NCHP Activity
Which action would the nurse take for a patient on bed rest who is concerned about developing constipation? A. Increase the patient's dietary fiber and fluid intake. B. Complete the Braden Scale assessment tool. C. Increase the frequency of passive range-of-motion exercises. D. Administer enoxaparin prophylactically.
Answer: A
Which interpretation would the nurse make when observing a darkened or reddened area of skin in an immobile patient? A. Tissue ischemia has occurred. B. Blanching has developed. C. Cyanosis has occurred. D. DVT has developed.
Answer: A
Which actions would the nurse take if the patient falls while ambulating in the hall? SATA A. Call for help. B. Assess the patient's physical and neurologic status. C. Notify the charge nurse and primary HCP. D. Leave the patient to go get help. E. Complete occurence report.
Answer: A, B, C, E
Patients on bed rest are likely at risk for which physiologic effects and conditions? SATA A. Increased venous return. B. Decreased lung expansion. C. Decreased cardiac workload. D. Atelectasis. E. Pneumonia.
Answer: A,B, D, E
Match each type of exercise to its example. A. Ambulating B. Kegel exercises C. Heavy weight-lifting D. Repeated stair-climbing Choices: 1. Isotonic. 2. Isometric. 3. Aerobic. 4. Anaerobic.
Answer: A- 1 B- 2 C- 4 D-3
In which position would the nurse place the patient to perform coughing and deep breathing? A. Dorsal recumbent. B. Fowler's. C. Side-lying. D. Sim's.
Answer: B
Which action would the nurse take to improve an immobile patient's nutritional intake? A. Monitor the patient's serum albumin. B. Assess the patient's nutritional intake. C. Allow the patient to make food choices. D. Weigh the patient at routine intervals.
Answer: C
Which SMART (specific, measurable, assignable, relevant, time-based) outcomes would the nurse develop for a patient who is light-headed and fatigued and has feeble handgrip with reduced bone density? SATA A. Patient's pulse oximetry will be above 90% during an activity. B. Patient will have intact skin throughout hospital stay. C. Patient will exercise arm and leg muscles. D. Patient will brush teeth after breakfast with one person assisting. E. Patient will exercise joints at least twice per shift.
Answer: D, E
The nurse would inform unlicensed assistive personnel to turn the patient how often (in hours) to maintain skin integrity? Record your answer as a whole number. __ hour(s)
Answer: 2 hrs
Which action would the nurse take first when assisting a patient who has been in bed for several days after surgery to transfer from the bed to the chair? A. Allow the patient to dangle. B. Stand the patient up with assistance. C. Transfer the patient with a slide board. D. Place the transfer belt after the patient stands.
Answer: A
Which cue is relevant to alterations in the musculoskeletal system? A. Has a shoulder joint that is edematous B. Has a low sodium level C. Has a history of hemorrhoids D. Has five grandchildren
Answer: A
Which device would be most appropriate for a patient who has had surgery on a fractured femur and needs help repositioning in bed? A. Trapeze bar. B. Mechanical lift. C. Transfer board. D. Friction-reducing sheet.
Answer: A
Which patient finding would alert the nurse to stop passive range-of-motion exercises? A. Resistance to movement is felt. B. The patient is unable to participate. C. The patient's joints move freely. D. Atrophy occurs.
Answer: A
Which cues are relevant for activity intolerance? SATA A. Struggles to complete activities of daily living B. Exhibits dyspnea on exertion C. Has to sit down while doing the dishes D. Has an inability to move E. Has no feeling in the lower extremities
Answer: A, B, C
Which evaluative cues indicate the patient with a Risk for Deep Vein Thrombosis is deteriorating? SATA A. Experiences a pulmonary embolus. B. Has dusky toes. C. Has coagulation laboratory results that indicate the patient is clotting too fast. D. States the sequential compression device pressure is maintained at 40 mm Hg. E. Experiences intact skin with no abnormalities in the lower leg
Answer: A, B, C
When providing care to patients, which safety and body mechanic aspects would the nurse consider to prevent injury to him- or herself and the patient? SATA A. Leave top side rails up. B. Bend at the knees. C. Carry weight close to the body. D. Use mechanical lift equipment. E. Relax pelvic muscles.
