Chapter 47: Mobility and Immobility

Of the following nursing goals, which is the most appropriate for a patient who has had a total hip replacement? a. The patient will walk 1000 feet using her walker by the time of discharge. b. The patient will ambulate by the time of discharge. c. The patient will ambulate briskly on the treadmill by the time of discharge. d. The nurse will assist the patient to ambulate in the hall.

ANS: A "The patient will walk 1000 feet using her walker by the time of discharge" is individualized, realistic, and measurable. "The patient will ambulate by the time of discharge" is not measurable because it does not specify the distance. Even though we can see that the patient will ambulate, this does not quantify how far. "Ambulating briskly on a treadmill" is not realistic for this patient. The last option focuses on the nurse, not the patient, and is not measurable.

The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. One strategy that the nurse could use is a. A foot cradle. b. A trochanter roll. c. The trapeze bar. d. Hand rolls.

ANS: A A foot cradle may be used in patients with poor peripheral circulation as a means of reducing pressure on the tips of a patient's toes. A trochanter roll prevents external rotation of the hips when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bed frame. It allows the patient to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises.

The nurse is caring for an elderly patient with the diagnosis of urinary tract infection (UTI). The patient is confused and agitated. It is important for the nurse to realize that confusion in the elderly is a. Not a normal expectation. b. Purely psychological in origin. c. Not a common manifestation with UTIs. d. Acceptable and needs no further assessment.

ANS: A Acute confusion in older adults is not normal; a thorough nursing assessment is the priority. Abrupt changes in personality often have a physiological cause such as surgery, a medication reaction, a pulmonary embolus, or an acute infection. For example, the primary symptom of compromised older patients with an acute urinary tract infection or fever is confusion. Identifying confusion is an important component of the nurse's assessment.

The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique to keep the spinal column in straight alignment. Which of the following is the proper technique for logrolling? a. Obtain assistance from at least two or three other people. b. Have the patient reach for the opposite side rail when turning. c. Move the top part of the patient's torso, then the bottom part. d. Do not use pillows after turning because the softness causes misalignment.

ANS: A At least three to four people are needed to perform this skill safely. Have the patient cross arms on chest to prevent injury to the arms. Move the patient as one unit in a smooth, continuous motion on the count of three. Gently lean the patient as a unit back toward pillows for support.

The patient is being admitted to the neurological unit with the diagnosis of stroke. The nurse should begin discharge planning a. At the time of admission. b. The day before the patient is to be discharged. c. As soon as the patient's discharge destination is known. d. When outpatient therapy will no longer be needed.

ANS: A Discharge planning begins when a patient enters the health care system. In anticipation of the patient's discharge from an institution, the nurse makes appropriate referrals or consults a case manager or a discharge planner to ensure that the patient's needs will be met at home. Referrals to home care or outpatient therapy are often needed.

What is meant by "concentric tension" of muscles? a. Increased muscle contraction results in movement. b. The speed and direction of movement are controlled. c. Tension causes no shortening or active movement. d. Tension does not result in isotonic contraction.

ANS: A In concentric tension, increased muscle contraction causes muscle shortening, resulting in movement. Eccentric tension helps control the speed and direction of movement. Concentric and eccentric muscle actions are necessary for active movement and are referred to as dynamic or isotonic contraction. Isometric contraction (static contraction) causes an increase in muscle tension or muscle work but no shortening or active movement of the muscle.

The nurse is caring for a patient who has been diagnosed with a stroke. As part of her ongoing care, the nurse should a. Encourage the patient to perform as many self-care activities as possible. b. Provide a complete bed bath to promote patient comfort. c. Place the patient on bed rest to prevent fatigue. d. Understand that the patient will not eat owing to a decreased energy need.

ANS: A Nurses should encourage the patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient's immobility by providing unnecessary help with activities such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. Anorexia and insufficient assistance with eating lead to malnutrition.

The patient who is experiencing an alteration in mobility often has one or more nursing diagnoses. The nurse would use the diagnosis of Impaired physical mobility for a patient who is a. Not completely immobile. b. Completely immobile. c. At risk for multisystem problems. d. At risk for single-system involvement.

ANS: A The diagnosis of Impaired physical mobility applies to the patient who has some limitation but is not completely immobile. The diagnosis of Risk for disuse syndrome applies to the patient who is immobile and at risk for multisystem problems because of inactivity. Beyond these diagnoses, the list of potential diagnoses is extensive because immobility affects multiple body systems.

When preparing a plan of care for an immobilized patient, the nurse should a. Use established expected outcomes to evaluate the patient's response to care. b. Display an air of professional superiority when interventions are not successful. c. Never vary from interventions that have been successful for other patients. d. Use objective data only in determining whether interventions have been successful.

