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Chapter 28: Immobility
Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. A nurse is assessing body alignment. What is the nurse monitoring?
a. The relationship of one body part to another while in different positions
b. The coordinated efforts of the musculoskeletal and nervous systems
c. The force that occurs in a direction to oppose movement
d. The inability to move about freely
ANS: A
The terms body alignment and posture are similar and refer to the positioning of the joints,
tendons, ligaments, and muscles while standing, sitting, and lying. Body alignment means that
the individual’s center of gravity is stable. Body mechanics is a term used to describe the
coordinated efforts of the musculoskeletal and nervous systems. Friction is a force that occurs in
a direction to oppose movement. Immobility is the inability to move about freely.
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2. A nurse is providing range of motion to the shoulder and must perform external rotation.
Which action will the nurse take?
a. Moves patient’s arm in a full circle
b. Moves patient’s arm cross the body as far as possible
c. Moves patient’s arm behind body, keeping elbow straight
d. Moves patient’s arm until thumb is upward and lateral to head with elbow flexed
ANS: D
External rotation: With elbow flexed, move arm until thumb is upward and lateral to
head. Circumduction: Move arm in full circle (Circumduction is combination of all movements
of ball-and-socket joint.) Adduction: Lower arm sideways and across body as far as
possible. Hyperextension: Move arm behind body, keeping elbow straight.
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3. A nurse is providing passive range of motion (ROM) for a patient with impaired mobility.
Which technique will the nurse use for each movement?
a.
Each movement is repeated 5 times by the patient.
b.
Each movement is performed until the patient experiences pain.
c.
Each movement is completed quickly and smoothly by the nurse.
d. Each movement is moved just to the point of resistance by the nurse.
ANS: D
Passive ROM exercises are performed by the nurse. Carry out movements slowly and smoothly,
just to the point of resistance; ROM should not cause pain. Never force a joint beyond its
capacity. Each movement needs to be repeated 5 times during the session. The patient moves all
joints through ROM unassisted in active ROM.
4. A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient.
Which finding will indicate goal achievement for the nurse’s action?
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a.
Prevention of atelectasis
b.
Prevention of renal calculi
c.
Prevention of pressure ulcers
d.
Prevention of joint contractures
ANS: D
Goal achievement for passive ROM is prevention of joint contractures. Contractures develop in
joints not moved periodically through their full ROM. ROM exercises reduce the risk of
contractures. Researchers noted that prompt use of splinting with prescribed ROM exercises
reduced contractures and improved active range of joint motion in affected lower extremities.
Deep breathing and coughing and using an incentive spirometer will help prevent atelectasis.
Adequate hydration helps prevent renal calculi and urinary tract infections. Interventions aimed
at prevention of pressure ulcers include positioning, skin care, and the use of therapeutic devices
to relieve pressure.
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5. A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing
assistive personnel?
a.
Determining the level of comfort
b.
Changing the patient’s position
c.
Identifying immobility hazards
d.
Assessing circulation
ANS: B
The skill of moving and positioning patients in bed can be delegated to nursing assistive
personnel (NAP). The nurse is responsible for assessing the patient’s level of comfort and for
any hazards of immobility and assessing circulation.
6. A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment
will the nurse obtain to assess for this condition?
a.
Thermometer
b.
Elastic stockings
c.
Blood pressure cuff
d.
Sequential compression devices
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ANS: C
A blood pressure cuff is needed. Orthostatic hypotension is a drop of blood pressure greater than
20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure and symptoms of dizziness,
light-headedness, nausea, tachycardia, pallor, or fainting when the patient changes from the
supine to standing position. A thermometer is used to assess for fever. Elastic stockings and
sequential compression devices are used to prevent thrombus.
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7. The patient has been in bed for several days and needs to be ambulated. Which action will the
nurse take first?
a.
Maintain a narrow base of support.
b.
Dangle the patient at the bedside.
c.
Encourage isometric exercises.
d.
Suggest a high-calcium diet.
ANS: B
To prevent injury, nurses implement interventions that reduce or eliminate the effects of
orthostatic hypotension. Mobilize the patient as soon as the physical condition allows, even if
this only involves dangling at the bedside or moving to a chair. A wide base of support increases
balance. Isometric exercises (i.e., activities that involve muscle tension without muscle
shortening) have no beneficial effect on preventing orthostatic hypotension, but they improve
activity tolerance. A high-calcium diet can help with osteoporosis but can be detrimental in an
immobile patient.
