Evolve Quiz 1: Immobility

What is the correct order of assessments of patient mobility performed by the nurse?

1. Lying position 2. Sitting position in bed 3. Transferring to chair 4. Walking

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

80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA) 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 patient sustained a femur fracture due to a fall in the bathroom. The attending nurse understands that the femur bone forms a hip joint with the pelvic bone. Which type of joint is the hip joint?

Ball-and-socket joint The head of the femur acts as a ball and the pelvic bone as a socket, and together they form a ball-and-socket type of joint , which is a freely movable synovial joint. The elbow and knee joints are examples of hinge joints. The joints in the neck are pivot joints. Cartilaginous joints are found in the sternum where cartilage unites with the bone.

What are the risk factors for developing pathological fractures in patients with immobility?

Decreased metabolism Decreased calcium regulation Decreased metabolism and calcium regulation are the major risk factors for developing pathological fractures in patients with immobility. Decreased urinary output is a urinary elimination change seen in patients with immobility due to decreased intake of fluids. Decreased tissue catabolism is tissue breakdown due to muscle weakness and decreased muscle mass in patients with immobility. Decreased urinary concentration is a urinary elimination change seen in patients with immobility due to decreased fluid intake and output.

When assessing a patient, the nurse observes that the patient's legs are curved inward while walking. Which abnormality should the nurse anticipate in the patient? 1 Bowlegs 2 Footdrop 3 Knock-knee 4 Congenital hip dysplasia

Knock-knee Knock-knee is the abnormality that curves the legs inward so that knees come together while walking. Patients with bowlegs have legs that bend outward at the knee. Footdrop is the inability to dorsiflex and invert the foot because of perineal nerve damage. Congenital hip dysplasia is an abnormality in which hip instability is seen with the limited abduction of the hips.

What are the functions of the skeletal system?

Provide support Regulate calcium Protect vital organs The functions of the skeletal system include providing joint flexibility and support, regulating calcium, and protecting vital organs. The nervous system regulates movement and posture. Body alignment contributes to balance of the body.

The registered nurse is teaching a nursing student how to assess range of motion based on planes of the body. Which statements made by the nursing student indicate effective learning? Select all that apply. 1 "Inversion of the foot takes place in a line that divides the body into front and back." 2 "Abduction of the arm takes place in a line that divides the body into front and back." 3 "Rotation of the hip takes place in a line that divides the body into left and right sides." 4 "Extension of the elbow takes place in a line that divides the body into left and right sides." 5 "Plantar flexion of the foot takes place in a line that divides the body into upper and lower body."

"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 frontal plane divides the body into front and back. Inversion, abduction, eversion, and adduction are the movements that occur along the frontal plane. Sagittal plane divides the body into left and right sides. Extension and flexion are the movements assessed in sagittal plane. Rotation is assessed in transverse plane. It is a line that divides the body into upper and lower body. Plantar flexion is assessed in sagittal plane.

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? Select all that apply. 1 Prevent footdrop 2 Improve breathing 3 Reduce external rotation of the hips 4 Eliminate mattress pressure on the toes 5 Reduce hyperextension of the cervical vertebrae

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

The nurse is attending to a patient who is immobilized due to stroke. Which measures should the nurse take to prevent development of pressure ulcers in the patient? Select all that apply. 1 Reposition the patient every 1 to 2 hours. 2 Place the patient in supine position. 3 Place the patient in a 30-degree lateral position. 4 Avoid pulling the patient when repositioning. 5 Keep the patient well hydrated.

Reposition the patient every 1 to 2 hours. Place the patient in a 30-degree lateral position. Avoid pulling the patient when repositioning. Keep the patient well hydrated.

Which trouble areas should be assessed for correction when the patient is placed in the position depicted in the image?

Sacrum The image depicts the supported Fowler's position. The trouble areas in this position include the sacrum and heels. Unprotected pressure points at the ears are the trouble areas in side-lying position. Unprotected pressure points at the knees and humerus are the trouble points in Sims' position.

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? Select all that apply. 1 "I should consult an occupational therapist." 2 "I should increase the frequency of turning." 3 "I should allow the pain medication to take effect." 4 "I should administer analgesics if the patient is in pain." 5 "I should educate the patient about the benefits of moving."

"I should consult an occupational therapist." "I should increase the frequency of turning." When there is a critical situation, such as worsening of joint contractures; the nurse should consult an occupational therapist. Consulting an occupational therapist is not a correct intervention if a patient avoids moving. The nurse should increase the frequency of turning or repositioning the patient to decrease the erythema and breakdown of the skin, not if the patient avoids moving. When the patient avoids moving, the nurse should allow the pain medication to take effect before providing other treatment options. The nurse should administer analgesics if the patient is in pain, as ordered by the primary health care provider, to ensure the patient's comfort before moving. The nurse should also educate the patient about the benefits of moving if the patient is avoiding moving.

The registered nurse is teaching a nursing student about the range-of-motion exercises used to assess mobility. Which statement made by the nursing student indicates the need for further teaching? Select all that apply. 1 "I will assess the knee joint by flexion of 90 degrees." 2 "I will assess the elbow joint by flexion of 150 degrees." 3 "I will assess the foot joint by inversion of 10 degrees." 4 "I will assess the thumb joint by extension of 50 degrees." 5 "I will assess the condyloid joint of wrist by abduction of 30 degrees."

"I will assess the knee joint by flexion of 90 degrees." "I will assess the thumb joint by extension of 50 degrees." Mobility of the knee joint is assessed by flexion of 120 degrees to 130 degrees. Flexion of 90 degrees of knee joint may indicate disability. The thumb is a saddle joint and should extend up to 90 degrees. Extension of 50 degrees may indicate disability. Extension of the elbow joint up to 150 degrees would be a normal finding. The food is a gliding joint and should exhibit inversion up to 10 degrees. Abduction of the condyloid joint of the wrist is up to 30 degrees.

The registered nurse is teaching a student nurse about restorative and continuing care for a patient who underwent hip replacement. Which statements by the nursing student indicate effective learning? Select all that apply. 1 "I will provide a cane to facilitate walking." 2 "I will assist the patient while bathing." 3 "I will ensure that the patient can eat by him- or herself." 4 "I will ensure that the patient can take medication by himself or herself." 5 "I will ensure that the caregiver is assisting the patient during meal preparation."

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

Which statement made by a nursing student regarding the three planes of the body involved in maximum movement requires correction? 1 "Some joint movements are specific to each plane." 2 "In the frontal plane, movements are abduction of arms." 3 "In the sagittal plane, movements are pronation and supination." 4 "In the transverse plane, movements are internal and external rotation of hips."

"In the sagittal plane, movements are pronation and supination." In the sagittal plane, movements are flexion and extension of fingers and elbows. Ligaments, muscles, and the nature of the joint limit mobility in each of the planes, but some joint movements are specific to each plane. In the frontal plane, movements are abduction and adduction of arms and legs. In the transverse plane, the movements are internal and external rotation of hips, pronation, and supination.

Which statement made by a nursing student regarding the three planes of the body involved in maximum movement requires correction? 1 "Some joint movements are specific to each plane." 2 "In the frontal plane, movements are abduction of arms." 3 "In the sagittal plane, movements are pronation and supination." 4 "In the transverse plane, movements are internal and external rotation of hips."

"In the sagittal plane, movements are pronation and supination." In the sagittal plane, movements are flexion and extension of fingers and elbows. Ligaments, muscles, and the nature of the joint limit mobility in each of the planes, but some joint movements are specific to each plane. In the frontal plane, movements are abduction and adduction of arms and legs. In the transverse plane, the movements are internal and external rotation of hips, pronation, and supination.

The registered nurse is teaching a nursing student about postural abnormalities. Which statements made by the nursing student indicate the need for further learning? Select all that apply. 1 "Body alignment should be observed regularly." 2 "Postural abnormalities will only impair alignment." 3 "Patients should perform range of motion exercises." 4 "Positioning is necessary for patients with postural abnormalities." 5 "Postural abnormalities are more prevalent for muscle diseases in childhood."

"Postural abnormalities will only impair alignment." "Postural abnormalities are more prevalent for muscle diseases in childhood." Postural abnormalities can cause pain and impair alignment or mobility. Muscle abnormalities are more prevalent for muscle diseases in childhood. The nurse should observe body alignment in patients with postural abnormalities. The nurse should ask the patient to perform range of motion exercises to identify postural abnormalities. Lifting, transfer, and positioning are necessary for patients with postural abnormalities.