ANS: A The nurse should use established expected outcomes to evaluate the patient's response to care. The nurse should use creativity when designing new interventions to improve the patient's mobility status and should display humility when identifying those interventions that were not successful. Ask if the patient's expectations of care are being met and use objective data to determine the success of interventions.

The nurse is caring for a patient with the diagnosis of Impaired physical mobility. The nurse needs to be alert for which of the following potential complications? (Select all that apply.) a. Pulmonary emboli b. Pneumonia c. Impaired skin integrity d. Somnolence e. Increased socialization

ANS: A, B, C

The nurse is caring for a patient who has had a recent stroke and is paralyzed on his left side. He has no respiratory or cardiac issues, but he cannot walk. He becomes extremely frustrated when he cannot button his shirt and cannot feed himself because he was left-handed. He has shown no signs of dysphagia, but he has been eating very little and has lost 2 lbs. He asks the nurse, "How can I go home like this? I'm not getting better. I can't ask my wife to take care of me like a baby." Of the following list of health care team members, which member would the nurse need to consult? (Select all that apply.) a. Physical therapy b. Occupational therapy c. Respiratory therapy d. Cardiac rehabilitation e. Psychology services

ANS: A, B, E Physical therapists are a resource for planning ROM or strengthening exercises, and occupational therapists are a resource for planning ADLs that patients need to modify or re-learn. Referral to a mental health advanced practice nurse, a licensed social worker, or a physiologist to assist with coping or other psychosocial issues is also wise. Because the patient exhibits good cardiac and respiratory function, respiratory therapy and cardiac rehabilitation probably are not needed at this time.

The patient is admitted to a skilled care unit for rehabilitation 10 days after the surgical procedure of fixation of a fractured left hip and has a nursing diagnosis of Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which of the following nursing interventions is most appropriate for this patient? a. Obtain assistance and physically transfer the patient to the chair. b. Assist the patient with ambulation and measure how far she walks. c. Withhold pain medication so that she can ambulate with a clear mind. d. Bring the patient to the cafeteria for group instruction on ambulation.

ANS: B

The nurse is evaluating the body alignment of a patient in the sitting position. In this position a. The body weight is directly on the buttocks only. b. Both feet are supported on the floor with ankles flexed. c. The edge of the seat is in contact with the popliteal space. d. The arms hang comfortably at the sides.

ANS: B Both feet are supported on the floor, and the ankles are comfortably flexed. With patients of short stature, a footstool is used to ensure that the ankles are comfortably flexed. Body weight is evenly distributed on the buttocks and thighs. A 1- to 2-inch space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee to ensure that no pressure is placed on the popliteal artery or nerve. The patient's forearms are supported on the armrest, in the lap, or on a table in front of the chair.

When assessing the skin of an immobilized patient, the nurse should a. Assess the skin at least every 4 hours. b. Use a standardized tool such as the Braden Scale. c. Use nursing instinct instead of a standardized tool. d. Have special times for inspection so as to not interrupt routine care.

ANS: B Consistently use a standardized tool, such as the Braden Scale. This identifies patients with high risk of impaired skin integrity. Nursing instinct in this case is not enough. At a minimum, skin assessment occurs every 2 hours. Continually assess the patient's skin for breakdown and color changes such as pallor or redness. Continual assessment reduces the need for the creation of special times for inspection.

The patient is immobilized after undergoing hip replacement surgery. Which of the following would place the patient at risk for hemorrhage? a. Thick, tenacious pulmonary secretions b. Low-molecular-weight heparin doses to prevent DVT c. SCDs wrapped around the legs to prevent DVT formation d. Elastic stockings (TED hose) to promote venous return

ANS: B Heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of DVT. Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding. Pulmonary secretions that become thick and tenacious are difficult to remove and are a sign of inadequate hydration, but not of bleeding. SCDs consist of sleeves or stockings made of fabric or plastic that are wrapped around the leg and are secured with Velcro. They decrease venous stasis by increasing venous return through the deep veins of the legs. They do not usually cause bleeding. Elastic stockings also aid in maintaining external pressure on the muscles of the lower extremities and in promoting venous return. They do not usually cause bleeding.

Muscles that attach to bones to provide the needed strength to move an object use which of the following to obtain their objective? a. Posture b. Leverage c. Isometric contraction d. Muscle tone

ANS: B Leverage is an inducing or compelling force that occurs when specific bones, such as the humerus, ulna, and radius, and associated joints, such as the elbows, act together as a lever. Posture is the position of the body in relation to the surrounding space. Isometric contraction causes an increase in muscle tension but no active movement. Muscle tone is the normal state of balanced muscle tension.

