Immobility Chapter 28 part 1

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How many nurses would be required to place a patient in the semi-prone position? 1- 1 nurse 2- 2 nurses 3- 3 nurses 4- 4 nurses

1- 1 nurse Positioning the patient in the Sims position or the semi-prone position would require only one nurse. Positioning the patient in the prone position would require two or three nurses. For logrolling the patient, the assistance of three or four nurses would be required.

The nurse is positioning a hemiplegic patient in the supine position. The nurse places a folded towel under the hip of the patient. What is the reason behind this intervention? 1 Maintain mobility 2 Control hip position 3 Maintain dorsiflexion 4 Decrease possibility of pain

2 Control hip position

Which positioning aid decreases the shearing action from sliding across up and down in bed? 1 Thin pillow 2 Thick pillow 3 Trapeze bar 4 Trochanter roll

3 Trapeze bar The trapeze bar decreases the shearing action from sliding across or up and down in bed. Thin and thick pillows are used for positioning patients. The trochanter roll prevents external rotation of the hips when a patient is in a supine position.

Renal Calculi are also known as

Kidney stones

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? 1 Lordosis 2 Kyphosis 3 Scoliosis 4 Torticollis

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.

The nurse is reviewing the data of patients who have undergone surgery. Which patient would be at the highest risk of orthostatic hypotension based on the given data? Patient A Appendectomy 3 days bed rest Patient B Lobotomy 10 days bed rest Patient C Hip Replacement 20 days bed rest Patient D Byfpass surgery 15 days bed rest

Patient C Hip Replacement 20 days bed rest The longer the duration of a patient's immobility, the higher the risk is for orthostatic hypotension. Therefore, the patient who underwent hip replacement and required bed rest for 20 days would be at the highest risk of orthostatic hypotension.

semi-Fowler's position

Patients with a head injury would benefit from

30-degree lateral position

Patients with pressure ulcers would benefit. Helps eliminate pressure points over the bony prominences. Reduces the incidence of pressure ulcers.

Motions that can be done in the Transverse plane

Rotation- Internal (inward) or external (outward) turning about the vertical axis of the bone Pronation- Rotating the hand and wrist medially from the bone Supination-Rotating the hand and wrist laterally from the bone Horizontal Flexion (adduction)- From the 90-degree abducted arm position, the humerus is flexed (adducted) in toward the midline of the body in the transverse plane Horizontal Extension(abduction)- Return of the humerus from horizontal flexion

What is a cerebrovascular accident

The sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as a stroke.

What occurs as a result of hypercalcemia

Too much calcium in your blood can weaken your bones, create kidney stones, and interfere with the way your heart and brain works.

A 3-year-old child has rickets. Which vitamin should be supplemented to the child's diet? 1 Vitamin A 2 Vitamin B 3 Vitamin C 4 Vitamin D

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.

pulmonary embolism

a sudden blockage in a lung artery. The blockage usually is caused by a blood clot ...

Scoliosis

abnormal lateral curvature of the spine.

pallor

an unhealthy pale appearance.

supine position

beneficial for a postoperative patient to prevent footdrop

prone position would be used ______ .

beneficial in certain patients with pulmonary conditions such as acute respiratory distress syndrome, because it helps improve oxygenation.

hyperventilation

breathing that is rapid but deep, caused by a buildup of carbon dioxide in the lungs, which causes a buildup of carbon dioxide in the bloodstream.

Concave

curved inward

Hypoxemia

decreased concentration of oxygen in the blood

Dyspnea

difficult or labored breathing.

dysphagia

difficulty or discomfort in swallowing, as a symptom of disease.

Atelectasis

partial or complete collapse of the lung.

Enteral feeding

refers to the delivery of a nutritionally complete feed, containing protein, carbohydrate, fat, water, minerals and vitamins, directly into the stomach, duodenum or jejunum.

urinary stasis

when there is a difficulty emptying the bladder, and if urine accumulates for a long time. This favors the proliferation of bacteria in the urine, leading to the development of infection

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which menus should the nurse recommend? 1 Cream of broccoli soup with whole wheat crackers and tapioca for dessert 2 Hamburger on soft roll with a side salad and an apple for dessert 3 Low-fat turkey chili with sour cream and fresh pears for dessert 4 Chicken salad on toast with tomato and lettuce and honey bun for dessert

1 Cream of broccoli soup with whole wheat crackers and tapioca for dessert The dairy and broccoli in the soup, the whole grain crackers, plus the tapioca are all great sources of calcium.

After assessing a patient with immobility, the nurse observes that the patient has acute respiratory distress syndrome. Which positioning of the patient would be appropriate to improve oxygenation? 1 Prone position 2 Supine position 3 30-degree lateral position 4 Semi-Fowler's position

1 Prone position Positioning the patient in the prone position would be beneficial in certain patients with pulmonary conditions such as acute respiratory distress syndrome, because it helps improve oxygenation. The supine position would be beneficial for a postoperative patient to prevent footdrop. Patients with pressure ulcers would benefit from being placed in a 30-degree lateral position. Patients with a head injury would benefit from the semi-Fowler's position.

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

2 Alteration or slowing of blood flow 3 Damage to the wall of the blood vessels 5 Alteration of the constituents in the blood Prolonged immobility increases the risk of thrombus formation. Slow blood flow in the calf veins may lead to formation of thrombus. Damage to the blood vessels caused by any surgical procedure may also cause a blood clot. Alterations in the constituents of blood, such as clotting factors and platelets, may also contribute to formation of thrombus. These three factors are referred to as Vircho's triad. Alteration in body weight and the patient's nutritional status have no effect on thrombus formation.

2 Control hip position While positioning a hemiplegic patient in the supine position, the nurse should place a folded towel under hip of the involved side to diminish the effect of spasticity in the entire leg by controlling the hip position. A folded towel does not maintain mobility, dorsiflexion nor decrease pain.

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

2 Flexor carpi radialis 5 Extensor carpi radialis longus Flexor carpi radialis 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. The extensor carpi radialis brevis is used for hyperextension of the condyloid joint in the wrist region. (Table 28-2)

Which condition is associated with increased risk of footdrop? 1 Kyphosis 2 Hemiplegia 3 Osteoporosis 4 Disuse syndrome

2 Hemiplegia In foot drop, the foot is permanently fixed in plantar flexion, resulting limited mobility. Patients with hemiplegia are at increased risk of developing footdrop. Kyphosis refers to increased convexity in curvature of the thoracic spine. Osteoporosis may result from decreased bone density. Disuse syndrome refers to impaired physical mobility.