Answer: A, B, C, D
Which instructions about respiratory and range-of-motion measures would the nurse share with a patient who has limited mobility? SATA A. Use the incentive spirometer 5 to 12 times every 1 to 2 hours. B. Deep breathe 10 times every hour. C. Cough two to three times every 2 hours. D. Perform range-of-motion exercises at least five to six times each day. E. Move each joint three to five times during range-of-motion exercises.
Answer: A, B, C, E
Which musculoskeletal alterations does immobility predispose a patient to developing? SATA A. Weakness. B. Decreased muscle tone. C. Decreased muscle mass. D. Increased bone mass. E. Reduced bone density.
Answer: A, B, C, E
Which cues alert the nurse that the patient with Paralysis is declining? SATA A. Develops disuse osteoporosis. B. Has not lost muscle mass. C. Does not participate in physical therapy. D. Controls wheelchair according to capabilities. E. Avoids muscle atrophy.
Answer: A, C
Which cues are relevant for weakness? SATA A. Flaccidity B. Hypertonicity C. Shuffling gait D. Feeble handgrip E. Score of 5 on Johns Hopkins Fall Risk Assessment Tool
Answer: A, C, D
Which hypotheses would the nurse develop for a patient post surgery for hip replacement who is receiving opioid pain medication while the patient's spouse is in the room? SATA A. Impaired mobility. B. Social isolation. C. Risk for DVT. D. Risk for constipation. E. Activity intolerance.
Answer: A, C, D
Which interventions would the nurse select for a patient who is on bed rest? SATA A. Have the patient shift weight every 15 minutes while awake. B. Have the unlicensed assistive personnel teach about the importance of mobility. C. Reduce hallway light at night. D. Apply a pressure-relief ankle-foot orthotic (PRAFO) boot. E. Turn patient every 4 hours.
Answer: A, C, D
Which disorders decrease the body's ability to deliver oxygen and nutrients to the muscles and bones? SATA A. Heart failure B. Renal failure C. Spina bifida D. Peripheral vascular disease E. Chronic obstructive pulmonary disease
Answer: A, D, E
Which safety measures would the nurse implement for a patient who is a fall risk? SATA A. Use a low bed. B. Place in a room away from the nurses' station for quietness. C. Raise all four side rails. D. Frequently orient the patient. E. Place floor mats beside the bed.
Answer: A, D, E
Match the musculoskeletal condition to its associated description or causative factor. A. Bone deterioration B. Autoimmune disease C. Genetic disorder D. Decreased activity level Choices: 1. Osteoporosis 2. Rheumatoid arthritis 3. Hypotonicity 4. Muscular dystrophy 5. Spasticity 6. Cerebral palsy
Answer: A- 1 B- 2 C- 4 D- 3
Match the musculoskeletal system alteration to its cause. A. Porous, brittle bones B. Deterioration of the muscle itself C. Tissue that is usually easy to move tightens and pulls inward Choices: 1. Muscle atrophy. 2. Pathologic fracture. 3. Amputation. 4. Contracture.
Answer: A- 2 B- 1 C- 4
Match the function to its nervous system component of mobility. A. Regulated by the cerebral cortex B. Dependent on proprioception C. Dependent on the cerebellum and inner ear D. Regulated by the cerebellum Choices: 1. Voluntary movement. 2. Posture and gait. 3. Balance. 4. Coordination.
Answer: A-1 B-2 C-3 D-4
A patient with redness, warmth, and swelling in the right lower leg is at risk for which complication? A. Joint damage. B. Pulmonary Embolism. C. Orthostatic hypotension. D. Pathologic bone fractures.
Answer: B
In which area would the nurse place a pillow for a patient in the supine position? A. Between the legs. B. Under the calves. C. Between the arms, D. Under the scapula.