The registered nurse is teaching a nursing student about developmental changes in older adults. Which statements made by the nursing student indicate the need for further learning? Select all that apply. 1 "Prolonged immobilization in older adults delays gross motor skills." 2 "Immobilization in older adults is only caused by degenerative disease." 3 "Decreased physical activity can lead to loss of bone mass in older adults." 4 "Older adults experience functional status changes secondary to hospitalization." 5 "Medications may alter blood pressure when older adults change position too quickly."

"Prolonged immobilization in older adults delays gross motor skills." "Immobilization in older adults is only caused by degenerative disease." Prolonged immobilization in infants, toddlers, and preschoolers may lead to delayed development of gross motor skills. Immobilization in older adults can be caused by degenerative disease, neurological trauma, or chronic illness. Decreased physical activity and hormonal changes can lead to loss of bone mass in older adults. Older adults may experience functional status changes secondary to hospitalization and altered mobility status. Prescribed medications may alter blood pressure when older adults change position too quickly, increasing their risk for falls.

The registered nurse is teaching a nursing student about the skeletal system. Which statements by the nursing student indicate a need for further learning? Select all that apply. 1 "The skeletal system protects the vital organs." 2 "The skeletal system aids in calcium regulation." 3 "The skeletal muscle includes three types of bones." 4 "The skeletal system regulates movement and posture." 5 "The skeletal system enables the bones to withstand weight bearing."

"The skeletal muscle includes three types of bones." "The skeletal system regulates movement and posture." The skeletal system is the supporting framework of the body and is made up of four types of bones: long, short, flat, and irregular. The skeletal muscle provides attachments for muscles and ligaments and the nervous system regulates movement and posture. The skeletal system protect vital organs and aids in calcium regulation. The skeletal muscle enables the bones to withstand weight bearing.

Which conditions put the patient at high risk for complications when bedridden and immobile? Select all that apply. 1 Arthritis 2 Anemia 3 Back pain 4 Diabetes 5 Spinal cord injury

Arthritis Diabetes Spinal cord injury Immobility causes many complications, and patients with comorbid conditions are at a higher risk of developing one of these complications. The patients with arthritis, diabetes, and spinal cord injury are at high risk for complications when lying down. The patient with arthritis may have impaired joint mobility, which may aggravate complications. Diabetes may cause impaired circulation and increase the risk of skin breakdown. In case of spinal cord injury, there may be a lack of voluntary muscle control, making the patient susceptible to complications like pressure ulcers. The patient who has anemia or back pain is not at high risk for damage when immobile.

The nurse is caring for a patient who is bedridden due to surgery on the spine. Which respiratory complications may occur if the patient is bedridden for a long duration? Select all that apply. 1 Asthma 2 Atelectasis 3 Hypostatic pneumonia 4 Allergic rhinitis 5 Tuberculosis

Atelectasis Hypostatic pneumonia Bedridden patients are at risk such as atelectasis and hypostatic pneumonia. Atelectasis, or lung collapse, occurs when secretions block the bronchus or the bronchiole, and the distal alveoli collapse due to hypoventilation. Due to immobility, the secretions may pool in the lungs, which promotes bacterial growth. The resultant infection is called hypostatic pneumonia. Asthma is due to hypersensitivity of the airways to specific allergens and is not due to immobility. Allergic rhinitis is caused by inflammation of the nasal passage due to allergic reactions. Tuberculosis is caused by infection with Mycobacterium tuberculosis.

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

Calcium In osteoporosis the bones lack calcium due to demineralization. Therefore, calcium supplements are added to the prescription to improve bone strength. Zinc is useful in cellular metabolism but has no role in bone health. Sodium is important for cells to function but has no role in promoting bone health. Iron is needed for hemoglobin production. It does not help in managing osteoporosis related to bone changes.

Which assessment should the nurse make on priority before moving a patient? 1 Determine the patient's comfort level 2 Determine whether the patient understands what is expected 3 Determine whether the patient's illness contradicts exertion 4 Determine whether the patient is too heavy/immobile to move alone

Determine whether the patient's illness contradicts exertion Before moving the patient, the nurse should first determine whether the patient's illness contradicts exertion. Then, the nurse should determine the patient's comfort level. The nurse should determine whether the patient comprehends what is expected after determining the number of people required to move the patient. In the end, the nurse should assess whether the patient is too heavy or immobile for the nurse to move alone.

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? Select all that apply. 1 Fever 2 Crackles 3 Tachypnea 4 Pain on breathing 5 Blood-tinged sputum

Fever Crackles Pain on breathing The nurse should perform respiratory assessment every 2 hours after surgery for patients with restricted activity. Findings such as fever, crackles, and pain upon breathing indicate pneumonia. Dyspnea is associated with pneumonia, but not tachypnea. The sputum may be greenish yellow in pneumonia, not blood-tinged.

Which primary muscles are used for the abduction of the wrist joint? Select all that apply. 1 Flexor carpi ulnaris 2 Flexor carpi radialis 3 Extensor carpi ulnaris 4 Extensor carpi radialis brevis 5 Extensor carpi radialis longus

Flexor carpi radialis Extensor carpi radialis brevis Extensor carpi radialis longus Flexor carpi radialis, extensor carpi radialis brevis, and extensor carpi radialis longus are the muscles used for the abduction of the condyloid joint in the wrist region. The flexor carpi ulnaris is the primary muscle used for flexion and adduction of the condyloid joint in the wrist region. The extensor carpi ulnaris is used for extension of the condyloid joint in the wrist region.

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

Increased risk of renal calculi Increased urinary concentration Increased risk for urinary tract infections The urinary elimination changes that are often observed as the period of immobility continues are increased renal calculi, as immobilized patients may have hypercalcemia that causes calcium stones. As the immobility continues, the fluid intake decreases and the concentration of urine increases. As the concentration of urine increases, urinary tract infections also increase. As the period of immobility continues, fluid intake often diminishes and, therefore, urinary output also decreases.

Which complications would the nurse have to monitor for when using the supported Fowler's position? Select all that apply. 1 Pressure on the posterior aspect of the knees 2 Excessive lateral flexion of the spine 3 Hyperextension of the lumbar spine 4 Increased shearing force on the back 5 Unprotected pressure points at the ileum

Increased shearing force on the back Pressure on the posterior aspect of the knees In the supported Fowler's position, pressure is applied on the posterior aspect of the knees, decreasing circulation to the feet. Increased shearing force on the back may be due to the supported Fowler's position. Excessive lateral flexion on the spine is due to the side-lying position. Hyperextension of the lumbar spine may be due to the prone position. Lack of protection for pressure point at the ileum is due to the Sims' position.

The nurse is caring for a patient who receives anticoagulant treatment for thromboembolic disease. What is the action of anticoagulant drugs? 1 Dissolve the thrombi 2 Decrease blood viscosity 3 Prevent absorption of vitamin K 4 Inhibits the synthesis of clotting factors

Inhibits the synthesis of clotting factors Anticoagulant therapy is based on the premise that the initiation or extension of thrombi can be prevented by inhibiting the synthesis of clotting factors or by accelerating their inactivation. The anticoagulants heparin and warfarin do not induce thrombolysis but effectively prevent clot extension. These drugs do not decrease the blood viscosity or prevent absorption of vitamin K.

The patient is advised to perform pelvic floor exercises. The nurse explains to the patient that pelvic floor exercise is a type of isometric contraction. Which statements are true about isometric contractions? Select all that apply. 1 Isometric exercises increase the muscle mass of the body. 2 Isometric exercises improve activity tolerance. 3 They have a beneficial effect on preventing orthostatic hypotension. 4 Muscle tension increases, but there is no muscle shortening. 5 Isometric exercises decrease venous return.

