Functional Ability Review Questions
(P&P) The effects of immobility on the cardiac system include which of the following? (Select all that apply.) 1. Thrombus formation 2. Increased cardiac workload 3. Weak peripheral pulses 4. Irregular heartbeat 5. Orthostatic hypotension
1, 2, 5 The three major changes are orthostatic hypotension, increased cardiac workload, and thrombus formation.
(Giddens) Which of the following interventions are priorities in a plan of care for a patient who had a stroke 30 days ago and is now in home care rehabilitation? (Select all that apply) 1. Promoting rest and sleep 2. Promoting a diet rich in protein 3. Promoting exercise and ambulation 4. Assisting the patient with ADL's 5. Limiting visitors and social contacts
1, 3 It is important to promote independence in ADLs early in the plan of care to increase independence in general. Promoting rest and sleep will promote well-being. Ambulation and exercise promote well-being and increase healing by circulating oxygen to the brain. Protein promotes healing in postsurgical patients but is not a main focus in stroke patients. Assisting the patient does not promote independence. Limiting visitors will isolate the patient, which can lead to depression.
(Giddens) Instruments such as the Functional Activities Questionnaire (FAQ) for postoperative patients who are at home, the Minimum Data Set for Nursing Facility Resident Assessment and Care Screening (MDS) for nursing home patients, the Functional Status Scale (FSS) for children, and the Edmonton Functional Assessment Tool for cancer patients are used to assess activities of daily living (ADLs). The nurse needs to remember that a disadvantage of these instruments includes: 1. the measurement of efficacy and reliability of the instruments used to assess activities of daily living (ADLs) 2. the variations in assessments and responses may be subjective because of self-reporting of functional activities. 3. the instruments do not show a true measure of ability because of a lack of interactivity during the assessments. 4. the information contained in the instruments is insufficient to make a determination about functional status in these populations.
2 A disadvantage of many of the ADLs and instrumental activities of daily living (IADLs) instruments is the self-reporting of functional activities. Efficacy and reliability are not measured when assessing ADLs and IADLs. Interaction with the patient is necessary to complete the ADL and IADL assessments. The FAQ and FSS are comprehensive tools that can help the nurse determine functional status.
(P&P) A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken: 1. Myoclonus 2. Pathological fractures 3. Pressure ulcers 4. Pruritus
3 Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative.
(P&P) Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest? 1. Isometric exercises 2. Administration of low-dose heparin 3. Suctioning every 4 hours 4. Use of incentive spirometer every 2 hours while awake
4 Incentive spirometry opens the airway, preventing atelectasis.
(P&P) An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? 1. Loss of appetite 2. Gum soreness 3. Difficulty swallowing 4. Left ankle joint stiffness
4 Patients whose mobility is restricted require range-of motion (ROM) exercises daily to reduce the hazards of immobility. Temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Two weeks of joint immobilization without ROM can quickly result in contractures.
(P&P) A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: 1. Decreased peristalsis 2. Decreased heart rate 3. Increased blood pressure 4. Increased urinary output
1 Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.
(P&P) The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? 1. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert 2. Hot dog on whole wheat bun with a side salad and an apple for dessert 3. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert 4. Turkey salad on toast with tomato and lettuce and honey bun for dessert
1 Teach patient and/or caregiver the current recommended dietary allowances for calcium and review foods high in calcium (e.g., milk fortified with vitamin D, leafy green vegetables, yogurt, and cheese).
(ATI) A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? 1. Encourage the client to perform antiembolic exercises every 2 hr 2. Instruct the client to cough and deep breathe every 4 hr 3. Restrict the client's fluid intake 4. Reposition the client every 4 hr
1 The nurse should encourage the client to perform antiembolic exercises every 1 to 2 hr to promote venous return and reduce the risk of thrombus formation
(P&P) A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? 1. Encouraging use of an overhead trapeze for positioning and transfer 2. Frequent family visits 3. Assisting the patient to a wheelchair once per day 4. Ensuring that there is an order for physical therapy
1 The trapeze bar allows the patient to pull with the upper extremities to raise the trunk off the bed, aid in transfer from bed to wheelchair, or perform upper-arm exercises. It increases independence and maintains upper body strength to help in performing activities of daily living.
(Giddens) The nurse is assessing a patient's ability to perform basic activities of daily living (BADLs). Which of the following activities are considered in the BADLs assessment? (Select all that apply) 1. Brushing teeth or dentures 2. Dressing oneself in the mornings 3. Washing, drying, and folding laundry 4. Counting own pulse and taking heart pill 5. Taking the bus to the park 6. Calling family members
1, 2 BADLs include actions related to self care and mobility and also includes eating, personal hygiene, and grooming activities. Instrumental activities of daily living (IADLs) include shopping, meal preparation, housekeeping, doing laundry, managing finances, using the telephone, taking medications, and using transportation.
(P&P) A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply.) 1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if I should have a bone mineral density check this year." 3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." 4. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." 5. "My lactose intolerance should not be a concern when considering my calcium intake."
1, 2, 3 Patients at risk for or diagnosed with osteoporosis have special health promotion needs. Encourage patients at risk to be screened for osteoporosis and assess their diets for calcium and vitamin D intake. Multivitamins do not always have the needed amount of calcium for every individual. A patient needs to know his or her requirement and make a decision based on that.