Which condition is associated with increased risk of footdrop? 1 Kyphosis 2 Hemiplegia 3 Osteoporosis 4 Disuse syndrome

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

2 Speech therapist 3 Occupational therapist 4 Physical therapist 5 Prosthetist The physical therapist may collaborate to help the patient rehabilitate by giving the patient gait training. The physical therapist is the head of the rehabilitation team and should be able to guide the family members for rehabilitation. The occupational therapist may help the patient with activities of daily living (ADLs), such as dressing, bathing and toileting, or household chores. The prosthetist's role is to make prosthesis for amputees. The patient has not had an amputation and does not require prosthesis. The social worker focuses on assessment and evaluation of the patient's social situation. The patient's needs are related to the physical mobility; a social worker may not be of help.

Which can cause contracture of a joint? 1 The adductors muscles are weakened as a result of immobility. 2 The muscle fibers become shortened because of disuse. 3 The calcium-to-phosphorus ratio becomes disrupted. 4 There is a deficiency in vitamin D.

2 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.

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."

3 "The skeletal muscle includes three types of bones." 4 "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 muscles protect vital organs and aids in calcium regulation. The skeletal muscle enables the bones to withstand weight bearing.

Which movement is assessed in the frontal plane when the nurse is observing the mobility of the joint? 1 Rotation 2 Extension 3 Adduction 4 Supination

3 Adduction Adduction, abduction, eversion, and inversion are the movements assessed in the frontal plane. Rotation is a movement assessed in the transverse plane. Extension is a movement in the sagittal plane. Supination is also the movement assessed in the transverse plane.

Motions that can be done in the Frontal plane

Adduction: Motion toward the midline Abduction: Motion away from the midline of the body Elevation: Moving to a superior position (only at the scapula) Depression: Moving to an inferior position (only at the scapula) Inversion: Lifting the medial border of the foot Eversion: Lifting the lateral border of the foot

Motions that can be done in the sagittal plane

Flexion: Decreasing the angle between two bones Extension: Increasing the Angle between two bones Dorsiflexion: Moving the top of the foot toward the shin (only at the ankle) Plantar flexion: moving the sole of the foot downward (pointing the toes)

osteoblasts.

a cell that secretes the matrix for bone formation.

What is hypercalcemia

a condition in which the calcium level in your blood is above normal.

Hypoxia

a deficiency of oxygen getting to the tissues, it is not reaching the tissues.

hemiplegia

means that the paralysis is on one vertical half of the body. A similar medical term, hemiparesis, means a weakness on one side of the body. In children with this, the paralysis in the body occurs on the side opposite the affected part of the brain.

What causes Hypercalemia (commonly)

most commonly results from overactive parathyroid glands.

What is Hemiplegia

paralysis of one side of the body.

Genu varum

(also called bow-leggedness, bandiness, bandy-leg, and tibia vara), is a physical deformity marked by (outward) bowing of the lower leg in relation to the thigh, giving the appearance of an archer's bow. Usually medial angulation of both femur and tibia is involved.

4 Genu valgum

-(knock-knees) is a common lower leg abnormality that is usually seen in the toddler, preschool and early school age child. - the lower extremities turn inward, causing the appearance of the knees to be touching while the ankles remain apart.

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. 1 "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

1 "Every patient responds to immobility in a same way." 5 "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.

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

1 Arthritis 4 Diabetes 5 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.

Which positioning aid increases the cervical flexion? 1 Pillows 2 Arm splints 3 Trapeze bars 4 Trochanter rolls

1 Pillows When thick pillows are used under the patient's head, it increases cervical flexion. Arm splints help reduce musculoskeletal injuries. A trapeze bar helps patients perform upper arm exercises. Trochanter rolls prevent external rotation of the hips when a patient is in the supine position.

Which condition does the nurse infer from the given figure? 1. Foot drop 2 Atelectasis 3 Knock-knee 4 Disuse osteoporosis

1. Foot drop The given figure is a joint contracture called footdrop, in which the foot is permanently fixed in plantar flexion. Ambulation is difficult with the foot in this position, because the patient cannot dorsiflex the foot. Atelectasis is a respiratory complication that develops in patients with immobility. Knock-knee is a postural abnormality in which the legs are curved inwards so the knees come together as the person walks. Immobilization results in bone resorption, and the bone tissue becomes less dense or atrophied, resulting in disuse osteoporosis, in which the patient has compressed and weaker bones.

While assessing a patient for joint mobility, the nurse notices that the patient is unable to dorsiflex the foot. Which condition does the nurse suspect in the patient? 1 Scoliosis 2 Torticollis 3 Joint contracture 4 Disuse osteoporosis

3 Joint contracture A patient with the type of joint contracture known as foot drop is permanently fixed in plantar flexion and is unable to dorsiflex the foot. Disuse osteoporosis refers to atrophy and decreased density of the bone tissue. Torticollis involves inclining the head to the affected side with the sternocleidomastoid muscle is contracted. Scoliosis refers to a lateral S- or C-shaped spinal column with vertebral rotation, and unequal heights of the hips and shoulders.

The registered nurse is teaching a nursing student about the interventions performed in immobilized patients who are at risk for impaired skin integrity. Which statement made by the nursing student indicates the need for further learning? Repositioning should be done every 1 to 2 hours; however, this is not only limited to when the patient is awake. Use of pressure relief devices may reduce the risk of developing pressure ulcers. Using an objective tool to assess the risk of pressure ulcers would help in choosing the appropriate surface devices. Shifting the weight while sitting reduces the risk of developing pressure ulcers. a device to relieve pressure when the patient is seated." 3 "I should use an objective tool to assess the risk of developing pressure ulcers." 4 "I should teach the patient on how to shift weight at regular intervals while sitting.

Repositioning should be done every 1 to 2 hours; however, this is not only limited to when the patient is awake. Use of pressure relief devices may reduce the risk of developing pressure ulcers. Using an objective tool to assess the risk of pressure ulcers would help in choosing the appropriate surface devices. Shifting the weight while sitting reduces the risk of developing pressure ulcers. Patients with osteoporosis should make lifestyle changes to prevent the disease from becoming worse. Smoking poses a major risk for osteoporosis, but this risk can be drastically reduced if the patient stops smoking. Intake of leafy green vegetables is helpful for the patient who has osteoporosis and should not be avoided. Exercise is helpful in keeping the bones strong. The patient should increase intake of calcium to maintain bone health. Test-Taking Tip: If you did not know the answer to this question, your best guess would be to pick the statement that is consistent with good health practices. Read the choices again while thinking, "Would this statement support health?" Only one response meets that goal, so the answer is clear.