Isometric exercises improve activity tolerance. Muscle tension increases, but there is no muscle shortening. Isometric contractions involve energy expenditure without any active movement of the muscle; muscle tension increases, but no muscle shortening occurs. Isometric exercises improve activity tolerance, but they have no beneficial effect on preventing orthostatic hypotension. .Isometric exercises do not help in increasing muscle mass, because they involve energy expenditure, and they actually increase (rather than decrease) venous return. Recall that the prefix iso- means same. Isotonic means same tone. Isometric means same measure (or length). Isometric exercises are static; there is no change in muscle length

Which trouble points would the nurse anticipate while positioning the patient in the Sims' position? Select all that apply. 1 Lack of foot support 2 Increased cervical flexion 3 Lateral flexion of the neck 4 Lack of protection for pressure points 5 Pressure on posterior aspects of knee

Lack of foot support Lateral flexion of the neck Lack of protection for pressure points The trouble points that are common in the Sims' position are lack of foot support, lateral flexion of the neck, and lack of protection for pressure points. Increased cervical flexion and pressure on posterior aspects of the knee are the common trouble areas in the supported Fowler's position.

Which is a desired outcome for a patient diagnosed with osteoporosis? 1 Maintain serum level of calcium. 2 Maintain independence with activities of daily living (ADLs). 3 Reduce supplemental sources of vitamin D. 4 Reverse bone loss through dietary manipulation.

Maintain independence with activities of daily living (ADLs). Once osteoporosis is diagnosed, the main goal is to maintain independence in activities of daily living (ADLs). It is best to identify individuals at risk and work toward preventing the disease. The patient should be taught the current recommended dietary allowances for calcium and vitamin D. Bone loss cannot be totally reversed, but measures can be taken to prevent further bone loss and pathological fractures.

The nurse is assessing a patient with postural abnormality. The nurse observes a C-shaped column with vertebral rotation, and anticipates a diagnosis of scoliosis. Which treatment does the nurse expect the primary health care provider to prescribe for the patient? 1 Surgical treatment 2 Gentle range of motion 3 Spine-stretching exercises 4 Nonsurgical treatment with braces

Nonsurgical treatment with braces Nonsurgical treatment with braces is the best possible treatment for a patient with scoliosis. Gentle range of motion is suggested in cases of torticollis. Spine-stretching exercises can be suggested in cases of lordosis and kyphosis.

What is cartilage?

Nonvascular supporting connective tissue located chiefly in joints Cartilage is nonvascular supporting connective tissue located chiefly in joints and the thorax, trachea, nose, and ear. Joints are the connections between bones. Tendons are the white, glistening fibrous bands of tissues that connect muscles to bones, and are strong, flexible, and inelastic. Ligaments are shiny white flexible bands of fibrous tissues that bind joints together, connect bones and cartilage, and aid joint flexibility and support.

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? Patient A: Torticollis Patient B: Immobility Patient C: Cerebrovascular accident Patient D: Lactose intolerance

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.

The nurse is caring for a patient with hemiplegia. While assessing the patient's condition, the nurse observes erythema and breakdown of the skin. Which nursing intervention provided by the nurse would be correct in this condition? Select all that apply. 1 Allowing pain medication to take effect 2 Placing a turning schedule above the patient's bed 3 Placing the patient on a pressure-relieving mattress 4 Increasing the frequency of turning and repositioning 5 Ensuring that the range-of-motion exercises are implemented consistently

Placing a turning schedule above the patient's bed Placing the patient on a pressure-relieving mattress Increasing the frequency of turning and repositioning When the skin shows erythema and breakdown, the nurse should place the turning schedule above the patient's bed to implement correct positioning timings, place the patient on a pressure relieving mattress, and increase the frequency of turning and repositioning because it may help prevent skin related problems. The patient's pain medication should be allowed to take effect before administering other medications if the patient avoids moving. When joint contractures develop or worsen, the nurse should ensure that the activity and range of motion orders are implemented consistently.

The nurse is attending to a patient who is immobilized due to stroke. Which measures should the nurse take to prevent development of pressure ulcers in the patient? Select all that apply. 1 Reposition the patient every 1 to 2 hours. 2 Place the patient in supine position. 3 Place the patient in a 30-degree lateral position. 4 Avoid pulling the patient when repositioning. 5 Keep the patient well hydrated.

Reposition the patient every 1 to 2 hours. Place the patient in a 30-degree lateral position. Avoid pulling the patient when repositioning. Keep the patient well hydrated. Pressure ulcers develop in people who are immobile for a long duration. Repositioning helps to relieve pressure from the bony prominences and promote circulation. If the patient can lie down in lateral position, a 30-degree lateral position is preferred. In this position, the body weight rests on hip and shoulder. Pulling the patient when repositioning may increase the shearing force, leading to the development of pressure ulcers. Well-hydrated skin is less likely to break down. In supine position, the risk of pressure ulcer is highest.

Which treatment is provided for patients with lordosis?

Spine-stretching exercises Spine stretching exercises is a treatment provided for patients with lordosis. Knee braces are provided for patients with knock-knee. A Denis Browne splint is provided for patients with clubfoot. Bracing with ankle-foot orthotic is provided for patients with footdrop.

The nurse is assessing a postoperative patient and suspects deep vein thrombosis. Which other assessment findings will help the nurse confirm the suspicion? Select all that apply. 1 Tachycardia 2 Dehydration 3 Shortness of breath 4 Orthostatic hypotension 5 Increased calf circumference

Tachycardia Shortness of breath Increased calf circumference A thrombus formed due to deep vein thrombosis may be dislodged and impair circulation and oxygenation, resulting in tachycardia and shortness of breath. A unilateral increase in the calf region is an early indication for thrombus formation in the lower extremities. Dehydration may indicate the impairment of the metabolic system. Orthostatic hypotension may be caused by standing, especially after periods of immobilization.

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

The foot is permanently fixed in plantar flexion Footdrop is the leg contracture in which the foot is permanently fixed in plantar flexion, and the patient is unable to lift the toes off the ground. Internal rotation of the entire foot is a postural abnormality called pigeon toes. Bowleg is a condition in which the patient has both the legs bent outward at the knee. Knock-knee is the postural abnormality in which legs curve inward so the knees come together as the person walks.

Immobilized patients are at risk for bedsores. Which interventions would reduce this risk? Select all that apply. 1 Repositioning patient every 1 to 2 hours while awake 2 Using an objective, valid scale to assess patient's risk for pressure ulcer development 3 Using a device to relieve pressure when patient is seated in chair 4 Teaching patient how to shift weight at regular intervals while sitting in a chair 5 Following this good rule: the higher the risk for skin breakdown, the shorter the interval between position changes

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 Patients must be repositioned around the clock, not just when they are awake. All other choices are correct. An objective assessment scale allows the nurse to assess for pressure ulcer risk over time. Once the risk is identified, the assessment tool guides the nurse in selecting appropriate pressure-relief devices. Showing the patient how to reduce risk by shifting pressure is also important. Frequent and meaningful position changes that are in concert with the patient's condition and risk factors are necessary to reduce pressure ulcer development.

What are ligaments?

White, shiny, flexible bands of fibrous tissue Ligaments are white, shiny, flexible bands of fibrous tissue that bind joints together and connect bones, and cartilages. Joints are the connections between bones. Tendons are white, glistening fibrous bands of tissue that connect muscle to bone. Cartilage is a nonvascular, supporting connective tissue located chiefly in the joints.

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

- Kyphosis is the increased convexity in curvature of the thoracic spine. - Lordosis is the exaggeration of the anterior convex curve of lumbar spine. - Scoliosis is the lateral S- or C-shaped spinal column with vertebral rotation.

The nurse understands that an immobile patient is at high risk of thrombus formation. Which factors may contribute to the risk of thrombus formation? Select all that apply. 1 Alteration in body weight 2 Alteration or slowing of blood flow 3 Damage to the wall of the blood vessels 4 Alteration in the patient's nutritional status 5 Alteration of the constituents in the blood

Alteration or slowing of blood flow Damage to the wall of the blood vessels Alteration of the constituents in the blood

The nurse is caring for a child with clubfoot. Which should the nurse advise the caregiver to apply on the child? 1 Denis Browne splint 2 Knee braces 3 Abduction splints 4 Ankle-foot orthotic

Denis Browne splint Denis Browne splints are used for children with clubfoot to align the foot in the correct position. Knee braces are used for patients with knock-knee (genu valgum). Abduction splints are used for children with congenital hip dysplasia. An ankle-foot orthotic is used to maintain the position of the foot in patients with footdrop.

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? Select all that apply. 1 Eversion 2 Pronation 3 Extension 4 Abduction 5 Dorsiflexion

Extension Dorsiflexion The range of motion movements in the sagittal plane include extension and dorsiflexion. Eversion and inversion occur in the frontal plane. Pronation occurs in the transverse plane. Abduction is a frontal plane movement.