(ATI) A nurse is instructing a client, who has an injury on the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply) 1. Hold the cane on the right side 2. Keep two points of support on the floor 3. Place the came 38 cm (15 in) in front of the feet before advancing 4. After advancing the cane, move the weaker leg forward 5. Advance the stronger leg so that it aligns evenly with the cane
1, 2, 4 The client should hold the cane on the uninjured side to provide support for the injured left leg The client should keep two points of support on the ground at all times for stability. The client should advance the weaker leg first, followed by the stronger leg
(P&P) A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply.) 1. Bruising 2. Pale yellow urine 3. Bleeding gums 4. Coffee ground-like vomitus 5. Light brown stool
1, 3, 4 Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding such as hematuria, bruising, coffee ground-like vomitus or gastrointestinal aspirate, guaiac-positive stools, and bleeding gums.
(P&P) Place the following options in the order in which elastic stockings should be applied. 1. Identify patient using two identifiers. 2. Smooth any creases or wrinkles. 3. Slide the remainder of the stocking over the patient's heel and up the leg 4. Turn the stocking inside out until heel is reached. 5. Assess the condition of the patient's skin and circulation of the legs. 6. Place toes into foot of the stocking. 7. Use tape measure to measure patient's legs to determine proper stocking size.
1, 5, 7, 4, 6, 3, 2
(P&P) To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery? 1. Turn, cough, and deep breathe every 30 minutes while awake 2. Ambulate patient to chair in the hall 3. Passive range of motion 4 times a day 4. Immobility is not a concern the first postoperative day
2 Prevention of complications of immobility begins when the patient becomes immobilized. Every 30 minutes is not necessary and disruptive to the healing process. Active patient participation in exercises is more beneficial to preventing venous stasis.
(ATI) A nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? 1. "This device will keep me from getting sores on my skin." 2. "This thing will keep the blood pumping through my leg." 3. With this thing on, my leg muscles won't get weak." 4. "This device is going to keep my joints in good shape."
2 Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation
(P&P) The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.) 1. Initial patient measurement is made around the calves 2. Inflation pressure averages 40 mm Hg 3. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve. 4. Stockings are removed every 2 hours during application. 5. Yellow light indicates SCD device is functioning.
2, 3 The most effective way to prevent deep vein thrombosis is through an aggressive program of prophylaxis. A properly functioning SCD inflates with a pressure around 40 mm Hg. Inflation pressure averages 40 mm Hg, and the patient's leg should be placed in the SCD sleeve with the back of knee aligned with the popliteal opening on the sleeve. Measurement involves length of leg, not calf. A green light indicates the SCD device is functioning.
(P&P) An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) 1. B/P = 128/84 2. Respirations 26/min on room air 3. HR 114 4. Crackles over lower lobes heard on auscultation 5. Pain reported as 3 on scale of 0 to 10 after medication
2, 3, 4 Patients who are immobile are at high risk for developing pulmonary complications. The most common respiratory complications are atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Ultimately the distribution of mucus in the bronchi increases, particularly when the patient is in the supine, prone, or lateral position.
(Giddens) The nurse is assessing a patient's ability to perform instrumental activities of daily living (IADLs). Which of the following activities are considered in the IADLs assessment? (Select all that apply) 1. Feeding oneself 2. Preparing a meal 3. Balancing a checkbook 4. Walking 5. Toileting 6. Grocery shopping
2, 3, 6 IADLs include shopping, meal preparation, housekeeping, doing laundry, managing finances, taking medications, and using transportation. The other activities listed are activities of daily living (ADLs) related to self-care. IADLs are more complex skills that are essential to living in a community.
(ATI) A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply) 1. Instruct the client not to perform the Valsalva maneuver 2. Apply elastic stockings 3. Review laboratory values for total protein level 4. Place pillows under the client's knees and lower extremities 5. Assist the client to change position often
2, 5 Elastic stocking promote venous return and prevent thrombus formation. Frequent position changes prevents venous stasis
(P&P) Which of the following are physiological outcomes of immobility? 1. Increased metabolism 2. Reduced cardiac workload 3. Decreased lung expansion 4. Decreased oxygen demand
3 Physiologic outcomes of immobility include decreased metabolism, increased cardiac workload, decreased lung expansion, and increased oxygen demand.
(ATI) A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? 1. Decreased subcutaneous fat 2. Muscle atrophy 3. Pressure ulcer 4. Fecal impaction
3 The greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. The nurse should instruct the client to shift his weight every 15 min and reposition the client after 1 hr.
(Giddens) The nurse is caring for an 85-year-old woman 6 weeks following a hysterectomy secondary to ovarian cancer. The patient will need chemotherapy and irradiation on an outpatient basis. The nurse should identify and address which barriers to healing? (Select all that apply) 1. Can feed herself and prepare meals but cannot drive to the store 2. Lives on a fixed income and can balance her checkbook 3. Experiences stress incontinence 4. Cannot participate in activities at the senior center 5. Lives alone and has no nearby relatives 6. Has no transportation to the oncology clinic
3, 5, 6 The patient will not be able to get treatment if she has no transportation or no relatives that live nearby who can help her with recovery. Stress incontinence increases the risk of falls because of urgency and rushing to get to the bathroom. Income and social abilities are lower priorities during this phase of recovery.
(P&P) The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to __________________________.
Promote venous return to the heart. Elastic stockings (sometimes called antiembolitic stockings) aid in maintaining external pressure on the muscles of the lower extremities and thus promote venous return. Increase in venous return helps reduce the stasis of blood thereby, reducing the risk for deep vein thrombosis in the lower extremities.
