Week 4-Fundamentals-Quizzes Notes

Passive Range of Motion (PROM)

therapist putting a patient's joints through available range of motion without assistance from the patient

IMPLEMENT & TAKE ACTION 9. Which action would the nurse take for a patient on bed rest who is concerned about developing constipation? Increase the patient's dietary fiber and fluid intake. Complete the Braden Scale assessment tool. Increase the frequency of passive range-of-motion exercises. Administer enoxaparin prophylactically.

Increase the patient's dietary fiber and fluid intake.

ACCESS AND RECOGNIZE CUES 13. Patients on bed rest are likely at risk for which physiologic effects and conditions? Select all that apply. Increased venous return Decreased lung expansion Decreased cardiac workload Atelectasis Pneumonia

Increased venous return Decreased lung expansion Atelectasis Pneumonia

ACCESS AND RECOGNIZE CUES 11. Which graphic record cue is associated with constipation? Fever Soft stools 90% of meals eaten Infrequent stools

Infrequent stools

OVERVIEW OF ACTIVITY AND MOVEMENT 2. An infection of which structure would likely be the source for balance problems? Eye Cornea Inner ear Tonsils

Inner ear

OVERVIEW OF ACTIVITY AND MOVEMENT 12. Which types of impairments are expected with a cerebrovascular accident that occurred on the right side of the brain? Select all that apply. Right-sided paralysis Left-sided hemiparesis Lower body paralysis Inability to move all four extremities Left-sided hemiplegia

Left-sided hemiparesis Left-sided hemiplegia

OVERVIEW OF ACTIVITY AND MOVEMENT 10. Which musculoskeletal diseases are more prevalent in the older adult population? Select all that apply. Osteoporosis Osteoarthritis Cerebral palsy Spina bifida Muscular dystrophy

Osteoporosis Osteoarthritis

ACCESS AND RECOGNIZE CUES 9. Which movement is the nurse assessing in the image? ateral flexion Outward and inward rotation Adduction and abduction Flexion and extension

Outward and inward rotation

dysphagia

difficulty swallowing or eating

ACTIVITY AND MOVEMENT Which outcomes would the nurse develop for a patient experiencing weakness, cerebellum injury, and orthostatic hypotension? Patient will not lose muscle mass during hospital stay. Patient will ambulate with no assistance. Patient will not fall during hospitalization. Patient will not injure self during hospital stay. Patient will not experience a pulmonary embolus during hospitalization.

Patient will not fall during hospitalization. Patient will not injure self during hospital stay.

ACTIVITY AND MOVEMENT Place the patients in the order in which the nurse would prioritize their care. Patient with a cervical fracture and altered respirations Patient from a car accident with impaired mobility from a fractured leg Patient with osteoporosis

Patient with a cervical fracture and altered respirations-- Patient from a car accident with impaired mobility from a fractured leg Patient with osteoporosis

contracture

fibrosis of connective tissue in the skin, fascia, muscle, or joint capsule that prevents normal mobility of the related tissue or joint

ACTIVITY AND MOVEMENT Which solutions would the nurse choose for a patient experiencing dyspnea on exertion, oxygen saturation level of 86%, and pulse of 112 beats/min when grooming? Select all that apply. Sequential compression devices Turning Physical therapist consult Special equipment for hygiene needs Exercises for strengthening

Physical therapist consult Special equipment for hygiene needs Exercises for strengthening

IMPLEMENT & TAKE ACTION 21. Place the steps in the order the nurse would follow to teach a patient how to use a cane. Move the cane. Move the weaker leg. Move the stronger leg. Place cane on the patient's stronger side.

Place cane on the patient's stronger side. Move the cane. Move the weaker leg. Move the stronger leg.

IMPLEMENT & TAKE ACTION 2. In which area would the nurse place a pillow for a patient in the supine position? Between the legs Under the calves Between the arms Under the scapula

Under the calves

IMPLEMENT & TAKE ACTION 1. To which other member of a multidisciplinary team would the nurse delegate the task of moving an immobile patient to maintain skin integrity? Dietitian Primary health care provider Occupational therapist Unlicensed assistive personnel

Unlicensed assistive personnel

IMPLEMENT & TAKE ACTION 13. Which safety measures would the nurse implement for a patient who is a fall risk? Select all that apply. Use a low bed. Place in a room away from the nurses' station for quietness. Raise all four side rails. Frequently orient the patient. Place floor mats beside the bed.