Which areas of the patient would bear weight when placed in the side-lying position? Select all that apply. 1 Hip 2 Heel 3 Ileum 4 Shoulder 5 Humerus

Hip Shoulder In the side-lying position, most of the patient's body weight rests on the hip and shoulder. In supported Fowler's position, the pressure would be on the heels. In Sims' position, the major portion of the body weight rests on the ileum, humerus, and clavicle.

Which assessment findings indicate atelectasis that may result from immobility? 1 Bradypnea 2 Hypoventilation 3 Presence of crackles 4 Symmetrical chest wall

Hypoventilation Hypoventilation may occur due to atelectasis resulting from blockage of bronchioles by secretions and the collapse of distal lung tissue. Tachypnea is seen in atelectasis and not bradypnea. Crackle sounds are heard with pneumonia. Asymmetrical chest wall is observed due to lung collapse.

In a long-term health care facility, the nurse is evaluating the condition of a patient with immobility. Which assessment should the nurse perform to determine if the patient has developed joint contracture? 1 Measure range of motion 2 Determine the level of comfort 3 Evaluate the patient's body alignment 4 Observe the skin for areas of erythema/breakdown

Measure range of motion The nurse should assess range of motion to determine if joint contracture is developing. The nurse should determine the patient's level of comfort and evaluate the patient's body alignment to determine the level of comfort. Observing the skin for areas of erythema or breakdown, especially under bony prominences, determines if there is need to increase the frequency of repositioning.

The nurse is reading an x-ray report of a patient, which shows that the patient has increased convexity in curvature of the thoracic spine. Which instructions should the nurse give to the patient? Select all that apply. 1 Sleep without pillows. 2 Practice spine-stretching exercises. 3 Wear reversed shoes. 4 Use a bed board. 5 Apply heat to the spine.

Sleep without pillows. Practice spine-stretching exercises. Use a bed board. An increased convexity in the curvature of the spine is called kyphosis. The patient can benefit by sleeping without pillows, practicing spine-stretching exercises, and using a bed board. Wearing reversed shoes or applying heat to the spine will not help the patient, because kyphosis is a congenital condition.

The nurse is caring for a retired patient who has had a stroke. The nurse needs to assist the family in adapting to the condition and also help in rehabilitating the patient. Which interdisciplinary team members should the nurse collaborate with? Select all that apply. 1 Social worker 2 Speech therapist 3 Occupational therapist 4 Physical therapist 5 Prosthetist

Speech therapist Occupational therapist Physical therapist

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? 1 To prevent shoulder subluxation 2 To prevent hyperextension of the neck 3 To improve the patient's ability to swallow 4 To improve the patient opportunity to relax

To improve the patient opportunity to relax When positioning a patient in the supported Fowler's position, the nurse elevates the head of the bed to 45 to 60 degrees and adjusts the head of the bed according to the patients' condition to increase comfort, improve ventilation, and increase the patient's opportunity to relax. To prevent shoulder subluxation, pain, and edema, the nurse should provide support for the involved arm and hand on the overbed table. The nurse positions the head on a small pillow with the chin slightly forward to prevent hyperextension of the neck. Positioning the patient in the sitting position helps improve the patient's ability to swallow.

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

Full-body sling To decrease the surface area and to reduce the friction when the patients are unable to assist with moving up in bed, the nurse uses an ergonomic assistive device such as a full-body sling to help lift the patient off the surface of the bed. Arm splints help in reducing musculoskeletal injury. A trapeze bar helps in performing upper arm exercises. Trochanter rolls prevent external rotation of the hips when a patient is in the supine position.

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

Vitamin D A deficiency of vitamin D causes rickets. Therefore, the child should receive vitamin D supplements. Deficiency of vitamin A causes night blindness. Lack of vitamin B causes neural tube defects. Vitamin C deficiency leads to scurvy. STUDY TIP: Know the names of deficiencies for all the vitamins. If you are a visual learner, find photographs of the deficiencies in textbooks or reliable websites to help you remember them.

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? Select all that apply. 1 A 20-year-old unconscious patient 2 A 90-year-old frail patient 3 A 65-year-old patient who is visually impaired 4 A 40-year-old patient who has paraplegia 5 A 30-year old patient who has cholecystitis

A 20-year-old unconscious patient A 90-year-old frail patient A 40-year-old patient who has paraplegia Patients who are at the greatest risk for complications if not properly repositioned are those who are unconscious, frail, or paralyzed. The 20-year-old unconscious patient is at risk for pulmonary and cardiac complications, and at risk for deteriorated skin condition. The 90-year-old frail patient would be unable to change position independently. The 40-year-old paraplegia patient would be unable to move independently and is at risk of complications. The 65-year-old patient with visual impairment and the 30-year-old patient with cholecystitis can move by themselves. These patients are not at risk for developing complications.

While positioning a patient with pressure ulcers, the nurse observes lateral flexion of the neck and an internally rotated shoulder and hip joints. Which patient positioning would have caused the patient's position? 1 Prone position 2 Supine position 3 Side-lying position 4 Supported Fowler's position

A 30-degree side-lying position is recommended for patients with pressure ulcers. Some trouble points are common in the side-lying position, such as lateral flexion of the neck and internally rotated shoulder and hip joints. Placing patients in the prone position may cause neck hyperflexion and hyperextension of the lumbar spine. Placing the patient in the supine position may cause extended elbows and externally rotated hips. When the patient is placed in the supported Fowler's position, he or she may suffer from increased cervical flexion and external rotation of the hips.

Which can cause contracture of a joint?

The muscle fibers become shortened because of disuse. The adductor muscles are stronger than the abductor muscles; when patients are immobile and the joint is not exercised through its range of motion (ROM), the adductor muscle fibers shorten, resulting in the contracture of that joint, which is usually permanent.

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.

Ensure adequate fluid intake. Use elastic stockings on the legs. 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.

What are the common trouble areas for patients in the supine position? Select all that apply. 1 Extended elbows 2 Unsupported feet 3 Externally rotated hips 4 Decreased circulation to the feet 5 Increased shearing force on the back and knees

Extended elbows Unsupported feet Externally rotated hips Patients in the supine position rest on their backs and may experience extended elbows, unsupported feet, and externally rotated hips. Pressure on the posterior aspects of the feet leads to decreased circulation, observed in patients positioned in the supported Fowler's position. There is an increase in shear on the back of the knees when the head of the bed is raised greater than 60 degrees in the supported Fowler's position.

Which is a common debilitating contracture?

Footdrop Footdrop is a common and debilitating contracture in which the foot is permanently fixed in plantar flexion. Disuse, atrophy, and shortening of muscle fibers are the causes of joint contractures.

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

Footdrop The inability to dorsiflex and invert the feet indicates that the patient has footdrop which is usually found in patients who are bedridden and immobile. The foot becomes permanently fixed in plantar flexion, making ambulation difficult. The patient is unable to lift the toes off the ground. Exaggeration of the anterior convex curve of the lumbar spine is called lordosis. One or both legs bent outward at the knee indicates genu varum. Legs curved inward so that the knees come together while walking is a sign of genu valgum.

The nurse is caring for a patient with paralysis. The nurse understands that footdrop is a common but preventable complication in these patients. Which statements are true about footdrop? Select all that apply. 1 Footdrop is a type of debilitating contracture. 2 The foot is permanently fixed in dorsiflexion position. 3 The patient is unable to lift the toes off the ground. 4 Patients with left- or right-side paralysis are at increased risk of developing footdrop. 5 Footdrop can be treated with regular physiotherapy.

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. Footdrop is the most common type of debilitating contracture. The patient is unable to lift the toes from the ground, making it difficult to ambulate. Patients who have suffered a right- or left-sided paralysis are at increased risk of developing footdrop due to immobility. The foot is permanently fixed in plantar flexion. Once footdrop occurs, it cannot be treated. However, it can be prevented through regular physiotherapy.

A child has rickets. The health care provider suggests an increase of calcium, vitamin D, and phosphorus in the patient's diet. Which food items are good sources of calcium? Select all that apply. 1 Green leafy vegetables 2 Yogurt 3 Beans 4 Cereals 5 Cheese

Green leafy vegetables Yogurt Cheese The patient should increase dietary intake of calcium to strengthen the bones. Green leafy vegetables and milk products like yogurt and cheese are high in calcium. Beans are a good source of protein but contain less calcium. Cereals are good sources of carbohydrates but lack calcium.