Torticollis

a condition in which the head becomes persistently turned to one side, often associated with painful muscle spasms.

tachypnea.

abnormally rapid breathing. is the medical term for rapid and shallow breathing, caused by a buildup of carbon dioxide in the lungs, which causes a buildup of carbon dioxide in the bloodstream.

Osteoclastoma

also called giant cell tumour of bone, bone tumour found predominantly at the end of long bones in the knee region, but also occurring in the wrist, arm, and pelvis. ... A small percentage of osteoclastomas may spread to other parts of the body (metastasize), particularly the lungs A tumor of bone characterized by massive destruction of the end (epiphysis) of a long bone. The site most commonly struck by this tumor is the knee ? the far end of the femur and the near end of the tibia.

If a patient is receiving an anticoagulant like heparin what should you look for?

assess for signs of bleeding. These include overt signs, such as bleeding from the gums, or covert signs, which can be detected by testing the stool or observing the patient's aspirate from nasogastric (NG) tubes for coffee ground-like matter

Convex

curved outward

Lordosis

excessive inward curvature of the spine. a posture assumed by some female mammals during mating, in which the back is arched downward.

Kyphosis

excessive outward curvature of the spine, causing hunching of the back.

What color is sputum with pneumonia?

greenish yellow in pneumonia, not blood-tinged.

thrombophlebitis

inflammation of the wall of a vein with associated thrombosis, often occurring in the legs during pregnancy.

A physiological change

is a change in the normal function of a living organism. An example of a physiological change is the everyday shedding of dead skin cells in humans. dealing with the functions and activities of living organisms and their parts, including all physical and chemical processes. 2. the organic processes or functions in an organism or in any of its parts.

Footdrop

is a gait abnormality in which the dropping of the forefoot happens due to weakness, irritation or damage to the common fibular nerve including the sciatic nerve, or paralysis of the muscles in the anterior portion of the lower leg. It is usually a symptom of a greater problem, not a disease in itself.

Osteomyelitis

is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue. Infections can also begin in the bone itself if an injury exposes the bone to germs. In children, osteomyelitis most commonly affects the long bones of the legs and upper arms.

Disuse osteoporosis

is defined as localized or generalized bone loss resulting from reduction of mechanical stress on bones.

cerebrovascular accident (CVA)

is the medical term for a stroke. A stroke is when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel.

The registered nurse is teaching a nursing student about the interventions performed to prevent deep vein thrombosis in an immobilized patient. Which statement made by the nursing student indicates a need for correction? 1 "I will massage the legs." 2 "I will instruct the patient to avoid crossing the legs." 3 "I will assist the patient in performing range-of-motion exercises." 4 "I will position the patient without applying pressure on the posterior of knee.

1 "I will massage the legs." Massaging the leg should be avoided in cases of deep vein thrombosis, because it may lead to dislodgement of the thrombus and result in severe complications. Crossing of the legs should be avoided to increase the blood circulation. Performing range-of-motion exercises reduce the risk of contractures and aid in preventing thrombi. Proper positioning without applying pressure on the posterior of knee reduces a patient's risk of thrombus formation, because compression of the leg veins is minimized.

The nurse is teaching a patient diagnosed with arthritis of the knees about physical activity and lifestyle changes. Which statement by the patient indicates correct understanding of the teaching? 1 "I will perform exercises in a pool." 2 "I will go for a walk every morning." 3 "I will increase my intake of foods rich in vitamin D." 4 "I will frequently perform weight-bearing exercises."

1 "I will perform exercises in a pool." Aquatic therapy involves performing exercises in a pool, which is an appropriate therapy used to regain joint mobility in severe arthritis of knees. Aquatic therapy would be more beneficial for this patient than walking. Increased intake of foods rich in vitamin D is beneficial to strengthen the bones, but it would not help a patient regain joint mobility. Weight-bearing exercises strengthen the bones and the joints, but there is a risk for fractures in this patient while performing these exercises. Therefore, aquatic therapy is preferred for severe arthritis.

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

1 Ensure adequate fluid intake. 3 Use elastic stockings on the legs. 4 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.

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

1 Fever 2 Crackles 4 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 physiological changes are observed in a patient when the head of a hospital bed is elevated to 60 degrees? Select all that apply. 1 Formation of pressure ulcers 2 Skin remains against the sheets 3 Increased blood flow in the blood vessels 4 Blood vessels in the underlying tissues are strengthened 5 Bony skeleton moves forward towards the foot of the bed

1 Formation of pressure ulcers 2 Skin remains against the sheets 5 Bony skeleton moves forward towards the foot of the bed When the head of the hospital bed is elevated, pressure ulcers often develop within the undermined tissue. When the bed is elevated to 60 degrees, gravity pulls a patient so that bony skeleton moves towards the foot of the bed while the skin remains against the sheet. The blood vessels in the underlying tissue are not strengthened; instead they are stretched and damaged, resulting in the impeded blood flow to the deeper tissues and blood vessels.

What is the desired outcome when the head of the bed is elevated to 60 degrees in supported Fowler's position? 1 Improves ventilation 2 Prevents shoulder dislocation 3 Relieves the pressure on heels 4 Prevents hyperextension of knee

1 Improves ventilation When the head of the bed is elevated to 60 degrees in supported Fowler's position, it improves ventilation. Using a pillow to support the arms would help in preventing shoulder dislocation. Use of heel pressure relief devices would reduce pressure on the heels. Placing a small pillow under the thigh can prevent hyperextension of the knee.

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

1 Increase intake of vitamin D. 2 Increase intake of calcium. 5 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.

A patient has undergone a below-the-knee amputation. Which nursing intervention should the nurse suggest to the patient to promote mobility? 1 Lift soup cans. 2 Increase calcium intake. 3 Increase vitamin C intake. 4 Avoid performing range-of-motion exercises

1 Lift soup cans. The patient with a below-the-knee amputation has restricted mobility. The patient should be advised to exercise the rest of the body. Lifting soup cans helps to improve the patient's strength and abilities. Increase in calcium intake and vitamin C may help to increase bone strength but may not be helpful in increasing muscle strength. Performing range-of-motion exercises is helpful for the patient to build up muscle strength and mass.

