurse should be prioritized?

"Determine the effects of illness on exertion."

A patient is advised to be in supported Fowler's position. Which trouble areas can cause patient discomfort in this position?

Increased shearing force on the back and heels Unprotected pressure points at the sacrum and heels Pressure on the posterior aspect of the knees decreasing circulation to the feet

While positioning a hemiplegic patient in the supported Fowler's position, the nurse elevates the head of the bed to 50 degrees. What is the rationale behind this intervention?

To improve the patient opportunity to relax

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 registered nurse is teaching a nursing student about the interventions to be performed when the patient avoids moving. Which statements made by the nursing student indicate a need for further learning?

"I should consult an occupational therapist." "I should increase the frequency of turning."

The registered nurse is teaching a nursing student about the steps of planning for moving and positioning patients. Which statement made by the nursing student indicates the need for further learning?

"I should place all pillows on the bed." "I should keep the level of the bed in a low position."

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?

"I will perform exercises in a pool."

The registered nurse is teaching a student nurse about the positioning of a postsurgical patient. Which statement made by the nursing student indicates a need for further learning?

"I will position the patient in the prone position to prevent pressure ulcers."

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 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?

"Immobilization can lead to social isolation in infants."

Which statement made by a nursing student regarding the three planes of the body involved in maximum movement requires correction?

"In the sagittal plane, movements are pronation and supination."

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?

"Inversion of the foot takes place in a line that divides the body into front and back." "Abduction of the arm takes place in a line that divides the body into front and back." "Extension of the elbow takes place in a line that divides the body into left and right sides."

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?

Assessing for calf pain on dorsiflexion of the foot

Which urinary elimination changes are often observed as the period of immobility continues for a patient?

Increased risk of renal calculi Increased urinary concentration Increased risk for urinary tract infections

Which assessment findings indicate atelectasis that may result from immobility?

Hypoventilation

While assessing a patient with rickets, the nurse finds that the patient has bowlegs. Which appropriate interventions should the nurse suggest to the patient's parents?

Increase intake of vitamin D. Increase intake of calcium. Increase intake of phosphorus.

Which finding does the nurse anticipate while assessing a patient who has had limited mobility for the past month and is diagnosed with hemiplegia?

Increased calcium resorption

The nurse is caring for a patient who receives anticoagulant treatment for thromboembolic disease. What is the action of anticoagulant drugs?

Inhibits the synthesis of clotting factors

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?

Joint contracture

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?

Keep trunk erect and bend the knees.

Which trouble points would the nurse anticipate while positioning the patient in the Sims' position?

Lack of foot support Lateral flexion of the neck Lack of protection for pressure points

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?

Move the leg back toward the medial position.

Which statement is true regarding muscle abnormalities?

Muscle abnormalities cause degeneration of skeletal muscle fibers.

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?

Normal finding

The nurse is caring for four different patients with immobility with different conditions. Which patient should the nurse place in the side-lying position? PtA- Pressure Ulcers PtB- Respiratory Distress PtC- Deep Vein Thrombosis PtD- Musculoskeletal Complications

Patient A

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? PtA- Appendectomy- 3days bedrest PtB- Lobotomy- 10 days PtC- Hip Replacement- 20 days PtD- Bypass Surgery- 15 days

Patient C

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? PtA- Torticollis PtB- Immobility PtC- Cerebrovascular accident PtD- Lactose Intolerance

Patient D

Which aspect of positioning a patient in the supported Fowler's position has a goal of decreasing flexion of vertebrae?

Place a small pillow at the lower back

The registered nurse is supervising a nursing student who is using positioning aids with a patient. Which nursing action may lead to skin and tissue damage caused by pressure?

Placing a thin pillow under the bony prominences

Which nursing action prevents tension on the spinal column and adduction of the hips while logrolling the patient?

Placing small pillows between patient's knees

The nurse uses trochanter rolls or sand bags when performing which intervention?

Placing the patient in the supported supine position Placing the patient in the supported Fowler's position

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?

Pressure ulcers

While logrolling a patient, the nurse crosses the patient's arms on the chest. What is the reason for the nurse's action?

Prevent injury to arms

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?

Pronation

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

Which position would be beneficial for a patient who is suspected to have lung injury?

Prone position

What is the significance of the 30-degree lateral position?

Reduces the risk of pressure ulcers

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?

Respiratory rate 28 breaths/minute

Which patient conditions are contraindications for antiembolic stockings?

Skin lesions Gangrene Recent vein ligation

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? .

Speech therapist Occupational therapist Physical therapist

Increased cervical flexion is observed when the patient is placed in which position?

Supported Fowler's position

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

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.

The nurse is evaluating the patient's condition after providing care for immobility. The nurse observes the condition of the patient and places the patient on a pressure-relieving mattress. Why did the nurse implement this intervention?

The skin is showing areas of erythema and breakdown.

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

While caring for a patient with immobility, the nurse positions the patient in the supported supine position. The nurse places pillows under the pronated forearms keeping the upper arms parallel to the patient's body. What is the reason for this nursing action?

To reduce the internal rotation of shoulders

Which complications would the nurse have to monitor for when using the supported Fowler's position?

Which complications would the nurse have to monitor for when using the supported Fowler's position? Increased shearing force on the back