While caring for a patient with osteoporosis, the nurse finds that the patient has increased convexity in the curvature of the thoracic spine. Which postural abnormality is the patient likely to have?

Kyphosis Increased convexity in the curvature of the thoracic spine is a sign of kyphosis due to congenital conditions, rickets, osteoporosis, and tuberculosis of the spine. Sleeping without pillows, using a bed board, bracing, spinal fusion, and spine-stretching exercises are common treatments for this condition. Exaggeration of the anterior convex curve of the lumbar spine is called lordosis. Lateral S- or C-shaped spinal column with vertebral rotation and an unequal height of the hips and shoulders is called scoliosis. Inclining of the head to the affected side, in which the sternocleidomastoid muscle is contracted, is a sign of torticollis.

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 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.

The nurse is caring for a bedridden patient. The nurse understands that immobility results in many metabolic changes. Which metabolic changes may be found in this patient? Select all that apply. 1 Low calcium levels in the blood 2 Negative nitrogen balance 3 Decrease in the basal metabolic rate 4 Decreased appetite and slowing of peristalsis 5 Increased muscle mass due to tissue anabolism

Negative nitrogen balance Decrease in the basal metabolic rate Decreased appetite and slowing of peristalsis A patient confined to bed may have a negative nitrogen balance, because the body excretes more nitrogen than it ingests through proteins. The basal metabolic rate (BMR) may decrease as a result of reduced food intake. A patient confined to bed experiences decreased appetite and slowing of peristalsis in response to the low BMR. Immobility also results in calcium resorption from bones, in which the calcium is released into circulation, resulting in hypercalcemia. The muscle mass may decrease due to tissue catabolism.

What is the significance of the position depicted in the image? Reduces the risk of foot drop 2 Reduces the risk of pressure ulcers 3 Reduces the risk of deep vein thrombosis 4 Reduces the risk of musculoskeletal injury

Reduces the risk of pressure ulcers The image indicates the 30-degree lateral position. This position would be beneficial for reducing the risk of pressure ulcers. The risk of foot drop is reduced by placing the patient in the supine or prone positions. The risk of deep vein thrombosis is reduced by placing the patient in a supported Fowler's position. Placing the patient in the supine position reduces the risk of musculoskeletal injury.

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

Respiratory Lack of movement and exercise places patients at risk for respiratory complications. The metabolic changes seen in patients with impaired mobility are altered endocrine metabolism and calcium resorption. An ulcer is characterized by inflammation and usually forms over a bony prominence. It is seen due to integumentary changes in patients with impaired mobility. The musculoskeletal changes seen in patients with impaired mobility are temporary impairment and permanent disability. According to Maslow's hierarchy of needs, physiological complications take priority over social isolation. Respiratory complications take top priority to ensure the ABCs: Airway, Breathing, Circulation.

Which statement is true regarding muscle abnormalities?

Muscle abnormalities cause degeneration of skeletal muscle fibers. Muscle abnormalities like muscular dystrophies can cause degeneration of skeletal muscle fibers. Postural abnormalities may affect body alignment. Muscle abnormalities would not affect the central nervous system of the body. Muscle abnormalities are most prevalent for the muscle diseases in childhood.

Which statement is true regarding the skeletal system of different individuals? 1 Men are more susceptible to bone loss and osteoporosis. 2 Older persons' bones are more pliable than toddlers' bones. 3 Older persons are better able to withstand falls than toddlers. 4 Newborns have a larger amount of cartilage and are highly flexible.

Newborns have a larger amount of cartilage and are highly flexible. A newborn has a large amount of cartilage, which is highly flexible, but it is unable to support weight, because elasticity and skeletal flexibility change with age. Older adults, especially women, are more susceptible to bone loss and osteoporosis. A toddler's bones are more pliable than those of an older adult, so they are better able to withstand falls.

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

Osteoporosis In a postmenopausal patient, osteoporotic changes in the bone increase the risk of fractures. Impaired calcium metabolism causes bone resorption, making it less dense. Bones affected by resorption are fragile and more susceptible to fractures. Osteosarcoma and osteoclastoma are bone tumors. Osteomyelitis is an infection of the bone.

A patient who has attained menopause is diagnosed with osteoporosis. Which consequences of osteoporosis should the nurse consider in the patient?

Pathological fractures Osteoporosis results in decreased bone mass and brittle bones, which make the patient prone to pathological fractures. Joint contractures are a complication of immobility of joints. Footdrop is a type of joint contracture, where the foot is permanently fixed in plantar flexion. Urinary stasis is a complication of immobility, in which the urine gets stagnated in the bladder.

The nurse is caring for four different patients with immobility. Which patient should the nurse place in the supine position? 1 Patient with pressure ulcers 2 Patient with respiratory distress 3 Patient with deep vein thrombosis 4 Patient with musculoskeletal complications

Patient with musculoskeletal complications Patients with musculoskeletal complications would benefit from being placed in the supine position. Patients with pressure ulcers would benefit from being placed in the lateral side-lying position. Patients with deep vein thrombosis should be placed in supported Fowler's position. Patients with respiratory distress would benefit from being placed in the prone position because it helps improve oxygenation.

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? 1 "Determine the comfort level of the patient." 2 "Determine the effects of illness on exertion." 3 "Determine whether the patient understands what is expected." 4 "Determine whether the patient is immobile for you to move alone."

"Determine the effects of illness on exertion." Before moving a patient, the nurse should determine the effects of illness on exertion, because some conditions, such as cardiovascular disease, may contradict exertion. The nurse should determine the comfort levels of the patient after determining whether the patient understands the expectation of the nurse. Finally, the nurse should determine whether it is difficult to move the patient alone or there is a need for the assistance of other nurses.

The registered nurse is teaching a nursing student about the pathological influence on mobility. Which statement made by the nursing student indicates a need for further learning? 1 "Damage to the cerebellum causes problems with balance." 2 "Right-sided cerebral hemorrhage causes left-sided hemiplegia." 3 "Direct trauma to the central nervous system results in bruises and contusions." 4 "Complete transection of spinal cord causes bilateral loss of voluntary motor control below the level of the trauma."

"Direct trauma to the central nervous system results in bruises and contusions." Direct trauma to the musculoskeletal system results in bruises, sprains, and contusions. Damage to the cerebellum causes problems with balance and motor impairment. A person with right-sided cerebral hemorrhage with necrosis has destruction of the right motor strip that results in left-sided hemiplegia. A complete transection of spinal cord results in bilateral loss of voluntary motor control below the level of trauma because motor fibers are cut.

The nurse is reviewing the data of a patient with severe joint pain. Which questions asked by the nurse help assess joint mobility? Select all that apply. 1 "What is your daily diet like?" 2 "What are your normal daily activities?" 3 "Does your joint pain worsen if you walk?" 4 "Have you noticed any swelling of the joints?" 5 "Have you noticed any open sores at your joints?"

"Does your joint pain worsen if you walk?" "Have you noticed any swelling of the joints?" Joint pain may be a sign of arthritis. In cases of limited mobility, the joint pain may worsen while walking. The swelling of joints may also limit the mobility. Asking about changes in normal daily activities rather than just asking about normal daily activities would be helpful in assessing the immobility of the patient. Likewise, asking about dietary changes would also be beneficial in assessing the immobility of joints. Open sores at the joints and on the skin also would help in assessing the immobility of joints.

The registered nurse is teaching a nursing student about psychosocial effects on patients with immobility. Which statements made by the nursing student indicate a need for further learning? Select all that apply. "Every patient responds to immobility in a same way." 2 "Patients with restricted mobility may have depression." 3 "Impaired mobility can cause social isolation and loneliness." 4 "Immobilization leads to emotional and behavioral responses." 5 "Withdrawn patients often want to participate in their own care."

"Every patient responds to immobility in a same way." "Withdrawn patients often want to participate in their own care." Every patient responds to immobility in a different way. Withdrawn patients often do not want to participate in their own care. Patients with restricted mobility may experience depression. Impaired mobility can cause social isolation and loneliness. Immobilization often leads to emotional and behavioral responses, sensory alterations, and changes in coping.