While positioning a patient in the supported supine position, the nurse places a pillow under the upper shoulders. What is the rationale behind this intervention? 1 Maintain correct alignment 2 Reduce external rotation of hip 3 Provide support for lumbar spine 4 Reduce internal rotation of shoulder

1 Maintain correct alignment Placing of pillows under the shoulders while positioning a patient in the supine position maintains correct alignment and prevents flexion contractures of cervical vertebrae. Placing trochanter rolls to the lateral surface of the patient's thighs may reduce external rotation of the hip. Placing a small rolled towel under the lumbar area of the back provides support for the lumbar spine. Placing pillows under pronated forearms reduces internal rotation of the shoulder and prevents extension of the elbows.

Which assessment finding may indicate orthostatic hypotension associated with prolonged immobility? 1 Pallor 2 Pain upon breathing 3 Decreased heart rate 4 Increased cardiac output

1 Pallor Pallor may indicate the presence of orthostatic hypotension. The further findings to confirm this condition includes dizziness, light-headedness, nausea, and tachycardia. Pain upon breathing may indicate pneumonia but is not associated with orthostatic hypotension. Increase heart rate is seen in orthostatic hypotension, not decreased heart rate. Decreased cardiac output is seen in orthostatic hypotension, not increased cardiac output.

While logrolling a patient, the nurse crosses the patient's arms on the chest. What is the reason for the nurse's action? 1 Prevent injury to arms 2 Maintain alignment of the body 3 Prevent tension on spinal column 4 Prepare patient for turning onto one side

1 Prevent injury to arms While logrolling, the patient's arm should be crossed on the chest to prevent injuries to the arms. When one nurse grasps a drawsheet at the lower hips and thighs, and the other nurse grasps the drawsheet at the patient's shoulder and lower back, this maintains proper alignment of all body parts. Placing a small pillow between the patient's knees prevents tension on the spinal column and adduction of the hip. Placing the patient in supine position on the side of the bed opposite the direction to be turned prepares the patient for turning onto the side.

What are the functions of the skeletal system? Select all that apply. 1 Provide support 2 Regulate calcium 3 Regulate posture 4 Contribute balance 5 Protect vital organs

1 Provide support 2 Regulate calcium 5 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 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

1 Reposition the patient every 1 to 2 hours. 3 Place the patient in a 30-degree lateral position. 4 Avoid pulling the patient when repositioning. 5 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. Topics

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

1 Sleep without pillows. 2 Practice spine-stretching exercises. 4 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.

Which nursing intervention is depicted in the image? Nurse holding patient elbow and wrist. 1 Supporting the joint 2 Assessing the intensity of pain 3 Assessing the resistance of the joint 4 Supporting the patient to sit in upright position

1 Supporting the joint The nurse is supporting the joint by holding the adjacent distal and proximal areas. To assess the intensity of pain, pressure should be applied. However, as shown in the image, the nurse is just supporting the joint by holding the arm. The resistance of the joint is assessed by moving the joint, such as with flexion and extension. The patient should be supported to sit in an upright position by lifting the patient; lifting the patient by supporting the arm may cause joint dislocation.

Which nursing intervention would increase the risk for joint dislocation in a patient with hemiplegia who is immobile for an extended period? 1 Supporting the patient by holding the arm 2 Supporting the patient with assistive devices 3 Lowering the patient to the floor if he or she faints 4 Instructing the patient to use a cane while walking Supporting the patient by holding the arm may increase the risk of joint dislocation if the patient falls. Assistive devices, such as gait belts, reduce the risk of falling by maintaining the center of gravity in the midline. Lowering the patient to the floor if he or she faints helps reduce the risk for falls. Instructing the patient to use a cane while walking also helps reduce the risk of falls, but it would not be beneficial for patients with hemiplegia.

1 Supporting the patient by holding the arm Supporting the patient by holding the arm may increase the risk of joint dislocation if the patient falls. Assistive devices, such as gait belts, reduce the risk of falling by maintaining the center of gravity in the midline. Lowering the patient to the floor if he or she faints helps reduce the risk for falls. Instructing the patient to use a cane while walking also helps reduce the risk of falls, but it would not be beneficial for patients with hemiplegia.

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

1 Tachycardia 3 Shortness of breath 5 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.

Which device should the nurse use to prevent external rotation of the hips when the patient is in a supine position? 1 Trochanter roll 2 Positioning boots 3 Trapeze bars 4 Pillows

1 Trochanter roll When the patient is in the supine position, the nurse should use a trochanter roll to prevent external rotation of the hips. When the hips are correctly aligned, the patella faces directly upward. The positioning boots help in preventing footdrop. Patients use trapeze bars to lift themselves during repositioning. Pillows may not be helpful in preventing the external rotation of the hips.

The nurse is caring for a patient who has been immobile after a spine surgery. Which urinary changes are likely to occur in the patient? 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

1 Urinary output decreases. 4 Urinary stasis occurs. 5 Risk for developing urinary tract infection increases Fluid intake is often diminished during immobility, causing a decrease in urine output. 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 may not happen immediately; however, untreated renal calculi and urinary tract infections may gradually lead to chronic renal failure. The urine is concentrated because the fluid intake is less.

What is the desired outcome when the head of the bed is elevated to 60 degrees in supported Fowler's position? Correct1 Improves ventilation 2 Prevents shoulder dislocation 3 Relieves the pressure on heels 4 Prevents hyperextension of knee When the head of the bed is elevated to 60 degrees in supported Fowler's position, it improves ventilation. Using a pillow to support the arms would help in preventing shoulder dislocation. Use of heel pressure relief devices would reduce pressure on the heels. Placing a small pillow under the thigh can prevent hyperextension of the knee.

1. Improves ventilation When the head of the bed is elevated to 60 degrees in supported Fowler's position, it improves ventilation. Using a pillow to support the arms would help in preventing shoulder dislocation. Use of heel pressure relief devices would reduce pressure on the heels. Placing a small pillow under the thigh can prevent hyperextension of the knee.

What is the correct order of assessments of patient mobility performed by the nurse? 1. Walking 2. Lying position 3. Transferring to chair 4. Sitting position in bed

1. Lying position 2. Sitting position in bed 3. Transferring to chair 4. Walking Assessment of mobility focuses on range of motion, gait, exercise, and activity tolerance. Generally, the nurse performs the assessment of movement starting with the patient in a lying position, proceeding to assessing sitting positions in bed, then transferring to a chair, and finally walking.