The nurse is aware that patients who are immobile are at increased risk of developing deep vein thromboses (DVTs). Because of this, the nurse should a. Make sure that elastic stockings are not removed. b. Measure the calf circumference of both legs. c. Dorsiflex the foot while assessing for patient discomfort. d. Measure both ankles to determine size.

ANS: B Measure bilateral calf circumference and record it daily as an assessment for DVT. Homans' sign, or calf pain on dorsiflexion of the foot, is contraindicated in patients when a DVT is suspected. It is no longer a reliable indicator in assessing for DVT, and it is present in other conditions. Remove the patient's elastic stockings and/or sequential compression devices (SCDs) every 8 hours, and observe the calves for redness, warmth, and tenderness. Bilateral calf circumferences (not ankle) should be measured daily to detect unilateral increases that may be an early indication of thrombosis.

The nurse is caring for a patient who has had a stroke causing total paralysis of the right side. To help maintain joint function and to prevent contractures, passive ROM will be initiated. When should therapy begin? a. After the acute phase of the disease has passed b. As soon as the ability to move is lost c. Once the patient enters the rehab unit d. No ROM is needed.

ANS: B Passive ROM exercises should begin as soon as the patient's ability to move the extremity or joint is lost. The nurse should not wait for the acute phase to end. It may be some time before the patient enters the rehab unit, and contractures could form by then. ROM is certainly needed in this patient.

Immobilized patients frequently have hypercalcemia, placing them at risk for a. Osteoporosis. b. Renal calculi. c. Pressure ulcers. d. Thrombus formation.

ANS: B Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi because they frequently have hypercalcemia. Osteoporosis is caused by accelerated bone loss. A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) within tissues. A thrombus is an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel

The term body alignment refers to positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. A term that is similar to body alignment is a. Weight. b. Posture. c. Friction. d. Body mechanics.

ANS: B The terms body alignment and posture are similar and refer to positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Weight is the force exerted on a body by gravity. Friction is a force that occurs in a direction to oppose movement. Body mechanics is a term used to describe the coordinated efforts of the musculoskeletal and nervous systems.

When assessing the body alignment of a patient while he or she is standing, the nurse is aware that a. When observed posteriorly, the hips and shoulders form an "S" pattern. b. When observed laterally, the spinal curves align in a reversed "S" pattern. c. The arms should be crossed over the chest or in the lap. d. The feet should be close together with toes pointed out.

ANS: B When the patient is observed laterally, the head is erect and the spinal curves are aligned in a reversed "S" pattern. When observed posteriorly, the shoulders and hips are straight and parallel. The arms hang comfortably at the sides. The feet are slightly apart to achieve a base of support, and the toes are pointed forward.

Correct body alignment reduces strain on musculoskeletal structures and contributes to balance. Balance control is attained by (Select all that apply.) a. Keeping the body's center of gravity high. b. Maintaining a wide base of support. c. Keeping the body's center of gravity low. d. Maintaining correct body posture. e. Maintaining immobility to prevent falls.

ANS: B, C, D Without balance control, the center of gravity is displaced, thus creating risk for falls and injuries. Balance is enhanced by keeping the body's center of gravity low (not high) with a wide base of support and by maintaining correct body posture. Prolonged immobility leads to impaired balance.

The nurse needs to reposition a 300-lb patient. Which of the following strategies is most likely to prevent back injury? a. Turn the patient alone using the lift pad and applying pillows. b. Put the bed in Trendelenburg and pull from the head of the bed. c. Assess and obtain the number of people needed to help. d. Bend at the waist and pull the lift pad using the arms.

ANS: C Assess and determine the number of people needed; to prevent injury, do not start until the task can be completed safely. Assess the situation and do not turn the patient alone if this cannot be done safely. The trunk should be erect and the knees bent, so that multiple muscle groups (not just the arms) work together in a coordinated manner. This is not a one-person task: DO NOT PULL FROM THE HEAD OF THE BED.

The nurse must assess the patient for hazards of immobility by performing a head-to-toe physical assessment. When assessing the respiratory system, the nurse should a. Assess the patient at least every 4 hours. b. Inspect chest wall movements during the expiratory cycle only. c. Auscultate the entire lung region to assess lung sounds. d. Focus auscultation on the upper lung fields.

ANS: C Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes. Perform a respiratory assessment at least every 2 hours for patients with restricted activity. Inspect chest wall movements during the full inspiratory-expiratory cycle. Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions.

The nurse needs to transfer the patient from the bed to the chair. The nurse should a. Avoid using a transfer or gait belt around the patient's waist prior to transfer. b. Not allow the patient to help in any way because resistance can lead to injury. c. Assess for the need of a mechanical lift and help. d. Ensure that the patient has stockings on his feet for transfer.