The nurse is evaluating a patient who was diagnosed with osteoporosis 3 months ago. The patient has limited mobility and has been taught measures to limit risks associated with osteoporosis. Which statements made by the patient indicate effective outcomes of the teaching? Select all that apply. 1 "I have reduced smoking to three cigarettes per day." 2 "I am using a cane to walk when I am alone." 3 "I reduced drinking coffee to 1 cup per day." 4 "I added spinach to my daily diet because I am lactose intolerant." 5 "I can perform normal daily activities with the support of my son."

"I am using a cane to walk when I am alone." "I reduced drinking coffee to 1 cup per day." "I added spinach to my daily diet because I am lactose intolerant." Using a cane to walk is a safety measure that reduces the risk of falls. Reducing the intake of caffeinated products such as coffee indicates effective teaching, as it will improve bone strength by enhancing calcium absorption. Spinach is a calcium rich food that also improves the bone strength. Smoking should be stopped completely. The patient should be able to perform normal daily activities independently.

The registered nurse is teaching a nursing student about positioning techniques. Which statement made by the nursing student indicates effective learning? 1 "I can use a thick pillow, because it decreases cervical flexion." 2 "I can use pillows of any size to position the patient." 3 "I can use folded sheets when additional pillows are unavailable." 4 "I can use a thin pillow to protect the skin from pressure ulcers."

"I can use folded sheets when additional pillows are unavailable." When additional pillows are unavailable, or if they are an improper size, the nurse can use folded sheets, blankets, or towels as positioning aids. A thick pillow under a patient's head increases cervical flexion, which would not be desirable. Therefore, a thick pillow should not be used. Pillows of a particular size should be used depending on the position and the patient to prevent discomfort. A thin pillow under bony prominences does not protect the skin and tissue from damage caused by pressure ulcers.

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? Select all that apply. 1 "I should perform hand hygiene." 2 "I should place all pillows on the bed." 3 "I should collect appropriate equipment." 4 "I should explain the procedure to the patient." 5 "I should keep the level of the bed in a low position." 6 "I should close the room door and bedside curtains."

"I should place all pillows on the bed." "I should keep the level of the bed in a low position." All the pillows from the bed should be removed while planning for positioning a patient on the bed. The level of the bed should be raised to a comfortable working height. The nurse should perform hand hygiene for positioning a patient to reduce the transfer of microorganisms. The nurse should collect the appropriate equipment required for positioning. The nurse should explain the procedure to the patient to relieve anxiety in the patient and to allow active participation. The nurse should close the room door and curtains to provide privacy for the patient.

The registered nurse is teaching a nursing student about how to assess for deep vein thrombosis in a postoperative patient. Which statements made by the nursing student indicate effective learning? Select all that apply. 1 "I will assess for calf pain by dorsiflexing the foot." 2 "I will observe the calves for redness and tenderness." 3 "I will measure calf circumference every other day." 4 "I will notify the primary health care provider if a peripheral pulse is present." 5 "I will remove the sequential compression dressing every 8 hours to assess the skin."

"I will observe the calves for redness and tenderness." "I will remove the sequential compression dressing every 8 hours to assess the skin." To assess deep vein thrombosis (DVT), the nurse should observe the calves for redness and tenderness. The nurse should also remove the sequential compression dressing every 8 hours to assess the skin, because skin discoloration may indicate DVT. Assessing calf pain by dorsiflexion of the foot is not considered an indicator for DVT. Calf circumference should be measured every day to assess DVT, because a unilateral increase in calf circumference is an early sign of the condition. The presence of peripheral pulse may not be a sign of DVT, but if the peripheral pulse is absent, it indicates DVT. Therefore, the nurse should notify the primary health care provider.

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? 1 "I will position the patient in the Sims' position to prevent foot drop." 2 "I will position the patient in the supine position to reduce musculoskeletal injury." 3 "I will position the patient in the prone position to prevent pressure ulcers." 4 "I will position the patient in the supported Fowler's position to prevent deep vein thrombosis."

"I will position the patient in the prone position to prevent pressure ulcers." Positioning the patient in the prone position prevents foot drop, not pressure ulcers. Placing the patient in the Sims' position may reduce the risk of foot drop. Placing the patient in the supine position may reduce the risk of musculoskeletal injury. Placing the patient in the supported Fowler's position may reduce the risk of deep vein thrombosis by improving the peripheral circulation.

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

"I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." 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. Any type of activity can help with calcium metabolism and is beneficial for helping to reduce the risk of osteoporosis. Patients should have a bone density scan yearly or according to their primary care physician's recommendations. To decrease the risk of osteoporosis, patients should be eating foods high in calcium and vitamin D.

What is the correct order of steps for positioning a patient in Sims' (semi-prone) position? 1. Place pillow under flexed upper leg 2. Place pillow under flexed upper arm 3. Position the patient in the supine position. 4. Place a small pillow under patient's head 5. Move to another side of the bed and turn patient on side 6. Support feet in dorsiflexion with foot support devices

1. Position the patient in the supine position. Correct 2. Move to another side of the bed and turn patient on side Correct 3. Place a small pillow under patient's head Correct 4. Place pillow under flexed upper arm Correct 5. Place pillow under flexed upper leg Correct 6. Support feet in dorsiflexion with foot support devices While positioning a patient in the Sims' position, the patient should first be positioned in the supine position on the side of the bed opposite the direction toward which the patient is to be turned. Next, the nurse should move to another side of the bed and turn the patient onto the side. The patient should be positioned in the lateral position, lying partially on the abdomen. Then, a small pillow should be placed under the patient's head, and a pillow should be placed under the flexed upper arm, supporting the arm level with the shoulder. Next, a pillow should be placed under the flexed upper leg, supporting the leg level with the hip. Finally, the feet should be supported in dorsiflexion with foot support devices.

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

Calcium imbalance Gastrointestinal disturbances Alteration in the metabolism of protein Immobility affects normal metabolic functioning. Calcium imbalance occurs because immobility causes the release of calcium into circulation. Calcium resorption may cause pathological fracture. Gastrointestinal disturbances occur due to lack of mobility, which may lead to constipation. Immobility causes alteration in the metabolism of protein. The body is constantly synthesizing proteins and breaking them down into amino acids to form other proteins. In immobile patients, the body excretes more nitrogen than it ingests as proteins. This causes negative nitrogen balance. Immobility decreases appetite as well as peristalsis.

The laboratory reports of an immobilized patient indicate the presence of thrombus. Which changes in the body are responsible for this condition in the patient? 1 Metabolic changes 2 Respiratory changes 3 Cardiovascular changes 4 Musculoskeletal changes

Cardiovascular changes Patients with immobility are at a risk of thrombus formation. Cardiovascular changes in the body lead to orthostatic hypotension, increased cardiac work load, and thrombus formation. The metabolic changes seen in patients with impaired mobility are altered endocrine metabolism and calcium resorption. The respiratory changes seen in patients with impaired mobility are pulmonary complications like atelectasis and hypostatic pneumonia. The musculoskeletal changes seen in patients with impaired mobility are temporary impairment and permanent disability.

The patient with hemiparesis needs passive range-of-motion (ROM) exercises to promote musculoskeletal health. Which precautions should be taken to ensure effective ROM exercises? Select all that apply. 1 Carry out movements slowly and smoothly. 2 Be aware that ROM may cause mild pain. 3 Never force a joint beyond its capacity. 4 Repeat each movement ten times during a session. 5 Perform exercises using head-to-toe sequence.

Carry out movements slowly and smoothly. Never force a joint beyond its capacity. Perform exercises using head-to-toe sequence. Unlike active range-of-motion (ROM) exercises, which are performed by the patient, passive ROM is performed by either the nurse or the physical therapist. The movements should be carried out slowly and smoothly to prevent injury to the soft tissues. Forcing a joint beyond its capacity may injure the bones and other soft tissues of the joint. The exercises should be performed in a head-to-toe sequence to prevent missing any joint. ROM should not cause pain; the joint, if forced beyond its capacity may cause pain. Each movement should be repeated five times during a session for optimal effect.

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? Select all that apply. 1 Increase intake of vitamin D. 2 Increase intake of calcium. 3 Increase intake of vitamin E. 4 Increase intake of vitamin A. 5 Increase intake of phosphorus.

Increase intake of vitamin D. Increase intake of calcium. Increase intake of phosphorus. Bowlegs is a postural abnormality in which one or both legs bend outward at the knee. It occurs due to a congenital condition or rickets. An increase in the intake of vitamin D, calcium, and phosphorus is useful for the treatment of bowlegs. These vitamins and minerals mineralize the bones and make them stronger. Increased intake of vitamin E and vitamin A are not helpful for the treatment of bowlegs as these do not affect bone health.