Use a low bed. Frequently orient the patient. Place floor mats beside the bed.

IMPLEMENT & TAKE ACTION 12. Which instructions about respiratory and range-of-motion measures would the nurse share with a patient who has limited mobility? Select all that apply. Use the incentive spirometer 5 to 12 times every 1 to 2 hours. Deep breathe 10 times every hour. Cough two to three times every 2 hours. Perform range-of-motion exercises at least five to six times each day. Move each joint three to five times during range-of-motion exercises.

Use the incentive spirometer 5 to 12 times every 1 to 2 hours. Deep breathe 10 times every hour. Cough two to three times every 2 hours. Move each joint three to five times during range-of-motion exercises.

ACTIVITY AND MOVEMENT Match the solution the nurse would select based on the patient's pathophysiology. Venous stasis Friction and prolonged pressure Loss of sensation Reduced basal metabolic rate

Venous stasis--Sequential compression devices Friction and prolonged pressure--Turning Loss of sensation--Rehabilitation therapy Reduced basal metabolic rate--Dietitian/nutritionist consult

IMPLEMENT & TAKE ACTION 4. 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? Cane Walker Crutches Trochanter roll

Walker

ACCESS AND RECOGNIZE CUES 12. Which musculoskeletal alterations does immobility predispose a patient to developing? Select all that apply. Weakness Decreased muscle tone Decreased muscle mass Increased bone mass Reduced bone density

Weakness Decreased muscle tone Decreased muscle mass Reduced bone density

tachypnea

rapid breathing >26

ACCESS AND RECOGNIZE CUES 8. Which response would the nurse make to an immobile patient who says, "I am just not hungry. I don't understand it. I am always hungry"? "Don't worry about it, every patient gets that way in the hospital." "Your loss of appetite is unusual; I will let your health care provider know." "You have been immobile for several days, which can decrease your metabolism and appetite." "Your lack of appetite is your body's way of telling you that bed rest interferes with your body's ability to digest food and not to eat too much."

"You have been immobile for several days, which can decrease your metabolism and appetite."

IMPLEMENT & TAKE ACTION 20. 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)

2

TRANSFERRING FROM A BED TO A STRETCHER 3. When turning a patient to place a slide board, where do the assistants stand? A. At the side of the bed to which the patient will be turned B. At the side of the bed from which the patient will be turned C. At the head and foot of the bed D. At the foot of the bed only

A. At the side of the bed to which the patient will be turned

TRANSFERRING FROM A BED TO A STRETCHER 4. The nurse and his or her assistants are using a slide board to move a patient from the bed to a stretcher. The nurse, standing alone on the side of the bed opposite the stretcher, will perform which action during this move? A. Hold the slide board. B. Pull the draw sheet. C. Hold the patient's head stationary. D. Lock the brakes on the stretcher.

A. Hold the slide board.

ACTIVITY AND MOVEMENT Which hypothesis would the nurse select for a patient who experiences increased heart rate and increased oxygen requirements when eating? Fall Activity Intolerance Risk for Deep Vein Thrombosis Risk for Impaired Skin Integrity

Activity Intolerance

ACCESS AND RECOGNIZE CUES 4. Patient reports of shortness of breath and fatigue while performing activities of daily living are indicative of which alteration? Orthostatic hypotension Deep vein thrombosis Activity intolerance Cerebellar problems

Activity intolerance

TRANSFERRING FROM A BED TO A STRETCHER 1. The nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer? A. Four B. Two C. One D. None

B. Two

ACCESS AND RECOGNIZE CUES 18. Match the pressure injury stage to its cues. Blistering of epidermis or dermis Intact skin with reddened area Exposure of muscle and bone Subcutaneous injury with possible tunneling

Blistering of epidermis or dermis--STAGE 2 Intact skin with reddened area--STAGE 1 Exposure of muscle and bone--STAGE 4 Subcutaneous injury with possible tunneling--STAGE 3