ANS: C Careful assessment of your patient's ability to assist in the positioning technique to be used is extremely important. Consider the use of a mechanical lift. Your role in assisting your patient to a sitting position is to guide and instruct. If the patient can bear weight and move to a sitting position independently, allow him or her to do so and offer assistance. A transfer belt maintains stability of the patient during transfer and reduces risk for falls. Ensure that the patient has stable nonskid shoes on his feet.

To prevent injury, the nurse should not begin a task (e.g., moving a bed from one room to another, lifting heavy objects) until the task can be completed safely. To prevent injury a. Keep the weight as far from the body as possible. b. Keep the knees still to prevent loss of balance. c. Tighten abdominal muscles and tuck the pelvis. d. Bend at the waist to move weight forward.

ANS: C Follow these steps to prevent injury: (1) tighten abdominal muscles and tuck the pelvis to provide balance and help protect the back; (2) keep the weight to be lifted as close to the body as possible; (3) bend at the knees to maintain the center of gravity, and use the stronger leg muscles; and (4) maintain the trunk erect and the knees bent so that multiple muscle groups work together in a coordinated manner.

The nurse is admitting a patient who has been diagnosed as having had a stroke. The physician writes orders for "ROM as needed." The nurse understands that a. The nurse will have to move all the patient's extremities. b. The patient is unable to move his extremities. c. Further assessment of the patient is needed. d. The patient needs to restrict his mobility as much as possible.

ANS: C Further assessment of the patient is needed. Some patients are able to move some joints actively, whereas the nurse passively moves others. With a weak patient, the nurse may have to support an extremity while the patient performs the movement. In general, exercises need to be as active as health and mobility allow.

Patients on bed rest or otherwise immobile are at risk for a. Increased metabolic rate. b. Increased diarrhea (peristalsis). c. Altered metabolic function. d. Increased appetite.

ANS: C Immobility disrupts normal metabolic functioning: decreasing the metabolic rate, altering the metabolism of carbohydrates, fats, and proteins (nutritional function); causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.

Immobility is a major risk factor for pressure ulcers. In caring for the patient who is immobilized, the nurse needs to be aware that a. Breaks in skin integrity are easy to heal. b. Preventing a pressure ulcer is more expensive than treating one. c. Immobilized patients can develop skin breakdown within 3 hours. d. Pressure ulcers are caused by a sudden influx of oxygen to the tissue.

ANS: C Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore, preventive nursing interventions are imperative. An older adult who is immobilized can develop skin breakdown within 3 hours. Tissue metabolism depends on the supply of oxygen and nutrients to and the elimination of metabolic wastes from the blood. Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation.

In applying for a job on a nursing unit that requires frequent patient positioning, the nurse should be aware that nurses a. Are at low risk for back injury. b. Are especially at risk for high back injuries. c. Should be aware of agency policies. d. Should not need to use assistive devices.

ANS: C Nurses and other health care staff are especially at risk for injury to lumbar muscles when lifting, transferring, or positioning immobilized patients. Therefore, the nurse should be aware of agency policies and protocols that protect staff and patients from injury. Current evidence supports that using mechanical or other ergonomic assistive devices is the safest way to reposition and lift patients who are unable to do these activities themselves.

The director of a nursing home has decided to institute ergonomic programs in the facility because these programs increase employee satisfaction and have been shown to a. Be ineffective in reducing injury. b. Be cost neutral in budgeting. c. Enhance recruitment. d. Decrease retention rates.

ANS: C Research has demonstrated that ergonomic programs in health care facilities reduce costs, injuries to employees, and missed workdays. These programs also enhance recruitment, retention, and satisfaction of employees.

In caring for a patient who is immobile, it is important for the nurse to understand that a. The effects of immobility are the same for everyone. b. Immobility helps maintain sleep-wake patterns. c. Changes in role and self-concept may lead to depression. d. Immobile patients are often eager to help in their own care.

ANS: C The immobilized patient often becomes depressed because of changes in role and self-concept. Every patient responds to immobility differently. Immobility or bed rest frequently affects coping and creates sleep-wake alterations because of changes in routine or in the environment. Because immobilization removes the patient from a daily routine, he or she has more time to worry about disability. Worrying quickly increases the patient's depression, causing withdrawal. Withdrawn patients often do not want to participate in their own care.

In developing an individualized plan of care for a patient, it is important for the nurse to a. Set goals that are a little beyond the capabilities of the patient. b. Use his or her judgment and not be swayed by family desires. c. Establish goals that are measurable and realistic. d. Explain that without taking alignment risks, there can be no progress.