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."

2 "Postural abnormalities will only impair alignment." 5 "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.

Which statement by a nursing student regarding the respiratory changes in immobile patients needs correction? 1 "Mucus accumulates in dependent regions of the airways." 2 "There is increased cough productivity in immobile patients." 3 "Hypostatic pneumonia may develop in patients with immobility." 4 "Distribution of mucus in the bronchi increases when the patient is in the supine position."

2 "There is increased cough productivity in immobile patients." At some point in the development of respiratory complications, there is proportional decline in the patient's ability to cough productively. In patients with respiratory complications, mucus accumulates in dependent regions of the airways. Hypostatic pneumonia frequently results because mucus is an excellent place for bacteria to grow. Distribution of the mucus in the bronchi increases, particularly when the patient is in the supine or lateral position.

While assessing a child, the nurse finds that the child's legs are bent outward at the knee. Which instruction to the parents is most beneficial for the child? 1 "You need to limit phosphorus intake for your child." 2 "You should provide a vitamin D-rich diet for your child." 3 "You should limit mobility in your child for a few days." 4 "You should purchase a Denis Browne splint for your child."

2 "You should provide a vitamin D-rich diet for your child." Outward bending of the legs at the knee indicates bowlegs. It is generally associated with rickets, which occurs due to deficiency of vitamin D. Therefore, the child should be provided with foods that are rich in vitamin D. Phosphorus reduces the risk of rickets in the children. Therefore, parents should not limit phosphorus in a child's diet. Limiting mobility in a child with rickets can impair mobility permanently. A Denis Browne splint is used to reduce the risk of clubfoot; however, it is not useful as a treatment for rickets.

Which patient is at greatest risk for developing multiple adverse effects of immobility? 1 1-year-old child with a hernia repair 2 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA) 3 51-year-old woman following a thyroidectomy 4 38-year-old woman undergoing a hysterectomy

2 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 who has hemiplegia is unable to dorsiflex and invert the feet. Which condition does the patient likely have? 1 Lordosis 2 Footdrop 3 Genu varum 4 Genu valgum

2 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 teaching a nursing student about various deformities of the spine. Which statements are true about spine deformities? Select all that apply. 1 Scoliosis is the medial deviation and plantar flexion of the foot. 2 Kyphosis is the increased convexity in curvature of the thoracic spine. 3 Kyphosis is the internal rotation of forefoot or entire foot. 4 Lordosis is the exaggeration of the anterior convex curve of lumbar spine. 5 Scoliosis is the lateral S- or C-shaped spinal column with vertebral rotation

2 Kyphosis is the increased convexity in curvature of the thoracic spine. 4 Lordosis is the exaggeration of the anterior convex curve of lumbar spine. 5 Scoliosis is the lateral S- or C-shaped spinal column with vertebral rotation Kyphosis is the increased convexity in the curvature of the thoracic spine, which may be caused by rickets, osteoporosis, or tuberculosis of the spine. Lordosis is the exaggeration of the anterior convex curve of the lumbar spine. This can be a congenital condition or a temporary condition as in the case of pregnancy. Scoliosis is the lateral S- or C-shaped spinal column with vertebral rotation. This can be a consequence of numerous congenital, connective tissue, and neuromuscular disorders. The medial deviation and plantar flexion of the foot is called clubfoot and is not a spinal deformity. The internal rotation of forefoot or entire foot is called pigeon toes, and it is not a spine deformity.

2 Massaging the area may dislodge the thrombus. A patient who is immobile with limited movement of the lower limbs may develop deep vein thrombosis due to stagnation of blood. This thrombus may get dislodged if the affected calf muscles are massaged. A dislodged thrombus may block any blood vessel and lead to complications. Therefore, in the patient who has developed thrombosis, massage should be avoided. Massaging may not be painful and may not cause skin breakdown or an ulcer.

Following surgery, a patient has become bedridden and has developed a thrombus in the left leg. The nurse instructs the patient, caregiver, and staff members to avoid massaging the affected area. What is the most likely reason for this instruction? 1 Massaging the area may be painful for the patient. 2 Massaging the area may dislodge the thrombus. 3 Massaging the area may cause skin breakdown. 4 Massaging the area may promote ulcer formation. A patient who is immobile with limited movement of the lower limbs may develop deep vein thrombosis due to stagnation of blood. This thrombus may get dislodged if the affected calf muscles are massaged. A dislodged thrombus may block any blood vessel and lead to complications. Therefore, in the patient who has developed thrombosis, massage should be avoided. Massaging may not be painful and may not cause skin breakdown or an ulcer.

The nurse is caring for a postoperative patient. Which nursing action should the nurse take if deep vein thrombosis (DVT) is suspected in an immobilized patient? 1 Assessing the feet for temperature 2 Measuring the calf and thigh circumference 3 Assessing for calf pain on dorsiflexion of the foot 4 Observing for loss of skin integrity in the lower extremities

2 Measuring the calf and thigh circumference A unilateral increase in calf circumference is an early indicator for deep vein thrombosis. Therefore, circumferences of the thigh and calf should be measured to assess for DVT. The temperature of the feet is not a reliable assessment in determining a DVT. Assessing for calf pain on dorsiflexion of the foot is contraindicated for a patient who is suspected to have developed DVT. Loss of skin integrity is a sign of increased risk of DVT; therefore, skin assessment in the lower extremities is a correct action.

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

2 Negative nitrogen balance 3 Decrease in the basal metabolic rate 4 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.

The nurse is assessing four patients. Which patient does the nurse suspect to be at increased risk of pulmonary embolism due to immobility? 1 Patient with dehydration 2 Patient with enlarged calf circumference 3 Patient with decreased blood pressure 4 Patient with increased serum calcium levels

2 Patient with enlarged calf circumference Increased calf circumference may indicate deep vein thrombosis, which may further result in pulmonary embolism. A patient with dehydration is at increased risk of impaired skin integrity due to immobility. Decreased blood pressure may indicate orthostatic hypotension due to immobility. Increased serum calcium levels may result from increased bone resorption, resulting in osteoporosis due to immobility.

The nurse is caring for a patient with acute respiratory distress syndrome. While positioning the patient, the nurse observes hyperextension of the lumbar spine. Which patient positioning would likely have caused this condition? 1 Sims' position 2 Prone position 3 Side-lying position 4 Supported Flower's position

2 Prone position Prone positioning is most suitable for patients with acute respiratory distress syndrome and acute lung injury. The potential trouble points with patients in the prone position include hyperextension of the lumbar spine and neck hyperextension. The trouble points of the Sims' position and the side-lying position are lateral flexion of the neck and lack of foot support. The trouble points of the supported Fowler's position are increased cervical flexion and pressure on the posterior aspects of the knee.