OVERVIEW OF ACTIVITY AND MOVEMENT 3. Which area is impaired if a tendon is damaged? Bone to muscle attachment Bone to cartilage attachment Joint cushion Joint fluid

Bone to muscle attachment

ACTIVITY AND MOVEMENT Which cues would alert the nurse to develop a hypothesis of Risk for Impaired Skin Integrity for a patient? Select all that apply. Braden Scale score of 16 Inability to move or turn Braden Scale score of 20 Pulse oximetry of 95% Dyspnea on exertion

Braden Scale score of 16 Inability to move or turn

TRANSFERRING FROM A BED TO A STRETCHER 2. The nurse is preparing to move a patient from the bed to a stretcher. What will the nurse do first? A. Cross the patient's arms over his or her chest. B. Lower the side rails of the bed. C. Make sure the bed brakes are locked. D. Fanfold the draw sheet.

C. Make sure the bed brakes are locked.

TRANSFERRING FROM A BED TO A STRETCHER 5. After moving a patient from the bed to a stretcher, what will the nurse do next? A. Lock the wheels on the stretcher. B. Cover the patient with a blanket. C. Raise the head of the stretcher if doing so is not contraindicated. D. Unlock the wheels of the bed.

C. Raise the head of the stretcher if doing so is not contraindicated.

OVERVIEW OF ACTIVITY AND MOVEMENT 1. Which mineral is stored in bones? Sodium Calcium Chloride Potassium

Calcium

IMPLEMENT & TAKE ACTION 18. Which actions would the nurse take if the patient falls while ambulating in the hall? Select all that apply. Call for help. Assess the patient's physical and neurologic status. Notify charge nurse and primary health care provider. Leave the patient to go get help. Complete occurrence report.

Call for help. Assess the patient's physical and neurologic status. Notify charge nurse and primary health care provider. Complete occurrence report.

ACCESS AND RECOGNIZE CUES 15. Which parameters would the nurse assess to determine if a urinary tract infection (UTI) has developed? Select all that apply. Peripheral pulses Chills Urinary frequency Serum albumin levels Presence of dysuria

Chills Urinary frequency Presence of dysuria

ACTIVITY AND MOVEMENT Match the health care team member with the patient cue indicating a need for consult with that individual. Chokes during meals Needs strengthening exercises Experiencing social isolation Needs help on how to bathe at home

Chokes during meals--Speech Therapist Needs strengthening exercises---Physical Therapist Experiencing social isolation---Spiritual Advisor Needs help on how to bathe at home---Occupational Therapist

ACCESS AND RECOGNIZE CUES 16. Which cues would likely occur with atelectasis? Select all that apply. Cyanosis Dyspnea Chills Graphic record indicates a fever Diminished breath sounds noted in nurse's notes

Cyanosis Dyspnea Diminished breath sounds noted in nurse's notes

ACCESS AND RECOGNIZE CUES 5. Which nutritional alteration is associated with immobility? Enhanced appetite Positive nitrogen balance Decreased basal metabolic rate Increased serum albumin levels

Decreased basal metabolic rate

OVERVIEW OF ACTIVITY AND MOVEMENT 9. Which effects are typical of decreased physical activity? Select all that apply. Spasticity Hypertonicity Deterioration Bone fragility Loss of strength

Deterioration Bone fragility Loss of strength

IMPLEMENT & TAKE ACTION 16. Which cues alert the nurse that the patient with Paralysis is declining? Select all that apply. Develops disuse osteoporosis Has not lost muscle mass Does not participate in physical therapy Controls wheelchair according to capabilities Avoids muscle atrophy

Develops disuse osteoporosis Does not participate in physical therapy

ACTIVITY AND MOVEMENT Which solution would the nurse select for a patient who is experiencing anorexia? Dietary measures for favorite foods Fall risk protocol Occupational therapist consult Mobility aids for ambulation

Dietary measures for favorite foods

OVERVIEW OF ACTIVITY AND MOVEMENT 5. Which characteristic is typical of paresis? Lower body paralysis Complete loss of movement Impaired mobility and movement Weakness on one side of the body

Impaired mobility and movement

HYPERTONICITY

Excessive tension of the arterial walls or muscles.