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8. A nurse reviews an immobilized patient’s
laboratory results and discovers hypercalcemia.
Which condition will the nurse monitor for most closely in this patient?
a.
Hypostatic pneumonia
b.
Renal calculi
c.
Pressure ulcers
d.
Thrombus formation
ANS: B
Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters.
Immobilized patients are at risk for calculi because they frequently have hypercalcemia.
Hypercalcemia does not lead to hypostatic pneumonia, pressure ulcers, or thrombus formation.
Immobility is one cause of hypostatic pneumonia, which is inflammation of the lung from stasis
or pooling of secretions. A pressure ulcer is an impairment of the skin that results from
prolonged ischemia (decreased blood supply) within tissues. A thrombus is an accumulation of
platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of
a vein or artery, which sometimes occludes the lumen of the vessel.
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9. A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor
for in this patient?
a.
Increased appetite
b.
Increased diarrhea
c.
Increased metabolic rate
d.
Altered nutrient metabolism
ANS: D
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, leading to constipation.
10. A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect
will the nurse consider?
a.
Loss of bone mass
b.
Loss of strength
c.
Loss of weight
d.
Loss of hope
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ANS: D
Loss of hope is a psychosocial aspect. Patients with restricted mobility may have some
depression. Depression is an affective disorder characterized by exaggerated feelings of sadness,
melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion to reality.
All the rest are physiological aspects: bone mass, strength, and weight.
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11. The nurse is preparing to lift a patient. Which action will the nurse take first?
a.
Position a drawsheet under the patient.
b.
Assess weight and determine assistance needs.
c.
Delegate the task to a nursing assistive personnel.
d.
Attempt to manually lift the patient alone before asking for assistance.
ANS: B
When lifting, assess the weight you will lift, and determine the assistance you will need. The
nurse has to assess before positioning a drawsheet or delegating the task. Manual lifting is the
last resort, and it is used when the task at hand does not involve lifting most or all of the patient’s
weight; most facilities have a no-lift policy.
12. The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which
intervention will the nurse add to the care plan?
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a. Encourage the patient to perform as many self-care activities as possible.
b. Provide a complete bed bath to promote patient comfort.
c. Coordinate with occupational therapy for gait training.
d. Place the patient on bed rest to prevent fatigue.
ANS: A
Nurses should encourage the older-adult patient to perform as many self-care activities as
possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently
contribute to a patient’s immobility by providing unnecessary help with activities such as bathing
and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of
mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. After
a stroke or brain attack, a patient likely receives gait training from a physical therapist; speech
rehabilitation from a speech therapist; and help from an occupational therapist for ADLs such as
dressing, bathing and toileting, or household chores.
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13. The nurse is observing the way a patient walks. Which aspect is the nurse assessing?
a.
Activity tolerance
b.
Body alignment
c.
Range of motion
d.
Gait
ANS: D
Gait describes a particular manner or style of walking. Activity tolerance is the type and amount
of exercise or work that a person is able to perform. Body alignment refers to the position of the
joints, tendons, ligaments, and muscles while standing, sitting, and lying. Range of motion is the
maximum amount of movement available at a joint in one of the three planes of the body:
sagittal, frontal, or transverse.
14. A nurse is assessing the body alignment of a standing patient. Which finding will the nurse
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report as normal?
a. When observed laterally, the spinal curves align in a reversed “S” pattern.
b. When observed posteriorly, the hips and shoulders form an “S” pattern.
c. The arms should be crossed over the chest or in the lap.
d. The feet should be close together with toes pointed out.
ANS: A
When the patient is observed laterally, the head is erect and the spinal curves are aligned in a
reversed “S” pattern. When observed posteriorly, the shoulders and hips are straight and parallel.
The arms hang comfortably at the sides. The feet are slightly apart to achieve a base of support,
and the toes are pointed forward.
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15. The nurse is evaluating the body alignment of a patient in the sitting position. Which
observation by the nurse will indicate a normal finding?
a.
The edge of the seat is in contact with the popliteal space.
b.
Both feet are supported on the floor with ankles flexed.
c.