ANS: C The nurse must develop an individualized plan of care for each nursing diagnosis and must set goals that are individualized, realistic, and measurable. The nurse should set realistic expectations for care and should include the patient and family when possible. The goals focus on preventing problems or risks to body alignment and mobility.

The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair. The nurse opts to use a mechanical lift (Hoyer lift). The nurse understands that when this lift is used, the a. Straps need to be removed before lowering the patient to the chair. b. Horseshoe-shaped base should be on the opposite side from the chair. c. Longer straps hook to the bottom of the sling. d. Short straps are hooked to the bottom of the sling.

ANS: C The nurse should attach the hooks on the strap to the holes in the sling. Short straps hook to top holes of the sling; longer straps hook to the bottom of the sling. This prevents the sling from flipping upside down. The horseshoe-shaped base goes under the side of the bed on the side with the chair. Position the patient and lower slowly into the chair in accordance with manufacturer guidelines to safely guide the patient into the back of the chair as the seat descends; then remove the straps and the mechanical/hydraulic lift.

When creating a plan of care for a patient who is experiencing alterations in mobility, the nurse a. Cannot delegate interventions to nursing assistive personnel. b. Is solely responsible for modifying ADLs. c. Consults other health care team members to help plan therapy. d. Consults wound care specialists only when wounds are apparent.

ANS: C The nurse should collaborate with other health care team members such as physical or occupational therapists when considering mobility needs. Nurses often delegate some interventions to nursing assistive personnel. Nursing assistive personnel may turn and position patients, apply elastic stockings, help patient use the incentive spirometer, etc. Occupational therapists are a resource for planning ADLs that patients need to modify or relearn. It is especially important in priority setting to make sure not to overlook potential complications. Many times, actual problems such as pressure ulcers are addressed only after they develop. They should be addressed before they develop.

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. The nurse is aware that the rate of occupational injury and illness in the hospital setting a. Is the same as in the private industry sector. b. Is higher than in the nursing home setting. c. Is about 4.4%. d. Has decreased in recent years.

ANS: C The rate of work-related injury in health care settings has increased in recent years. In 2006, 4.4 cases per 100 full-time workers who experienced occupational injury and illness were reported compared with 5 cases per 100 for private industry overall. The rate for nursing homes was 10.1 per 100 workers.

During voluntary movement, impulses descend from the motor strip to the spinal cord. Impulses stimulate muscles by way of a. Ligaments. b. Tendons. c. Neurotransmitters. d. Cartilage.

ANS: C Through a complex process, neurotransmitters, or chemicals such as acetylcholine transfer electrical impulses from the nerve across the neuromuscular junction to the muscle. The neurotransmitter reaches a muscle and stimulates it. Ligaments are white, shiny, flexible bands of fibrous tissue that bind joints together and connect bones and cartilages. Tendons connect muscle to bone. Cartilage is nonvascular, supporting connective tissue located chiefly in the joints and in the thorax, trachea, larynx, nose, and ear.

The nurse is assessing the way the patient walks. The manner of walking is known as the patient's a. Activity tolerance. b. Body alignment. c. Range of motion. d. Gait.

ANS: D

Although isometric contractions do not result in muscle shortening, the nurse understands that isometric contractions a. Result in decreased energy expenditure. b. Are always desirable regardless of patient condition. c. Are necessary for the active movement of muscles. d. Result in increased energy expenditure.

ANS: D Although isometric contractions do not result in muscle shortening, energy expenditure increases. It is important to understand the energy expenditure associated with isometric exercises because they are sometimes contraindicated in certain illnesses. Isometric contractions increase muscle tension but not active movement of the muscle.

The nurse is assessing body alignment for a patient who is immobilized. To do this, the nurse must a. Place the patient in the supine position. b. Remove the pillow from under the patient's head. c. Insert positioning supports to help the patient. d. Place the patient in a lateral position.

ANS: D Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position, not supine. Remove all positioning support from the bed, except for the pillow under the head.

In caring for immobile patients, the nurse understands that back injuries occur a. Only when lifting patients. b. Only when transferring patients. c. Only when providing direct patient care. d. With many clinical activities.

ANS: D Musculoskeletal injuries among health care workers are related not only to lifting and transferring patients. Nurses spend time in many activities involving bending and twisting, which also cause injury. Examples of such activities include lifting objects, pushing beds, and providing direct patient care such as bathing, feeding, dressing, and undressing patients

In preparing to create a nursing diagnosis for a patient who is immobile, it is important for the nurse to understand that a. Physiological issues should be the major focus. b. Psychosocial issues should be the major focus. c. Developmental issues should be the major focus. d. All dimensions are important to health.

ANS: D Often the physiological dimension is the major focus of nursing care for patients with impaired mobility. Thus the psychosocial and developmental dimensions are neglected. Yet all dimensions are important to health.