An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment the nurse notes that the patient cannot tolerate lying flat. Which assessment data support a possible pulmonary problem related to impaired mobility? Select all that apply. 1 B/P = 128/84 2 Respirations 26 per minute on room air 3 HR 114 4 Crackles heard on auscultation 5 Pain reported as 3 on scale of 0 to 10 after medication

2 Respirations 26 per minute on room air 3 HR 114 4 Crackles heard on auscultation Patients with reduced mobility are at risk for retained pulmonary secretions , and this risk increases in postoperative patients. As a result of retained secretions, the respiratory rate increases. The heart rate also increases because the heart is trying to improve oxygen levels. These symptoms are of concern for older adults because, if left untreated, further complications such as heart failure can occur.

While assessing a patient with impaired mobility, the nurse observes that the patient is unable to perform range of motion exercises. Which complications are most likely to occur in the patient? 1 Metabolic 2 Respiratory 3 Integumentary 4 Musculoskeletal

2 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.

The home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a cane. Which must be corrected or removed for the patient's safety? Select all that apply. 1 Rubber mat in the walk-in shower 2. Three-legged stool on wheels in the kitchen 3 Braided throw rugs in the entry hallway and between the bedroom and bathroom 4 Night-lights in the hallways, bedroom, and bathroom 5 Cordless phone next to the patient's bed

2. Three-legged stool on wheels in the kitchen 3 Braided throw rugs in the entry hallway and between the bedroom and bathroom 5 Cordless phone next to the patient's bed The three-legged stool on wheels and throw rugs are hazards that put the patient at risk for falls. The rubber mat in the shower, night-lights, and cordless phone are all safety measures that should be put in place to prevent fall or injury. By planning ahead and collaborating, the home care nurse can provide a safe home environment for the patient after discharge.

A patient has her call bell on and looks frightened when the nurse enters the room. The patient has been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my breath." What should the nurse do first? 1 Call the healthcare provider to report this change in c condition. 2 Give the patient a paper bag to breathe into to decrease anxiety. 3 Assess vital signs, perform a respiratory assessment, and be prepared to start oxygen. 4 Explain that this is normal after such trauma and administer the ordered pain medication

3 Assess vital signs, perform a respiratory assessment, and be prepared to start oxygen. The patient is exhibiting signs of possible pulmonary emboli, which can be life threatening. The nurse must assess the patient, be prepared to start oxygen, and have someone call the surgeon while staying with the patient to continue to monitor the patient's status.

The nurse is caring for a postoperative patient. Which nursing action should be avoided if deep vein thrombosis (DVT) is suspected in an immobilized patient? 1 Assessing the feet for temperature 2 Measuring the calf and thigh circumference 3 Assessing for calf pain on dorsiflexion of the foot 4 Observing for loss of skin integrity in the lower extremities

3 Assessing for calf pain on dorsiflexion of the foot A unilateral increase in calf circumference is an early indicator for deep vein thrombosis. Therefore, circumferences of the thigh and calf should be measured to assess for DVT. The temperature of the feet is not a reliable assessment in determining a DVT. Assessing for calf pain on dorsiflexion of the foot is contraindicated for a patient who is suspected to have developed DVT. Loss of skin integrity is a sign of increased risk of DVT; therefore, skin assessment in the lower extremities is a correct action.

Which finding may indicate metabolic change as a result of immobility? 1 Muscle atrophy 2 Peripheral edema 3 Delayed wound healing 4 Orthostatic hypotension

3 Delayed wound healing Delayed wound healing is a metabolic change, because the rate of healing is affected by nutritional intake and nutrient absorption. Muscle atrophy is a musculoskeletal change due to immobility. Peripheral edema and orthostatic hypotension are cardiovascular changes due to immobility.

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

3 Extension 5 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 assistive device would the nurse use to reduce surface area and friction when patients are unable to assist with moving up in bed? 1 Arm splints 2 Trapeze bar 3 Full-body sling 4 Trochanter roll

3 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.

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

3 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.

Which urinary elimination changes are often observed as the period of immobility continues for a patient? Select all that apply. 1 Increased fluid intake 2 Increased urinary output 3 Increased risk of renal calculi 4 Increased urinary concentration 5 Increased risk for urinary tract infections

3 Increased risk of renal calculi 4 Increased urinary concentration 5 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.

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? 1 Arthritis 2 Contracture 3 Ligament tear 4 Fluid in the join

3 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.

What is cartilage? 1 Connection between bones 2 White fibrous bands of tissues that connect muscles to bones 3 Nonvascular supporting connective tissue located chiefly in joints 4 Shiny white flexible bands of fibrous tissues that bind joints together

3 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.

Which intervention should the nurse perform while positioning a patient in the supported Fowler's position to decrease flexion of vertebrae? 1 Place a small pillow under thigh 2 Place the head on a small pillow 3 Place a small pillow at the lower back 4 Place a pillow to support arms and hands

3 Place a small pillow at the lower back The nurse should place a small pillow at lower back to decrease flexion of vertebrae. Placing a small pillow under the thigh prevents hyperextension of the knee. Placing the head on a small pillow prevents flexion contractures of cervical vertebrae. Placing a pillow to support the arms and hands prevents shoulder dislocation.

Which movement is assessed based on the line that divides the body into upper and lower regions when the nurse is observing the mobility of the joint? 1 Flexion 2 Eversion 3 Pronation 4 Abduction

3 Pronation The transverse plane is a horizontal line that divides the body into upper and lower regions. Pronation, supination, and rotation are movements observed in the transverse plane. Flexion is a movement assessed in the sagittal plane. Eversion and abduction are movements assessed in the frontal plane.

While caring for a postoperative patient, the nurse spreads trochanter rolls on the bed before positioning the patient. In which position is the nurse preparing to place the patient? 1 Sims' position 2 Prone position 3 Supine position 4 Supported Fowler's Position

3 Supine position Trochanter rolls are used to increase comfort for the patient and to reduce the risk of injury to the skin and musculoskeletal system when the patient is placed in the supine position. In the Sims' position, the patient places the weight on the anterior ileum, humerus, and clavicle. Trochanter rolls would not be used in this position. In the prone position, the nurse uses pillows under the lower extremities to reduce the risk of foot drop. In the supported Fowler's position, the knees are supported to reduce the risk of deep vein thrombosis.