The body weight is directly on the buttocks only.
d.
The arms hang comfortably at the sides.
ANS: B
Both feet are supported on the floor, and the ankles are comfortably flexed. Body weight is
evenly distributed on the buttocks and thighs. A 1- to 2-inch space is maintained between the
edge of the seat and the popliteal space on the posterior surface of the knee to ensure that no
pressure is placed on the popliteal artery or nerve. The patient’s forearms are supported on the
armrest, in the lap, or on a table in front of the chair.
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16. The nurse is assessing body alignment
for a patient who is immobilized. Which patient
position will the nurse use?
a.
Supine position
b.
Lateral position
c.
Lateral position with positioning supports
d.
Supine position with no pillow under the patient’s head
ANS: B
Assess body alignment for a patient who is immobilized or bedridden with the patient in the
lateral position, not supine. Remove all positioning supports from the bed except for the pillow
under the head, and support the body with an adequate mattress.
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17. The nurse is assessing the patient for respiratory complications of immobility. Which action
will the nurse take when assessing the respiratory system?
a.
Inspect chest wall movements primarily during the expiratory cycle.
b.
Auscultate the entire lung region to assess lung sounds.
c.
Focus auscultation on the upper lung fields.
d.
Assess the patient at least every 4 hours.
ANS: B
Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes.
Perform a respiratory assessment at least every 2 hours for patients with restricted activity.
Inspect chest wall movements during the full inspiratory-expiratory cycle. Focus auscultation on
the dependent lung fields because pulmonary secretions tend to collect in these lower regions.
18. The nurse is assessing an immobile patient for deep vein thromboses (DVTs). Which action
will the nurse take?
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a.
Remove elastic stockings every 4 hours.
b.
Measure the calf circumference of both legs.
c.
Lightly rub the lower leg for redness and tenderness.
d.
Dorsiflex the foot while assessing for patient discomfort.
ANS: B
Measure bilateral calf circumference and record it daily as an assessment for DVT. Unilateral
increases in calf circumference are an early indication of thrombosis. Homan’s sign, or calf pain
on dorsiflexion of the foot, is no longer a reliable indicator in assessing for DVT, and it is present
in other conditions. Remove the patient’s elastic stockings and/or sequential compression devices
(SCDs) every 8 hours, and observe the calves for redness, warmth, and tenderness. Instruct the
family, patient, and all health care personnel not to massage the area because of the danger of
dislodging the thrombus.
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19. A nurse is assessing the skin of an immobilized patient. What will the nurse do?
a.
Assess the skin every 4 hours.
b.
Limit the amount of fluid intake.
c.
Use a standardized tool such as the Braden Scale.
d.
Have special times for inspection so as to not interrupt routine care.
ANS: C
Consistently use a standardized tool, such as the Braden Scale. This identifies patients with a
high risk for impaired skin integrity. Skin assessment can be as often as every hour. Limiting
fluids can lead to dehydration, increasing skin breakdown. Observe the skin often during routine
care.
20. The nurse is caring for an older-adult patient with a diagnosis of urinary tract infection (UTI).
Upon assessment the nurse finds the patient confused and agitated. How will the nurse interpret
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these assessment findings?
a.
These are normal signs of aging.
b.
These are early signs of dementia.
c.
These are purely psychological in origin.
d.
These are common manifestation with UTIs.
ANS: D
The primary symptom of compromised older patients with an acute urinary tract infection or
fever is confusion. Acute confusion in older adults is not normal; a thorough nursing assessment
is the priority. With the diagnosis of urinary tract infection, these are not early signs of dementia
and they are not purely psychological.
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21. A patient has damage to the cerebellum. Which disorder is most important for the nurse to
assess?
a.
Imbalance
b.
Hemiplegia
c.
Muscle sprain
d.
Lower extremity paralysis
ANS: A
Damage to the cerebellum causes problems with balance, and motor impairment is directly
related to the amount of destruction of the motor strip. A stroke can lead to hemiplegia. Direct
trauma to the musculoskeletal system results in bruises, contusions, sprains, and fractures. A
complete transection of the spinal cord can lead to lower extremity paralysis.
22. Which patient will cause the nurse to select a nursing diagnosis of Impaired physical
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mobilityfor a care plan?
a.