IMPLEMENT & TAKE ACTION 15. Which evaluative cues indicate the patient with a Risk for Deep Vein Thrombosis is deteriorating? Select all that apply. Experiences a pulmonary embolus Has dusky toes Has coagulation laboratory results that indicate the patient is clotting too fast States the sequential compression device pressure is maintained at 40 mm Hg Experiences intact skin with no abnormalities in the lower leg

Experiences a pulmonary embolus Has dusky toes Has coagulation laboratory results that indicate the patient is clotting too fast

IMPLEMENT & TAKE ACTION 6. In which position would the nurse place the patient to perform coughing and deep breathing? Dorsal recumbent Fowler's Side-lying Sim's

Fowler's

IMPLEMENT & TAKE ACTION 10. Which interventions would the nurse select for a patient who is on bed rest? Select all that apply. Have the patient shift weight every 15 minutes while awake. Have the unlicensed assistive personnel teach about the importance of mobility. Reduce hallway light at night. Apply a pressure-relief ankle-foot orthotic (PRAFO) boot. Turn patient every 4 hours.

Have the patient shift weight every 15 minutes while awake. Reduce hallway light at night. Apply a pressure-relief ankle-foot orthotic (PRAFO) boot.

ACCESS AND RECOGNIZE CUES 10. Which fall risk score would the nurse anticipate in a patient who is weak? Hendrich II Fall Risk Model score of 8 Morse Fall Scale score of 10 Braden Scale score of 22 Johns Hopkins Fall Risk Assessment Tool score of 5

Hendrich II Fall Risk Model score of 8 A patient with weakness is at risk for falls. A score of 8, which is in the 5 or above range, indicates the patient is at high risk for falls.

ACTIVITY AND MOVEMENT 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? Select all that apply. Impaired Mobility Social Isolation Risk for Deep Vein Thrombosis Risk for Constipation Activity Intolerance

Impaired Mobility Risk for Deep Vein Thrombosis Risk for Constipation

ACCESS AND RECOGNIZE CUES 3. Which finding would be unexpected when the nurse is assessing for mobility issues? Joint crepitus Morse Fall Scale score of 18 Braden Scale score of 22 Straight posture

Joint crepitus

OVERVIEW OF ACTIVITY AND MOVEMENT 6. Which characteristic is typical of lower extremity flaccidity? Bone fragility Muscle spasms Joint inflammation Lack of muscle tone

Lack of muscle tone

IMPLEMENT & TAKE ACTION 19. 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? Select all that apply. Leave top side rails up. Bend at the knees. Carry weight close to the body. Use mechanical lift equipment. Relax pelvic muscles.

Leave top side rails up. Bend at the knees. Carry weight close to the body. Use mechanical lift equipment.

OVERVIEW OF ACTIVITY AND MOVEMENT 4. Which condition would likely result in right-sided hemiplegia? Right-sided brain injury Left-sided brain injury Lower spinal cord trauma Upper spinal cord trauma

Left-sided brain injury

IMPLEMENT & TAKE ACTION 17. Which cues prompt the nurse to determine the patient with impaired mobility who needs a one-person assist is improving? Select all that apply. Needs a one-person assist to ambulate Needs no assistance to transfer Ambulates unassisted down the corridor and back Needs a two-person assist to walk to the bathroom Ambulates with no slips on the floor

Needs no assistance to transfer Ambulates unassisted down the corridor and back Ambulates with no slips on the floor

IMPLEMENT & TAKE ACTION 8. Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills? Place the patient flat in bed. Encourage the patient to take deep breaths. Assess the patient for signs of deep vein thrombosis. Notify the health care provider that the patient may have pneumonia.

Notify the health care provider that the patient may have pneumonia.