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. This diagnosis means that the nurse should a. Encourage the patient to do self-care. b. Keep the patient as mobile as possible. c. Encourage the patient to perform ROM. d. Assist the patient with comfort measures.

ANS: D The diagnosis related to pain requires the nurse to assist the patient with comfort measures so that the patient is then willing and better able to move. Pain must be controlled before so that the patient will not be reluctant to initiate movement. The diagnosis of Reluctance to initiate movement requires interventions aimed at keeping the patient as mobile as possible and encouraging the patient to do self-care and ROM. This cannot be accomplished until comfort is achieved.

While performing passive ROM exercises, the nurse stands at the side of the bed closest to the joint being exercised and a. Forces the joint just a bit beyond the point of resistance. b. Moves the joint until the patient complains of pain. c. Repeats each movement twice. d. Carries out movements slowly and smoothly.

ANS: D The nurse carries out movements slowly and smoothly, just to the point of resistance. ROM should not cause pain. Never force a joint beyond its capacity. Each movement needs to be repeated five times during the session.

Joints are the connections between bones. The joint that is freely movable is known as the _____ joint. a. Synostotic b. Cartilaginous c. Fibrous d. Synovial

ANS: D The synovial joint, or true joint, is a freely movable joint in which contiguous bony surfaces are covered by articular cartilage and are connected by ligaments lined with a synovial membrane. The synostotic joint refers to bones jointed by bones. No movement is associated with this type of joint. In the cartilaginous joint, or synchondrosis joint, cartilage unites bony components. When bone growth is complete, the joints ossify. The fibrous joint, or syndesmosis joint, is a joint in which a ligament or membrane unites two bony surfaces, permitting a limited amount of movement only.

The patient is unable to move himself and needs to be pulled up in bed. For this repositioning to be done safely, the nurse must understand that a. The procedure can be done by one person if the bed is in the flat position. b. Side rails should be in the up position to prevent the patient from falling out. c. The pillow should be placed under the patient's head and shoulders. d. Assistive devices or additional nurses should be used.

ANS: D This is not a one-person task. Helping a patient move up in bed without help from other coworkers or without the aid of an assistive device (e.g., friction-reducing pad) is not recommended and is not considered safe for the patient or the nurse. When pulling a patient up in bed, the bed should be flat or in a Trendelenburg position (when tolerated) to gain gravity assistance, and the side rails should be down. Remove the pillow from under head and shoulders and place it at the head of the bed to prevent striking the patient's head against the head of the bed.

Without balance control, the center of gravity is displaced, thus creating risk for falls and subsequent injuries. Balance is enhanced by a. Maintaining a narrow base of support. b. Creating a high center of gravity. c. Disregarding body posture. d. Keeping a low center of gravity.

ANS: D Without balance control, the center of gravity is displaced, thus creating risk for falls and subsequent injuries. Balance is enhanced by keeping the center of gravity of the body low with a wide base of support and by maintaining correct body posture.

A nurse evaluating the performance of an unlicensed assistant corrects a client's position. Which client requires repositioning? A. A client in a Fowler's position, with the head of the bed raised 75 degrees, a large pillow placed under the head, and plantar flexion of the feet B. A client in a Dorsal Recumbent position, with the head flat, a small pillow under the lumbar curve, and sandbags placed lateral to the trochanter of the femur C. A client in a prone position, with the head turned to the side, a small pillow under the abdomen, and the lower legs supported on a pillow with feet extended D. A client in a right lateral position, with the arms in front of the body, the upper arm supported with a pillow, and the shoulders and hips aligned with one another

Answer: A Rationale: A client in a Fowler's position, with the head of the bed raised 75 degrees, a large pillow placed under the head, and plantar flexion of the feet, requires repositioning. Answers 2, 3, and 4 are positioned correctly.

A position that puts an unconscious client at greatest risk for aspirating secretions is: A. Supine B. Lateral C. Sims' D. Prone

Answer: A Rationale: Supine position puts client at greatest risk for aspirating secretions. Lateral, Sims', and prone positions allow secretions to drain from the mouth.

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

Answer: A Rationale: The dairy and broccoli in the soup, the whole grain crackers, plus the tapioca are all great sources of calcium.

efore transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.) A. Patient's weight B. Patient's level of cooperation C. Patient's ability to assist D. Presence of medical equipment E. 24-hour calorie intake

Answer: A,B,C,D Rationale: By assessing the patient thoroughly you make the correct decision concerning your ability to manage him or her safely, the need for additional personnel, the patient's ability or inability to assist you with the transfer, and the proper equipment to use for the transfer. The calorie intake for the past 24 hours does not affect safe transfer.