The nurse assesses a patient's condition and suspects that the patient has footdrop. Which assessment finding supports the nurse's suspicion? 1 Internal rotation of entire foot 2 Both the legs bent outward at knee 3 The foot is permanently fixed in plantar flexion 4 Legs curved inward, so knees come together as person walks

3 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.

Which indicates that additional assistance is needed to transfer a patient from the bed to the stretcher? 1 The patient is 5 feet 6 inches and weighs 120 lbs. 2 The patient speaks and understands English. 3 The patient received an injection of morphine 30 minutes ago for pain. 4 The nurse feels comfortable handling a patient of this size and with this level of cooperation. The morphine injection would change the patient's ability to safely follow directions and participate in the transfer; therefore, additional help would be needed to safely transfer the patient from the bed to the stretcher. The patient's height and weight, ability to speak English, and the nurse's comfort level in handling the patient do not change the patient's ability to participate in the transfer.

3 The patient received an injection of morphine 30 minutes ago for pain. The morphine injection would change the patient's ability to safely follow directions and participate in the transfer; therefore, additional help would be needed to safely transfer the patient from the bed to the stretcher. The patient's height and weight, ability to speak English, and the nurse's comfort level in handling the patient do not change the patient's ability to participate in the transfer.

The nurse places the patient in prone position. Which nursing action reduces the flexion or hyperextension of the cervical vertebrae? 1 Bringing the dependent shoulder blade forward 2 Supporting the lower legs with pillows to elevate the toes 3 Turning the patient's head to one side and supporting it w with a small pillow 4 Placing a small pillow under the patient's abdomen below the level of diaphragm

3 Turning the patient's head to one side and supporting it w with a small pillow By turning the patient's head to one side and supporting it with a small pillow in prone position, flexion or hyperextension of the cervical vertebrae can be prevented. Bringing the dependent shoulder blade forward in the side-lying position helps prevent the patient's weight from resting directly on the shoulder joint. Supporting the lower legs with pillows to elevate the toes may prevent foot drop. Placing a small pillow under the patient's abdomen below the level of diaphragm in prone position helpsdecrease the hyperextensionof lumbar vertebrae and strain on lower back.

The nurse places the patient in prone position. Which nursing action reduces the flexion or hyperextension of the cervical vertebrae? 1 Bringing the dependent shoulder blade forward 2 Supporting the lower legs with pillows to elevate the toes 3 Turning the patient's head to one side and supporting it with a small pillow 4 Placing a small pillow under the patient's abdomen below the level of diaphragm

3 Turning the patient's head to one side and supporting it with a small pillow By turning the patient's head to one side and supporting it with a small pillow in prone position, flexion or hyperextension of the cervical vertebrae can be prevented. Bringing the dependent shoulder blade forward in the side-lying position helps prevent the patient's weight from resting directly on the shoulder joint. Supporting the lower legs with pillows to elevate the toes may prevent foot drop. Placing a small pillow under the patient's abdomen below the level of diaphragm in prone position helpsdecrease the hyperextensionof lumbar vertebrae and strain on lower back.

While positioning a hemiplegic patient in the supported Fowler's position, the nurse positions the head of the patient against a small pillow with the chin slightly forward. What is the rationale behind this nursing action? 1 Promote circulation 2 Support lumbar vertebrae 3 Prevent shoulder dislocation 4 Prevent flexion contractures

4 Prevent flexion contractures While positioning a hemiplegic patient who is unable to control head movement in the supported Fowler's position, the nurse should position the head on a small pillow with the chin slightly forward to prevent hyperextension of the neck. Using pillows to support the arms and hands of a patient who does not have voluntary control promotes circulation by preventing venous pooling. Positioning a small pillow at the lower back of a hemiplegic patient helps support the lumbar vertebrae and decreases flexion of the vertebrae. Use of pillows to support arms and hands may help prevent shoulder dislocation from the effect of a downward pull of unsupported arms.

The nurse is positioning a patient in supported Fowler's position. Which action should the nurse perform to prevent flexion contractures of the cervical spine? 1 Place a small pillow under the thigh 2 Position a small pillow at the lower back 3 Elevate the head of the bed to 50 degrees 4 Rest the head of the patient against the mattress

4 Rest the head of the patient against the mattress While positioning a patient in the supported Fowler's position, the nurse should rest the patient's head against the mattress or on a small pillow to prevent flexion contractures of the cervical vertebrae. With a patient in the supine position, the nurse elevates the head of the bed from 45 to 60 degrees to increase patient comfort and to improve ventilation. To prevent hyperextension of the knee, the nurse should place a small pillow under the thigh. Positioning a small pillow at the lower back helps support the lumbar vertebrae and decreases the flexion of the vertebrae.

A patient with left-sided weakness asks the nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." What would be the best therapeutic response? 1 "Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you." 2 "Would you like me to walk on your right side so you feel more secure?" 3 "Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side." 4 "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.

4 "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint. Walking on the affected (weak side) side and holding the patient around the waist or using a gait belt gives the nurse better control if the patient starts to fall. If the nurse were holding the patient's arm as the patient was falling, this might dislocate the shoulder.

The registered nurse is teaching a nursing student about the safety guidelines for nursing skills. Which statement by the nursing student indicates the need for further learning? 1 "I should raise the side rail on the opposite side of the bed from where I'm standing." 2 "I should evaluate the patient for correct body alignment." 3 "I should determine the type of assistance required for safe positioning." 4 "I should arrange the positioning equipment as close as possible to the patient's bed.

4 "I should arrange the positioning equipment as close as possible to the patient's bed. The positioning equipment should be arranged in such a way that it does not interfere with the positioning process; therefore, the equipment should not always be placed next to or too far away from the bed, but should be placed appropriately. The side rails on the side of the bed should be raised on the opposite side where the nurse stands to prevent the patient from falling out of the bed. The nurse should evaluate the patient for correct body alignment and pressure risks after repositioning. The nurse should determine the amount and type of assistance required for safe positioning, including any transfer equipment and the number of personnel to safely transfer the patient.

The nurse reviews discharge instructions with a patient who has osteoporosis. Which statement by the patient indicates that the patient understands the instructions? 1 "I will avoid intake of leafy green vegetables." 2 "I will avoid exercises, because they may cause bone fracture." 3 "I will reduce consumption of food containing calcium."