A patient who is completely immobile
b.
A patient who is not completely immobile
c.
A patient at risk for single-system involvement
d.
A patient who is at risk for multisystem problems
ANS: B
The diagnosis of Impaired physical mobility applies to the patient who has some limitation but is
not completely immobile. The diagnosis of Risk for disuse syndrome applies to the patient who is
immobile and at risk for multisystem problems because of inactivity. Beyond these diagnoses,
the list of potential diagnoses is extensive because immobility affects multiple body systems.
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23. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left
shoulder. Which priority action will the nurse take?
a.
Encourage the patient to do self-care.
b.
Keep the patient as mobile as possible.
c.
Encourage the patient to perform ROM.
d.
Assist the patient with comfort measures.
ANS: D
The diagnosis related to pain requires the nurse to assist the patient with comfort measures so
that the patient is then willing and more able to move. Pain must be controlled so the patient will
not be reluctant to initiate movement. The diagnosis related to reluctance to initiate movement
requires interventions aimed at keeping the patient as mobile as possible and encouraging the
patient to perform self-care and ROM.
24. A nurse is developing an individualized plan of care for a patient. Which action is important
for the nurse to take?
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a.
Establish goals that are measurable and realistic.
b.
Set goals that are a little beyond the capabilities of the patient.
c.
Use the nurse’s own judgment and not be swayed by family desires.
d.
Explain that without taking alignment risks, there can be no progress.
ANS: A
The nurse must develop an individualized plan of care for each nursing diagnosis and must set
goals that are individualized, realistic, and measurable. The nurse should set realistic
expectations for care and should include the patient and family when possible. The goals focus
on preventing problems or risks to body alignment and mobility.
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25. Which behavior indicates the nurse is using a team approach when caring for a patient who is
experiencing alterations in mobility?
a. Delegates assessment of lung sounds to nursing assistive personnel
b. Becomes solely responsible for modifying activities of daily living
c. Consults physical therapy for strengthening exercises in the extremities
d. Involves respiratory therapy for altered breathing from severe anxiety levels
ANS: C
The nurse should collaborate with other health care team members such as physical or
occupational therapists when considering mobility needs. For example, physical therapists are a
resource for planning ROM or strengthening exercises. Nurses often delegate some interventions
to nursing assistive personnel, but assessment of lung sounds is the nurse’s responsibility.
Nursing assistive personnel may turn and position patients, apply elastic stockings, help patients
use the incentive spirometer, etc. Occupational therapists are a resource for planning activities of
daily living that patients need to modify or relearn. A mental health advanced practice nurse or
psychologist should be used for severe anxiety.
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26. The patient is being admitted to the neurological unit with a diagnosis of stroke. When will
the nurse begin discharge planning?
a.
At the time of admission
b.
The day before the patient is to be discharged
c.
When outpatient therapy will no longer be needed
d.
As soon as the patient’s discharge destination is known
ANS: A
Discharge planning begins when a patient enters the health care system. In anticipation of the
patient’s discharge from an institution, the nurse makes appropriate referrals or consults a case
manager or a discharge planner to ensure that the patient’s needs are met at home. Referrals to
home care or outpatient therapy are often needed. Planning the day before discharge, when
outpatient therapy is no longer needed, and as soon as the discharge destination is known is too
late.
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27. Which goal is most appropriate for a patient who has had a total hip replacement?
a.
The patient will ambulate briskly on the treadmill by the time of discharge.
b. The patient will walk 100 feet using a walker by the time of discharge.
c.
The nurse will assist the patient to ambulate in the hall 2 times a day.
d.
The patient will ambulate by the time of discharge.
ANS: B
“The patient will walk 100 feet using a walker by the time of discharge” is individualized,
realistic, and measurable. “Ambulating briskly on a treadmill” is not realistic for this patient. The
option that focuses on the nurse, not the patient, is not a measurable goal; this is an intervention.
“The patient will ambulate by the time of discharge” is not measurable because it does not
specify the distance. Even though we can see that the patient will ambulate, this does not
quantify how far.
28. The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning
of patients. Which personal injury will the nurse most likely try to prevent?
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a.
Arm
b.
Hip
c.
Back
d.