A patient of any age can develop a contracture of a joint when: A. The adductors muscles are weakened as a result of immobility. B. The muscle fibers become shortened because of disuse. C. The calcium-to-phosphorus ratio becomes disrupted. D. There is a deficiency in vitamin D

Answer: B Rationale: The adductor muscles are stronger than the abductor muscles; when patients are immobile and the joint is not exercised through their ROM, the adductor muscle fibers shorten, resulting in the contracture of that joint, which is usually permanent.

A teen in a full leg cast asks about preventing muscle mass loss in the cast. The best type of exercise the nurse can recommend is: A. Isotonic B. Isometric C. Isokinetic D. Aerobic

Answer: B Rationale: The client requires a form of exercise that does not require joint movement but does allow a change in muscle tension. Isotonic, isokinetic, and aerobic forms of exercises require active movement.

Two nurses plan to move a client with weakness into a wheelchair. As they prepare to make the transfer, one of the nurses correctly instructs the client to: A. Use the IV pole as a lever when rising from the bed B. Push up from the bed using her arms on the count of three C. Hold on to the side rails facing the bottom of the bed before standing D. Put feet behind the nurses' feet

Answer: B Rationale: The client should push up from the bed using her arms on the count of three. The IV pole is unstable, and may roll away from the client. A client should face in the direction in which she is moving. The nurses' feet need to be in front of the client's.

Which is an outcome for a patient diagnosed with osteoporosis? A. Maintain serum level of calcium. B. Maintain independence with activities of daily living (ADLs). C. Reduce supplemental sources of vitamin D. D. Reverse bone loss through dietary manipulation.

Answer: B Rationale: The main goal is to maintain independence in ADLs once osteoporosis is diagnosed. It is best to identify individuals at risk and work toward preventing the disease.

The patient at greatest risk for developing multiple adverse effects of immobility is a: A. 1-year-old child with a hernia repair. B. 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA). C. 51-year-old woman following a thyroidectomy. D. 38-year-old woman undergoing a hysterectomy.

Answer: B Rationale: The older the patient and the greater the period of immobility, which can be significant following a hemorrhagic stroke, the greater is the number of systems that can be affected by the immobility.

A 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 quad-cane. Which of the following must be corrected or removed for the patient's safety? (Select all that apply.) A. The rubber mat in the walk-in shower B. The three-legged stool on wheels in the kitchen C. The braided throw rugs in the entry hallway and between the bedroom and bathroom D. The night-lights in the hallways, bedroom, and bathroom E. The cordless phone next to the patient's bed

Answer: B,C Rationale: Stools on wheels and braided throw rugs are hazards that put the patient at risk for falls. By planning ahead and collaborating, the home care nurse can provide a safe home environment for the patient after discharge.

An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) A. B/P = 128/84 B. Respirations 26 per minute on room air C. HR 114 D. Crackles heard on auscultation E. Pain reported as 3 on scale of 0 to 10 after medication

Answer: B,C,D Rationale: Patients with reduced mobility are at risk for retained pulmonary secretions, and this risk increases in postoperative patients. As a result of retained secretions, the respiratory rate increases. The heart rate also increases because the heart is trying to improve oxygen levels. These symptoms are of concern for older adults because, if left untreated, further complications such as heart failure can occur.

Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would reduce this risk? (Select all that apply.) A. Repositioning patient every 1 to 2 hours while awake B. Using an objective, valid scale to assess patient's risk for pressure ulcer development C. Using a device to relieve pressure when patient is seated in chair D. Teaching patient how to shift weight at regular intervals while sitting in a chair E. A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes

Answer: B,C,D,E Rationale: Patients must be repositioned around the clock, not just when they are awake. 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 his or her 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 developments.

Which of the following describes a client with a nursing diagnosis of Activity Intolerance III? A. Fatigued at rest B. Able to climb one flight of stairs slowly without stopping C. Unable to climb one flight of stairs without stopping D. Able to walk one city block without stopping

Answer: C Rationale: Activity Intolerance III. Fatigued at rest is Level IV. Able to climb one flight of stairs slowly without stopping is Level II. Able to walk one city block without stopping is Level II.

Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher? A. The patient is 5 feet 6 inches and weighs 120 lbs. B. The patient speaks and understands English. C. The patient received an injection of morphine 30 minutes ago for pain. D. You feel comfortable handling a patient of his size and with his level of cooperation.

Answer: C Rationale: 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.

On the fifth postoperative day after major abdominal surgery, the nurse evaluates a client for the effects of immobility. The nurse notes that the care plan was successful when the client states: A. "I'm not using as much pain medication as I did yesterday." B. "I'm still dizzy when I get up, but it is getting better." C. "I am ready to eat something besides Jell-O and broth." D. "I hardly even think about smoking anymore."