4 "I will stop smoking as soon as possible." Patients with osteoporosis should make lifestyle changes to prevent the disease from becoming worse. Smoking poses a major risk for osteoporosis, but this risk can be drastically reduced if the patient stops smoking. Intake of leafy green vegetables is helpful for the patient who has osteoporosis and should not be avoided. Exercise is helpful in keeping the bones strong. The patient should increase intake of calcium to maintain bone health.

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? 1 "I usually go swimming with my family at the YMCA three 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."

4 "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.

A patient had a left-sided cerebrovascular accident (CVA) 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore nasogastric (NG) tube because of dysphagia. Which symptom requires the nurse to call the healthcare provider immediately? 1 Pale yellow urine 2 Unilateral neglect 3 Slight movement noted on the right side 4 Coffee ground-like aspirate from the feeding tube

4 Coffee ground-like aspirate from the feeding tube When patients are receiving medications such as heparin or enoxaparin, the nurse must assess for signs of bleeding. These include overt signs, such as bleeding from the gums, or covert signs, which can be detected by testing the stool or observing the patient's aspirate from nasogastric (NG) tubes for coffee ground-like matter. These are signs of bleeding in the gastrointestinal tract. Pale yellow urine is not cause for concern, because it may be diluted and pale due to the extra fluids the patient may be given. Unilateral neglect in a cerebrovascular accident (CVA) is common. Slight movement that was not there during the previous neurological check is important and should be documented, but it is not necessary to call the healthcare provider.

Which metabolic changes are observed in immobile patients? 1 Increased appetite 2 Increased peristalsis 3 Increased metabolic rate 4 Increased nitrogen levels

4 Increased nitrogen levels In an immobile patient, his or her body often excretes more nitrogen that in ingests, resulting in negative nitrogen balance. Immobility disrupts normal metabolic functioning, and causes gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. The metabolic rate decreases in patients with immobility. Increased risk of electrolyte imbalance. An absence of weight on the skeleton and immobility causes protein to be broken down faster than it is made, resulting in a negative nitrogen balance.

Healthcare professionals have an increased risk of musculoskeletal injuries, because their occupation involves lifting and transferring patients. How can the nurse reduce the risk of musculoskeletal injuries when lifting any person or object? 1 Keep the object away from the body. 2 Bend at the hips and not at the knees. 3 Relax the abdominal muscles. 4 Keep trunk erect and bend the knees ?????????

4 Keep trunk erect and bend the knees For Patient 3, the flexion of the neck that brings the chin to rest on the chest should be 45 degrees. Flexion of only 10 degrees indicates disability in the pivotal joint. In Patient 1, the extension of the elbow to 90 degrees indicates normal function. In Patient 2, the wrist with the hand in slight dorsiflexion is a normal finding. In Patient 4, a slight flexion of the thumb in opposition to the fingers is a normal finding.

The nurse is assessing a patient for the movement of the hip ball and socket joint. Which range-of-motion (ROM) exercise should the nurse ask the patient to perform to assess adduction? 1 Move the leg forward and up. 2 Move the leg behind the other leg. 3 Move the leg laterally away from body. 4 Move the leg back toward the medial position

4 Move the leg back toward the medial position. The nurse should ask the patient to move the leg back toward the medial position and beyond if possible to assess adduction in the hip joint. To assess flexion in the hip joint, the leg should be moved forward and up. To assess extension in the hip joint, the leg should be moved behind the other leg. To assess abduction in the hip joint, the leg should be moved laterally away from the body.

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

4 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? 1 Osteosarcoma 2 Osteoclastoma 3 Osteomyelitis 4 Osteoporosis

4 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.

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? Select all that apply. 1 Patient A 2 Patient B 3 Patient C 4 Patient D

4 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 assisting a patient in the supported supine position. Which nursing action should the nurse implement to reduce the rotation of the hip? 1 Placing pillows under the upper shoulders 2 Placing pillows under the pronated forearms 3 Placing small rolled towel under the lumbar area of back 4 Placing trochanter rolls parallel to the lateral surface of the thighs

4 Placing trochanter rolls parallel to the lateral surface of the thighs While positioning the patient in the supine position, the nurse should place trochanter rolls or sandbags parallel to the lateral surface of the patient's thighs if the patient is immobile. Placing pillows under the upper shoulders, neck, or head helps in maintaining the correct body alignment and prevents flexion contractures of the cervical spine. 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 a small rolled towel under the lumbar area of the back provides support to the lumbar region.

An older adult who was in a car accident and fractured the femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time? 1 Chronic pain 2 Impaired skin condition 3 Risk for ineffective cerebral tissue bloodflow 4 Risk for inability to tolerate activity

4 Risk for inability to tolerate activity Patients on bed rest are at risk for inability to tolerate activity, which increases patients' risk for falling. The patient is in acute pain, not chronic pain. The patient could have some skin breakdown, but this is not relevant to getting the patient out of bed. The patient's cerebral tissue bloodflow is not an issue in this situation.

The nurse puts elastic stockings on a patient following major abdominal surgery. Why are elastic stockings used after a surgical procedure? 1 To prevent varicose veins 2 To prevent muscular atrophy 3 To ensure joint mobility and prevent contractures 4 To promote venous return to the hear

4 To promote venous return to the hear Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces the risk for deep vein thrombosis (DVT) formation in the lower extremities. The stockings are not used to prevent varicose veins, muscular atrophy, and contractures, or to promote joint mobility.

4 To promote venous return to the heart Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces the risk for deep vein thrombosis (DVT) formation in the lower extremities. The stockings are not used to prevent varicose veins, muscular atrophy, and contractures, or to promote joint mobility.

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

4 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.

Which positioning aid prevents external rotation of the hips when the patient is in the supine position? 1 Thin pillow 2 Thick pillow 3 Trapeze bar 4 Trochanter roll

4 Trochanter roll A trochanter roll prevents external rotation of the hips when a patient is in the supine position. A thin pillow or thick pillow would not be helpful for preventing the external rotation of the hips, but may lead to increased flexion when the appropriate pillow size is not taken. The trapeze bar allows the patient to raise the upper extremities to raise the trunk off the bed, which helps in decreasing the shearing action from sliding across or up and down the bed.

Osteosarcoma

a malignant tumor of bone in which there is a proliferation of osteoblasts.(a cell that secretes the matrix for bone formation.

Osteoporosis

a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D.

Immobility Chapter 28 part 1

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