Ankle
ANS: C
Back injuries are often the direct result of improper lifting and bending. The most common back
injury is strain on the lumbar muscle group. While arm, hip, and ankle can occur, they are not as
common as back.
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29. A nurse is caring for a patient with osteoporosis and lactose intolerance. What will the nurse
do?
a.
Encourage dairy products.
b.
Monitor intake of vitamin D.
c.
Increase intake of caffeinated drinks.
d.
Try to do as much as possible for the patient.
ANS: B
Encourage patients at risk to be screened for osteoporosis and assess their diets for calcium and
vitamin D intake. Patients who have lactose intolerance need dietary teaching about alternative
sources of calcium. Caffeine should be decreased. The goal of the patient with osteoporosis is to
maintain independence with ADLs. Assistive ambulatory devices, adaptive clothing, and safety
bars help the patient maintain independence.
30. A nurse is providing care to a group NURSINGTB.COM
of patients. Which patient will the nurse see first?
A patient with a hip replacement on prolonged bed rest reporting chest pain and
a. dyspnea
b. A bedridden patient who has a reddened area on the buttocks who needs to be turned
c. A patient on bed rest who has renal calculi and needs to go to the bathroom
d. A patient after knee surgery who needs range of motion exercises
ANS: A
A patient on prolonged bed rest will be prone to deep vein thrombosis, which can lead to an
embolus. An embolus can travel through the circulatory system to the lungs and impair
circulation and oxygenation, resulting in tachycardia and shortness of breath. Venous emboli that
travel to the lungs are sometimes life threatening. While the patient with a reddened area needs
to be turned, a patient with renal calculi needing the restroom, and a patient needing range of
motion, these are not as life threatening as the chest pain and dyspnea.
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31. The patient is immobilized after undergoing hip replacement surgery. Which finding will
alert the nurse to monitor for hemorrhage in this patient?
a.
Thick, tenacious pulmonary secretions
b.
Low-molecular-weight heparin doses
c.
SCDs wrapped around the legs
d.
Elastic stockings (TED hose)
ANS: B
Heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of
deep vein thrombosis. Because bleeding is a potential side effect of these medications,
continually assess the patient for signs of bleeding. Pulmonary secretions that become thick and
tenacious are difficult to remove and are a sign of inadequate hydration or developing pneumonia
but not of bleeding. SCDs consist of sleeves or stockings made of fabric or plastic that are
wrapped around the leg and are secured with Velcro. They decrease venous stasis by increasing
venous return through the deep veins of the legs. They do not usually cause bleeding. Elastic
stockings also aid in maintaining external pressure on the muscles of the lower extremities and in
promoting venous return. They do not usually cause bleeding.
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32. The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse
helping. In which order will the nurses perform the steps, beginning with the first one?
1. Grasp the drawsheet firmly near the patient.
2. Move the patient and drawsheet to the desired position.
3. Position one nurse at each side of the bed.
4. Place the drawsheet under the patient from shoulder to thigh.
5. Place your feet apart with a forward-backward stance.
6. Flex knees and hips and on count of three shift weight from the front to back leg.
a.
1, 4, 5, 6, 3, 2
b.
4, 1, 3, 5, 6, 2
c.
3, 4, 1, 5, 6, 2
d.
5, 6, 3, 1, 4, 2
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ANS: C
Assisting a patient up in bed with a drawsheet (two or three nurses): (1) Place the patient supine
with the head of the bed flat. A nurse stands on each side of the bed. (2) Remove the pillow from
under the patient’s head and shoulders and place it at the head of the bed. (3) Turn the patient
side to side to place the drawsheet under the patient, extending it from shoulders to thighs. (4)
Return the patient to the supine position. (5) Fanfold the drawsheet on both sides, with each
nurse grasping firmly near the patient. (6) Nurses place their feet apart with a forward-backward
stance. Nurses should flex knees and hips. On the count of three, nurses should shift their weight
from front to back leg and move the patient and drawsheet to the desired position in the bed.
33. The nurse is caring for a patient who needs to be placed in the prone position. Which action
will the nurse take?
a.
Place pillow under the patient’s abdomen after turning.
b.
Turn head toward one side with large, soft pillow.
c.
Position legs flat against bed.
d.
Raise head of bed to 45 degrees.