While caring for a patient, the nurse suspects deep vein thrombosis. Which factor of Virchow's triad may lead to this condition? 1 Increased serum calcium 2 Decreased blood glucose 3 Increased platelet activity 4 Decreased red blood cell count

Increased platelet activity Alterations in blood constituents, such as a change in clotting factors and increased platelet activity, may result in deep vein thrombosis. Increased serum calcium may indicate osteoporosis due to increased bone resorption. A decrease in blood glucose might not indicate deep vein thrombosis. A decreased red blood cell count is not associated with deep vein thrombosis.

A patient is advised to be in supported Fowler's position. Which trouble areas can cause patient discomfort in this position? Select all that apply. 1 Increased shearing force on the back and heels 2 Thumb not in opposition to the fingers 3 Unprotected pressure points at the sacrum and heels 4 Shoulders unsupported and internally rotated 5 Pressure on the posterior aspect of the knees decreasing circulation to the feet

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 Shear injuries result from improper positioning, usually when the patient slides down in the bed. In the supported Fowler's position, the pressure points at the sacrum and heel are unprotected, increasing the risk of pressure ulcers. Pressure on the posterior aspect of the knees may decrease the circulation to the feet. Therefore, the knees should be kept slightly elevated without pressure. In the supine position, the thumb is not in opposition to the fingers, and the shoulders remain unsupported and internally rotated.

The nurse is positioning a quadriplegic patient to a supported Fowler's position. While positioning, the nurse uses a pillow to support the arms and hands of the patient. How will this help the patient? Select all that apply. 1 It increases comfort. 2 It prevents shoulder dislocation. 3 It prevents flexion contractures of the arm and wrists. 4 It supports the cervical vertebrae. 5 It prevents occlusion of the popliteal artery.

It prevents shoulder dislocation. It prevents flexion contractures of the arm and wrists. Using a pillow to support the arms and hands of the patient will help to prevent shoulder dislocation and flexion contractures of the arm and wrist. Elevation of the head of the bed helps to increase patient comfort. Resting the head on a small pillow will help to support cervical vertebrae. Occlusion of the popliteal artery can be prevented by placing a small pillow under the thigh.

Which trouble points would the nurse anticipate while positioning the patient in the Sims' position? Select all that apply. 1 Lack of foot support 2 Increased cervical flexion 3 Lateral flexion of the neck 4 Lack of protection for pressure points 5 Pressure on posterior aspects of knee

Lack of foot support Lateral flexion of the neck Lack of protection for pressure points The trouble points that are common in the Sims' position are lack of foot support, lateral flexion of the neck, and lack of protection for pressure points. Increased cervical flexion and pressure on posterior aspects of the knee are the common trouble areas in the supported Fowler's position.

Which condition is observed by placing the patient in the Sims' position? 1 Excessive lateral flexion 2 Increased cervical flexion 3 Lateral flexion of the neck 4 Plantar flexion of the ankles

Lateral flexion of the neck Patients positioned in the Sims' position may suffer from lateral flexion of the neck. Excessive lateral flexion of the spine may occur if a patient is positioned in a side-lying position. Patients positioned in the prone position may experience plantar flexion of the ankles. Increased cervical flexion is observed in patients positioned in the supported Fowler's position.

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

Lordosis Lordosis is a postural abnormality that involves an exaggeration of the anterior convex curve of the lumbar spine. Kyphosis is the increased convexity in the curvature of thoracic spine. Scoliosis is a lateral S- or C-shaped spinal column with vertebral rotation and unequal heights of hips and shoulders. Torticollis involves inclination of the head to the affected side and contraction of the sternocleidomastoid muscle.

The nursing student is performing range-of-motion (ROM) exercises for a patient who has been immobile for an extended period. Which action performed by the nursing student needs correction? 1 Performing ROM exercises when the pain score is 2 2 Performing ROM exercises 5 times during a session 3 Performing ROM exercises from smaller joints to larger joints 4 Performing ROM exercises by extending the joint as much as possible

Performing ROM exercises from smaller joints to larger joints The nurse should perform the ROM exercises from larger joints to smaller joints. Because a pain score of 0 is not possible, a pain score 2 is considered as a minimum in which ROM exercises can be performed. The movements should be repeated 5 times during each session. The joint can be extended as much as possible, but it should not be extended beyond resistance, and force should not be applied to perform the ROM exercises.

The nurse is caring for a patient who is on bed rest for a month. The nurse understands that an immobile patient may have poor body alignment, which may lead to complications. How should the nurse assess body alignment in this patient? Select all that apply. 1 Place the patient in a lateral position. 2 Support the patient with positioning aids. 3 Support the head with a pillow. 4 Support the body with an adequate mattress. 5 Assist the patient in sitting up for assessment.

Place the patient in a lateral position. Support the head with a pillow. Support the body with an adequate mattress. Bedridden patients are at risk of damaging the body due to the inability to perceive muscle strain and lack of circulation. For assessment of body alignment, the patient should be placed in a lateral position with a pillow under the head. The body should be supported with an adequate mattress. In this position, a full view of the back and spine is possible. It also helps to determine whether the patient can maintain this position without supporting aids. All the supporting aids should be removed before the assessment is done. A sitting position does not give a full view of the spine and back for assessment.

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 Placing a thin pillow under bony prominences may lead to skin and tissue damage due to pressure. Positioning boots are applied to reduce the risk of foot drop. Placing a pillow under the knees with slight elevation increases the peripheral circulation. Rolled washcloths should not be used as hand rolls because they do not keep the thumbs well abducted.

The nurse uses trochanter rolls or sand bags when performing which intervention? Select all that apply. 1 Placing the patient in the prone position 2 Placing the patient in the supported supine position 3 Placing the patient in the supported Fowler's position 4 Assisting the patient to sleep in the 30-degree lateral position 5 Assisting the patient in moving up in bed using a friction reducing device

Placing the patient in the supported supine position Placing the patient in the supported Fowler's position While positioning the patient in the supported supine position and the supported Fowler's position, the nurse places trochanter rolls and bags parallel to the lateral surface of the patient's thighs to reduce the external rotation of the hip. While placing the patient in the prone position, the 30-degree lateral position, and while helping the patient move up in bed using a friction-reducing device, the nurse would not use trochanter rolls, because these positions do not lead to external rotation of the hip.

A patient is undergoing treatment in a long-term health care facility. Which type of immobility complication is likely to develop in the immobilized patient? 1 Footdrop 2 Atelectasis 3 Pressure ulcers 4 Pathological fractures

Pressure ulcers A pressure ulcer is an impairment of the skin as a result of prolonged ischemia in the tissues, and the prevalence of pressure ulcers is highest in long-term care facilities due to decreased blood supply to the tissues. Patients who have suffered cerebrovascular accident with resulting left- or right-sided paralysis are at high risk for footdrop. Patients who are immobilized are at high risk for developing a pulmonary complication such as atelectasis, but it may not be observed in patients who are in long-term health care facilities. Patients with disuse osteoporosis are at high risk for pathological fractures.

The nurse is caring for a patient diagnosed with a spinal cord injury at T7 level. For which areas of care should the nurse seek out a physical therapist for assistance? Select all that apply. 1 Assisting with management of bed sores 2 Managing the controls of the ventilator 3 Preventing the development of any postural abnormalities 4 Assisting the patient in ambulation 5 Prescribing exercises to strengthen trunk musculature

Preventing the development of any postural abnormalities Assisting the patient in ambulation Prescribing exercises to strengthen trunk musculature The duty of a physical therapist is to assist patients in activities that enhance mobility such as ambulation, prescribing exercises to improve strength, and addressing any postural abnormalities that could further hamper mobility. A person with T7-level spinal cord injury does not require ventilator support. Physical therapists could assist in bed mobility to prevent bed sores, and they are knowledgeable about wound care, but managing bed sores is the duty of the nurse.

Which position may lead to plantar flexion of the feet?

Prone position Placing the patient in the prone position may lead to plantar flexion of the feet. The supine position may increase cervical flexion if a thick pillow is placed below the head. The side-lying position may lead to excessive lateral flexion of the spine. The supported Fowler's position may lead to increased cervical flexion.