Answer: B
Which action would the nurse take for a newly admitted patient who is unsteady when transferring from the wheelchair to the bed? A. Place the patient on complete bed rest. B. Initiate a fall prevention plan for the patient. C. Start passive range-of-motion exercises twice a day. D. Make sure the patient only ambulates with a walker.
Answer: B
Which ambulation aid would the nurse suggest for a patient who has a history of falls, is displaying generalized weakness, and requires some assistance with ambulation? A. Cane. B. Walker. C. Crutches. D. Trochanter roll.
Answer: B
Which hypothesis would the nurse select for a patient who experiences increased heart rate and increased oxygen requirements when eating? A. Fall B. Activity Intolerance C. Risk for Deep Vein Thrombosis D. Risk for Impaired Skin Integrity
Answer: B
Which instruction would the nurse share with the patient about coughing techniques? A. Fully inhale between coughs. B. Take two deep breaths in and out to start. C. Inhale through the nose as deeply as possible. D. Exhale slowly through the spirometer's mouthpiece.
Answer: B
Which patient is prone to paralysis? A. A patient on bed rest B. A patient with prolonged brain ischemia C. A patient with a fracture D. A patient on a low-calcium diet
Answer: B
Which question would the nurse ask a patient to determine symptom-related issues with the musculoskeletal system? A. "Do any of your family members have osteoporosis?" B. "Have you noticed any differences in your gait?" C. "Do you have an active lifestyle or sedentary lifestyle?" D. "Have you ever found yourself on the floor and don't know how you got there?"
Answer: B
Place the steps in the order the nurse would follow to teach a patient how to use a cane. A. Move the cane. B. Place cane on the patient's stronger side. C. Move the stronger leg. D. Move the weaker leg.
Answer: B A D C
Which actions by the nurse caring for patients with mobility problems would require correction by the charge nurse? SATA A. Refuses to massage a patient's leg with deep vein thrombosis. B. Places a gait belt on a patient with osteoporosis to assist with ambulation. C. Allows the patient's elbows to be bent at a 45-degree angle when using a cane. D. Tells the patient with a four-point crutch gait to move one crutch forward simultaneously with the opposite leg. E. Has the patient cough two times after using an incentive spirometer.
Answer: B, C, D
Which actions would the nurse take for a patient who is immobile? SATA A. Encourage at least 1500 mL of fluid daily. B. Suggest drinking at least 2000 mL during a 24-hour period. C. Encourage passive range-of-motion exercises. D. Place high-top tennis shoes on feet. E. Reposition at least once every 8 hours.
Answer: B, C, D
Which cues prompt the nurse to determine the patient with impaired mobility who needs a one-person assist is improving? SATA A. Needs a one-person assist to ambulate. B. Needs no assistance to transfer. C. Ambulates unassisted down the corridor and back. D. Needs a two-person assist to walk to the bathroom. E. Ambulates with no slips on the floor.
Answer: B, C, E
Which interventions would the nurse implement for a patient with lower extremity Paralysis? SATA A. Apply oxygen. B. Turn every 2 hours. C. Arrange for a special bed. D. Use a gait belt for transfers and ambulation. E. Perform range-of-motion (ROM) exercises at least two times per day.
Answer: B, C, E
Which parameters would the nurse consider to analyze medical record cues for a patient who is immobile? SATA A. Physical assessment findings B. Graphic chart information C. X-ray results D. Patient interview E. Diagnostic tests
Answer: B, C, E
Which functions are the primary responsibilities of the cardiopulmonary system in relation to movement? SATA A. Control posture and gait B. Circulate blood throughout the body C. Provide framework for movement D. Supply tissues with oxygen and nutrients E. Provide essential fluids for the body
Answer: B, D, E
Patient reports of shortness of breath and fatigue while performing activities of daily living are indicative of which alteration? A. Orthostatic hypotension. B. DVT. C. Activity intolerance. D. Cerebellar problems.