Answer: C Rationale: The nurse is evaluating for signs that the client has suffered no effects of immobility. Answer 2 is an effect of immobility. Other findings are present, but not related to immobility.

A patient has her call bell on and looks frightened when you enter the room. She 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." Your first action is to: A. Call the health care provider to report this change in condition. B. Give the patient a paper bag to breathe into to decrease her anxiety. C. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen. D. Explain that this is normal after such trauma and administer the ordered pain medication.

Answer: C Rationale: These are signs of possible pulmonary emboli, which can be life threatening. You must assess your patient, be prepared to start oxygen, and have someone call the surgeon while you stay with the patient to continue to monitor her status.

The nurse positions the immobilized client to maintain the ability for normal movement and stability. This is accomplished when the nurse: A. Positions the joints in the flexed position to prevent contracture formation B. Positions the shoulders anterior to the hips to balance upper and lower body parts C. Performs range of motion with every position change to keep joints flexible D. Balances the body off the center of gravity to prevent skin breakdown

Answer: C Rationale: When improperly positioned, joints flex into fixed positions and lose mobility. Properly aligned shoulders and hips fall into the same line of gravity. A properly balanced body is balanced at the center of gravity.

A nurse is assessing a client's range of motion. An abnormality is detected when: A. The head hyperextends back 10 degrees from an upright position B. The arm abducts 180 degrees laterally from the side of the body to the side and above the head C. The elbow supinates 90 degrees D. The thumb flexes 45 degrees toward the fifth finger

Answer: D Rationale: An abnormality is detected when the thumb flexes 45 degrees toward the fifth finger. Answers 1, 2, and 3 are not abnormalities.

An employee health nurse teaches a body mechanics class. While demonstrating proper lifting techniques, the nurse says: A. "Put the object to be lifted 12 inches from your feet." B. "Lift no more than 50% of your body weight plus 5 kilograms." C. "Lift with flexed knees and hyperextended back." D. "Lift with the large muscles of the legs, abdomen, and arms."

Answer: D Rationale: Body mechanics used for lifting indicate that the closer an object is to the one lifting, the greater the stability. Flexed knees and back help prevent injuries, as long as one does not lift more than one is able. Each person's limit is individual.

The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to: A. Prevent varicose veins. B. Prevent muscular atrophy. C. Ensure joint mobility and prevent contractures. D. Promote venous return to the heart.

Answer: D Rationale: 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.

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education? A. "I usually go swimming with my family at the YMCA 3 times a week." B. "I need to ask my doctor if I should have a bone mineral density check this year." C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill. "

Answer: D Rationale: Just because a multivitamin has calcium in it does not mean that the woman is receiving enough to meet her needs. She must know her requirement and make the decision based on that rather than on the value for calcium on the label.

An older adult who was in a car accident and fractured his 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? A. Chronic pain B. Impaired skin integrity C. Risk for ineffective cerebral tissue perfusion D. Risk for activity intolerance

Answer: D Rationale: Patients on bed rest are at risk for activity intolerance, which increases patients' risk for falling.

A patient with left-sided weakness asks his nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." What would be your best therapeutic response? A. "Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you." B. "Would you like me to walk on your right side so you feel more secure?" C. "Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side." D. "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint."

Answer: D Rationale: Walking on the affected (weak side) side and holding the patient around the waist or using a gait belt gives you better control if the patient starts to fall. If you were holding the patient's arm as he was falling, you might dislocate his shoulder.

A patient had a left-sided cerebrovascular accident 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 of the following symptoms requires the nurse to call the health care provider immediately? A. Pale yellow urine B. Unilateral neglect C. Slight movement noted on the R side D. Coffee ground-like aspirate from the feeding tube

Answer: D Rationale: When patients are receiving medications such as heparin or enoxaparin (Lovenox), you must assess for signs of bleeding. These include overt signs such as bleeding from their gums or covert signs, which can be detected by testing their stool or observing their aspirate from NG tubes for coffee ground-like matter. These are signs of bleeding in the gastrointestinal tract.

hich of the following techniques imposes the greatest stress on the nurse's back? A. Lifting with the large muscles of the legs B. Helping clients ambulate C. Turning immobilized clients in bed D. Transferring clients in and out of bed

Answer: DRationale: All of the answers may impose a stress on the nurse's back. Answer 4 imposes the greatest risk because of the potential for twisting and working in a small place.

The nurse is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. To help prevent injury secondary to this rotation, the nurse can use a. A trochanter roll. b. The trapeze bar. c. Hand rolls. d. Hand-wrist splints.

a. A trochanter roll