While assessing a postoperative patient, the nurse observes that the patient is unable to sleep in the lateral position. Which assessment finding indicates an increased risk of developing complications due to immobility? 1 Heart rate 60 beats/minute 2 Blood pressure 120/90 mm Hg 3 Pain reported as 2 on pain scale 4 Respiratory rate 28 breaths/minute

Respiratory rate 28 breaths/minute The normal respiratory rate is 12 to 18 breaths/minute. Patients with limited mobility may be at risk of pooling pulmonary secretions, which may result in increased respiratory rate. A heart rate of 60 beats/minute, blood pressure of 120/90, and pain reported as 2 on a scale of 1 to 10 are normal findings.

The nurse is caring for a patient who has been immobile for a month due to quadriplegia. Which risks should the nurse be prepared for? Select all that apply. 1 Risk of developing atelectasis 2 Risk of developing tension pneumothorax 3 Risk of developing hypostatic pneumonia 4 Risk of developing pulmonary tuberculosis 5 Risk of ineffective coughing

Risk of developing atelectasis Risk of developing hypostatic pneumonia Risk of ineffective coughing When a patient is on prolonged bed rest, the patient is exposed to the risk of developing atelectasis and hypostatic pneumonia. The secretions in the lungs may block a bronchiole or a bronchus, resulting in the collapse of the distal lung tissue. This causes hypoventilation and atelectasis. Hypostatic pneumonia frequently results because mucus pooled in the lung tissue is an excellent place for bacteria to grow. With prolonged immobility, there is an associated decline in the patient's ability to cough productively. Tension pneumothorax is caused after trauma. Pulmonary tuberculosis results from exposure to the causative microorganism.

The nurse is caring for different patients. Which patient's condition may benefit from logrolling? 1 Head injury 2 Hand fracture 3 Spinal cord injury 4 Abdominal surgery

Spinal cord injury Patients with a spinal cord injury often need to keep the spinal column in straight alignment to prevent further injury. Therefore, logrolling would be beneficial for this patient to prevent further injury. A patient with head injury would benefit from the semi-Fowler's position. A patient with a hand injury and a patient with an abdominal surgery are placed in the supine position.

Which positioning of the patient by the nurse will help prevent flexion contracture of the cervical vertebrae?

Supported Fowler's position The supported Fowler's position prevents the flexion contracture of the cervical vertebrae. The prone position would be beneficial for patients with acute respiratory distress. The 30-degree lateral position, or side-lying position, prevents pressure from bony prominences on the back. The semi-prone position prevents foot drop.

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.

Temperature of the skin Pedel pulse 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.

The nurse is teaching a group of nursing students about tendons. Which statements about tendons are true? Select all that apply.

Tendons are fibrous bands connecting muscles to bone.Tendons are strong, flexible, and inelastic. Tendons are fibrous bands connecting muscles to bone. They are strong, flexible, and inelastic. Cartilage is nonvascular, supportive connective tissue located in the joints and thorax, trachea, larynx, nose, and ear. Ligaments help to hold joints together, and connect bones and cartilage. Some ligaments may also protect two bony surfaces against friction.

A patient complains of limited mobility. While assessing the past medical history of the patient, the nurse finds that the patient underwent surgery for a hip fracture. Which reason does the nurse suspect is responsible for the patient's condition? Select all that apply. 1 The patient has contractures. 2 The patient has ligament tears. 3 The patient has a history of arthritis. 4 The patient has connective tissue disorders. 5 The patient has decreased synovial fluid in the joint.

The patient has contractures. The patient has a history of arthritis. The patient has decreased synovial fluid in the joint. Range of motion is limited in patients with limited nerve supply. Range of motion may be limited in patients with arthritis due to severe pain. Decreased synovial fluid in the joints also leads to decreased range of motion. If the patient has a ligament tear, it may lead to increased range of motion beyond normal. If the patient has a connective tissue disorder, the patient may have increased range of motion.

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

The patient has venous thrombus formation. The absence of pedal pulses and abnormally cold extremities indicate that the patient has venous thrombus formation. Venous thrombus formation occurs because of stagnation or alteration in the blood flow as a result of immobility or injury to the vessel wall during surgery. The thrombus may block the blood supply to the extremities. The clinical manifestations in the patient are not age-related effects. Hip joint dislocation may not result in absence of pedal pulses. A cool room temperature may cause the extremities to become cold but may not lead to an absence of pedal pulses.

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

The patient's use of hand is limited. Most functions of the hand are best carried out with the forearm in moderate pronation. When the forearm is fixed in a position of full supination, the patient's use of the hand is limited. When the wrist is fixed in even a slightly flexed position, the grasp is weakened. When the patient has limited movement in the shoulder, he/she may have difficulty moving the arms. When there is impaired range of motion in the fingers and thumbs, the patient is less able to perform fine-motor skills such as carpentry and painting.

The nurse is 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? 1 The patient avoids moving. 2 Joint contractures are worsening 3 The patient has difficulty moving. 4 The skin is showing areas of erythema and breakdown.

The skin is showing areas of erythema and breakdown. When the skin shows erythema and breakdown, the nurse should place the patient on a pressure-relieving mattress. When the patient avoids moving, the nurse administers analgesia as ordered by the health care provider. When worsening joint contractures are observed, the nurse ensures that activity and range of motion are implemented consistently. When the patient has difficulty moving, the nurse consults the physical or occupational therapist.

The nurse is caring for a patient who is immobile. Which cardiovascular changes does the nurse expect to observe in the patient? Select all that apply. 1 Thrombus formation 2 Orthostatic hypotension 3 Increased cardiac output 4 Increased cardiac workload 5 Increased circulating fluid volume

Thrombus formation Orthostatic hypotension Increased cardiac workload Immobilization affects the cardiovascular system, frequently causing thrombus formation, increased cardiac workload, and orthostatic hypotension. As immobilization increases, cardiac output falls, further decreasing cardiac efficiency and increasing workload. In the immobilized patient, decreased circulating fluid volume and pooling of blood in the lower extremities occurs.

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? 1 To reduce extension of fingers 2 To maintain correct body alignment 3 To provide support to the lumbar spine 4 To reduce the internal rotation of shoulders

To reduce the internal rotation of shoulders While positioning the patient in the supported supine position, the nurse places pillows under the pronated forearms, and keeps the upper arms parallel to the patient's body to reduce the internal rotation of the shoulder and prevent extension of the elbows. Placing the hand rolls in the patient's arms helps reduce the extension of the fingers and abduction of the thumb. Placing pillows under the upper shoulders, neck, or head helps in maintaining the correct body alignment and prevents flexion contractures of the cervical spine. Placing a small rolled towel under the lumbar area of the back provides support to the lumbar spine.

The nurse is assessing a patient with limited neck movement. The nurse finds that a patient is unable to perform flexion and lateral flexion of the neck, and inclines the head only to one side. Which condition does the nurse suspect in the patient? 1 Scoliosis 2 Lordosis 3 Kyphosis 4 Torticollis

Torticollis Inability to perform flexion, lateral flexion, and inclining the head only to one side of the neck indicates contracture of sternocleidomastoid muscle. Torticollis involves inclining the head to the affected side with contraction of the sternocleidomastoid muscle. Scoliosis refers to a lateral S- or C-shaped spinal column with vertebral rotation and unequal heights of hips and shoulders. Exaggeration of the anterior convex curve of the lumbar spine may indicate lordosis. Kyphosis refers to increased convexity in curvature of the thoracic spine.

The nurse is caring for a patient who has been immobile after a spine surgery. Which urinary changes are likely to occur in the first 72 postoperative hours? Select all that apply. 1 Urinary output decreases. 2 Risk for developing chronic renal failure increases. 3 Urine is more diluted. 4 Urinary stasis occurs. 5 Risk for developing urinary tract infection increases.

Urinary output decreases. Urinary stasis occurs. Risk for developing urinary tract infection increases. Fluid intake is often diminished during immobility, causing a decrease in urine output and an increase in the concentration (not dilution) of the urine. The urine produced by the kidneys needs gravitational force to enter the ureters. During immobility, the urine in the kidney fills up the pelvis. This condition is called urinary stasis. It increases the risk of urinary infection, because microorganisms can grow well in stagnated urine. Chronic renal failure will not happen in the first 72 hours after surgery, but untreated renal calculi and urinary tract infections may gradually lead to chronic renal failure.