Answer: C
Which action by the nurse initiates the physical assessment of a patient's mobility? A. Inquiring about the patient's health history B. Asking the patient questions C. Observing the patient D. Palpating the patient's joints
Answer: C
Which action would the nurse take for an immobile patient who needs help maintaining a normal sleep-wake cycle? A. Encourage contact with family and friends. B. Provide a clock in the patient's room. C. Open the window blinds during the day. D. Allow access to the radio.
Answer: C
Which exercise benefit would the nurse likely emphasize to a patient who has limited mobility to help facilitate normal movement? A. Improves mood. B. Minimizes joint flexibility. C. Promotes muscle strength. D. Stimulates bone reabsorption.
Answer: C
Which term is used to describe a slightly movable joint? A. Patellar B. Fibrous C. Cartilaginous D. Synovial
Answer: C
Which evaluative findings will alert the nurse an immobile patient with a left hip stage 1 pressure injury is declining? SATA A. Has a reddened area on hip that will not blanch B. Has dry, warm, intact skin C. Has a Braden Scale score that indicates a high risk for skin breakdown D. Develops a Stage 1 pressure injury on the buttocks E. Develops a Stage 2 pressure injury on the left hip
Answer: C, D, E
Tissue ischemia related to immobility can directly lead to the development of which complication? A. Atelectasis B. Contractures C. Pulmonary embolus D. Pressure injuries
Answer: D
To which other member of a multidisciplinary team would the nurse delegate the task of moving an immobile patient to maintain skin integrity? A. Dietician. B. Primary HCP. C. Occupational therapist. D. Unlicensed assistive personnel.
Answer: D
Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills? A. Place the patient flat in bed. B. Encourage the patient to take deep breaths. C. Assess the patient for signs of deep vein thrombosis. D. Notify the health care provider that the patient may have pneumonia.
Answer: D
Which action would the nurse take when caring for a patient with sequential compression devices (SCDs)? A.Ensure the fit of the sleeves is tight. B. Roll the sleeves inside out to apply them. C. Activate the heating feature once a shift. D. Monitor the patient's toes for impaired circulation.
Answer: D
Which action would the nurse take when using a mechanical lift for a patient who is experiencing limited mobility? A. Ensures that no more than 35 lb (15.9 kg) is placed in the lift. B. Has the patient grab the bars for stability. C. Transfers the patient toward the weaker side. D. Obtains two unlicensed assistive personnel to help.
Answer: D
Which anatomic structure serves the purpose of connecting bones to cartilage? A.Muscles B. Tendons C. Joints D. Ligaments
Answer: D
Which evaluative cue alerts the nurse that a patient with Activity Intolerance is improving? A. Ambulates 15 feet with shortness of breath B. Has a heart rate of 110 beats/min when ambulating C. Brushes hair while sitting in chair with assistance D. Has a pulse oximetry reading of 94% when standing to brush teeth
Answer: D
Which hypothesis would the nurse select for a patient who develops redness, warmth, and slight swelling in the right lower leg from bed rest? A. Paralysis. B. Weakness. C. Activity intolerance. D. Risk for DVT.
Answer: D
Which nervous system factor is likely associated with difficulty breathing? A. Right-sided brain injury B. Left-sided brain injury C. Lower spinal cord trauma D. Cervical spinal cord trauma
Answer: D
Which patient would likely be prone to reduced bone density? A. One with muscular dystrophy B. One with burns C. One who has been physically abused D. One who cannot perform weight-bearing exercises
Answer: D
T/F: A nurse can delegate patient teaching about mobility to a UAP.
Answer: False; teaching is the responsibility of the RN.
Function of ligaments.
Attach bones to cartilage.
Function of Tendons.
Attaches muscle to bone.
What are the components of musculoskeletal system?
Muscles Tendons Ligaments Cartilage Bones
Function of muscles.
Produces movement by contraction and relaxation; enable support for posture and stability.
Function of bones.
Provide support, strength, and movement; some bones protect body organs (rib cage, pelvis); produce all types of blood cells in the bone marrow; store calcium; maintain levels of calcium and phosphorus
Nervous system regulates.....
Voluntary movement Posture & gait Balance
Function of cartilage.
cushions joints and reduces friction