ACCESS AND RECOGNIZE CUES 1. Which action by the nurse initiates the physical assessment of a patient's mobility? nquiring about the patient's health history Asking the patient questions Observing the patient Palpating the patient's joints

Observing the patient

IMPLEMENT & TAKE ACTION 7. Which action would the nurse take when using a mechanical lift for a patient who is experiencing limited mobility? Ensures that no more than 35 lb (15.9 kg) is placed in the lift Has the patient grab the bars for stability Transfers the patient toward the weaker side Obtains two unlicensed assistive personnel to help

Obtains two unlicensed assistive personnel to help

ACTIVITY AND MOVEMENT 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? Select all that apply. Patient's pulse oximetry will be above 90% during an activity. Patient will have intact skin throughout hospital stay. Patient will exercise arm and leg muscles. Patient will brush teeth after breakfast with one person assisting. Patient will exercise joints at least twice per shift.

Patient will brush teeth after breakfast with one person assisting. Patient will exercise joints at least twice per shift.

OVERVIEW OF ACTIVITY AND MOVEMENT 7. Which person is most prone to osteoporosis? Adult large-frame male Older Asian female Middle-age Caucasian female Adult black female

Older Asian female Osteoporosis is more prevalent in the older population and in Asian women.

OVERVIEW OF ACTIVITY AND MOVEMENT 13. Match the musculoskeletal condition to the correct patient. Older adult who has a low intake of calcium Young adult who has no movement in any extremities from a motorcycle crash Older adult whose cartilage is deteriorating Young adult with proprioception problems

Older adult who has a low intake of calcium--Osteoporosis Young adult who has no movement in any extremities from a motorcycle crash--Quadriplegia Older adult whose cartilage is deteriorating--Osteoarthritis Young adult with proprioception problems--Unsteady gait

OVERVIEW OF ACTIVITY AND MOVEMENT 14. Match the activity-related condition to the correct patient. Older adult who has an intact inner ear with fluid and hairlike sensors Young adult who injured the structure connecting bone to cartilage Adult with decreased oxygen to muscles/bones from reduced cardiac pumping Adult with impaired gas exchange due to reduced lung capacity

Older adult who has an intact inner ear with fluid and hairlike sensors--Steady equilibrium Young adult who injured the structure connecting bone to cartilage--Torn Ligament Adult with decreased oxygen to muscles/bones from reduced cardiac pumping--Heart failure Adult with impaired gas exchange due to reduced lung capacity--Chronic obstructive pulmonary disease

The nurse is getting a patient with right-sided weakness up in a chair. On what side of the bed should the nurse place the chair? On the patient's left side. On the patient's weak side. It doesn't matter because you are assisting the patient. Whichever side the patient prefers.

On the patient's left side.

IMPLEMENT & TAKE ACTION 14. Which actions by the nurse caring for patients with mobility problems would require correction by the charge nurse? Select all that apply. Refuses to massage a patient's leg with deep vein thrombosis Places a gait belt on a patient with osteoporosis to assist with ambulation Allows the patient's elbows to be bent at a 45-degree angle when using a cane Tells the patient with a four-point crutch gait to move one crutch forward simultaneously with the opposite leg Has the patient cough two times after using an incentive spirometer

Places a gait belt on a patient with osteoporosis to assist with ambulation Allows the patient's elbows to be bent at a 45-degree angle when using a cane Tells the patient with a four-point crutch gait to move one crutch forward

OVERVIEW OF ACTIVITY AND MOVEMENT 8. Which effects can occur with cerebellar damage related to traumatic brain injury? Select all that apply. Poor balance Abnormal formation of the spinal cord Ability to move joints Lack of sensors in the inner ear Uncoordinated movement

Poor balance Uncoordinated movement

A nursing instructor asks what may cause orthostatic hypotension. The nursing student correctly replies: (Select all that apply.) Prolonged bed rest. Hypovolemia. Low body weight. Antihypertensives. Room temperature.

Prolonged bed rest. Hypovolemia. Antihypertensives.

IMPLEMENT & TAKE ACTION 5. Which exercise benefit would the nurse likely emphasize to a patient who has limited mobility to help facilitate normal movement? Improves mood Minimizes joint flexibility Promotes muscle strength Stimulates bone reabsorption

Promotes muscle strength

ACCESS AND RECOGNIZE CUES 7. A patient with redness, warmth, and swelling in the right lower leg is at risk for which complication? Joint damage Pulmonary embolism Orthostatic hypotension Pathologic bone fractures

Pulmonary embolism

ACCESS AND RECOGNIZE CUES 2. Which patient finding would alert the nurse to stop passive range-of-motion exercises? Resistance to movement is felt. The patient is unable to participate. The patient's joints move freely. Atrophy occurs.

Resistance to movement is felt.

ACTIVITY AND MOVEMENT Which cue would the nurse rank as priority for a patient who suffered multiple fractures after a motor vehicle accident? Pain Elevated heart rate Respiratory distress Decreased mobility

Respiratory distress

OVERVIEW OF ACTIVITY AND MOVEMENT 11. Which conditions would likely cause paralysis on one side of the body? Select all that apply. Right-sided stroke Paresis Cervical spinal cord injury Traumatic brain injury Left-sided cerebrovascular accident

Right-sided stroke Traumatic brain injury Left-sided cerebrovascular accident

ACTIVITY AND MOVEMENT Which hypothesis would the nurse select for a patient who develops redness, warmth, and slight swelling in the right lower leg from bed rest? Paralysis Weakness Activity Intolerance Risk for Deep Vein Thrombosis

Risk for Deep Vein Thrombosis

ACTIVITY AND MOVEMENT Which hypothesis would the nurse select for a patient who refuses to turn on their side and lies supine most of the time? Impaired Mobility Weakness Risk for Fall Risk for impaired Skin Integrity

Risk for impaired Skin Integrity

ACTIVITY AND MOVEMENT Which solution would the nurse select for an immobile patient who appears withdrawn and reports not having any visitors in the past week? Removal of cell phone Laxative administration Rest periods Spiritual consult

Spiritual consult

IMPLEMENT & TAKE ACTION 11. Which actions would the nurse take for a patient who is immobile? Select all that apply. Encourage at least 1500 mL of fluid daily. Suggest drinking at least 2000 mL during a 24-hour period. Encourage passive range-of-motion exercises. Place high-top tennis shoes on feet. Reposition at least once every 8 hours.

Suggest drinking at least 2000 mL during a 24-hour period. Encourage passive range-of-motion exercises. Place high-top tennis shoes on feet.

ACCESS AND RECOGNIZE CUES 14. Which changes in vital signs are indicative of postural hypotension when a patient stands up? Select all that apply. Heart rate increases from 60 to 70 beats/min Systolic blood pressure drops from 120 to 100 mm Hg Heart rate increases from 65 to 85 beats/min Systolic blood pressure drops from 110 to 100 mm Hg Diastolic blood pressure drops from 70 to 60 mm Hg

Systolic blood pressure drops from 120 to 100 mm Hg A drop in systolic blood pressure of 20 mm Hg when a patient stands is classified as postural hypotension. Heart rate increases from 65 to 85 beats/min An increase in heart rate of 20 beats/min when a patient stands is classified as postural hypotension. Diastolic blood pressure drops from 70 to 60 mm Hg A drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as postural hypotension.

Active Range of Motion (AROM)

The ability of the patient to voluntarily move a limb through an arc of movement

ACCESS AND RECOGNIZE CUES 6. Which interpretation would the nurse make when observing a darkened or reddened area of skin in an immobile patient? Tissue ischemia has occurred. Blanching has developed. Cyanosis has occurred. Deep vein thrombosis has developed.

Tissue ischemia has occurred.

IMPLEMENT & TAKE ACTION 3. Which device would be most appropriate for a patient who has had surgery on a fractured femur and needs help repositioning in bed? Trapeze bar Mechanical lift Transfer board Friction-reducing sheet

Trapeze bar

ACCESS AND RECOGNIZE CUES 17. Match the alteration to its patient cues. Unable to move joints because of foot drop Decreased muscle size with weak handgrip Inability to move, with a loss of sensation Irregular patterns of behavior from inadequate coping

Unable to move joints because of foot drop---contracture Decreased muscle size with weak handgrip--muscle atrophy Inability to move, with a loss of sensation--paralysis Irregular patterns of behavior from inadequate coping--altered self-concept

atelectasis

collapsed lung; incomplete expansion of alveoli