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ANS: A
Placing a pillow under the patient’s abdomen after turning decreases hyperextension of lumbar
vertebrae and strain on lower back; breathing may also be enhanced. Head is turned toward one
side with a small pillow to reduce flexion or hyperextension of cervical vertebrae. Legs should
be supported with pillows to elevate toes and prevent footdrop. Forty-five degrees is the position
for Fowler’s position; prone is on the stomach.
34. The nurse is caring for a patient with a spinal cord injury and notices that the patient’s hips
have a tendency to rotate externally when the patient is supine. Which device will the nurse use
to help prevent injury secondary to this rotation?
a.
Hand rolls
b.
A trapeze bar
c.
A trochanter roll
d.
Hand-wrist splints
ANS: C
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A trochanter roll prevents external rotation of the hips when the patient is in a supine position.
Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. Hand-wrist
splints are individually molded for the patient to maintain proper alignment of the thumb and the
wrist. The trapeze bar is a triangular device that hangs down from a securely fastened overhead
bar that is attached to the bedframe. It allows the patient to pull with the upper extremities to
raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm
exercises.
35. The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to
make this procedure safe?
a.
Place the pillow under the patient’s head and shoulders.
b.
Do by self if the bed is in the flat position.
c.
Place the side rails in the up position.
d.
Use a friction-reducing device.
ANS: D
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patient move up in bed without help from other coworkers or without the aid of an assistive device (e.g., friction-reducing pad) is not
recommended and is not considered safe for the patient or the nurse. Remove the pillow from
under head and shoulders and place it at the head of the bed to prevent striking the patient’s head
against the head of the bed. When pulling a patient up in bed, the bed should be flat to gain
gravity assistance, and the side rails should be down.
36. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The
patient has poor lower extremity circulation, and the nurse is concerned about irritation of the
patient’s toes. Which device will the nurse use?
a.
Hand rolls
b.
A foot cradle
c.
A trapeze bar
d.
A trochanter roll
ANS: B
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A foot cradle may be used in patients with poor peripheral circulation as a means of reducing
pressure on the tips of a patient’s toes. A trochanter roll prevents external rotation of the hips
when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in
opposition to the fingers. The trapeze bar is a triangular device that hangs down from a securely
fastened overhead bar that is attached to the bedframe. It allows the patient to pull with the upper
extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to
perform upper arm exercises.
37. A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the
NAP to place the patient in the lateral position. Which finding by the nurse indicates a correct
outcome?
a.
Patient is lying on side.
b.
Patient is lying on back.
c.
Patient is lying semiprone.
d.
Patient is lying on abdomen.
ANS: A
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In the side-lying (or lateral) position the patient rests on the side with the major portion of body
weight on the dependent hip and shoulder. Patients in the supine position rest on their backs.
Sims’ position is semiprone. The patient in the prone position lies face or chest down on the
abdomen.
38. A nurse is evaluating care of an immobilized patient. Which action will the nurse take?
a. Focus on whether the interdisciplinary team is satisfied with the care.
b. Compare the patient’s actual outcomes with the outcomes in the care plan.
c. Involve primarily the patient’s family and health care team to determine goal achievement.
d. Use objective data solely in determining whether interventions have been successful.
ANS: B
From your perspective as the nurse, you are to evaluate outcomes and response to nursing care
and compare the patient’s actual outcomes with the outcomes selected during planning. Ask if
the patient’s expectations (subjective data) of care are being met, and use objective data to
determine the success of interventions. Just as it was important to include the patient during the
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assessment and planning phase of the care plan, it is essential to have the patient’s evaluation of
the plan of care, not just the patient’s family and health care team.
39. A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely
providing care?
a.
A patient with neck surgery
b.
A patient with hypostatic pneumonia
c.
A patient with a total knee replacement
d.
A patient with a Stage IV pressure ulcer
ANS: A
A nurse supervises and aids personnel when there is a health care provider’s order to logroll a
patient. Patients who have suffered from spinal cord injury or are recovering from neck, back, or
spinal surgery often need to keep the spinal column in straight alignment to prevent further
injury. Hypostatic pneumonia, total knee replacement, and Stage IV ulcers do not have to be
logrolled.
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40. The nurse is providing teaching to an immobilized patient with impaired skin integrity about
diet. Which diet will the nurse recommend?
a.
High protein, high calorie
b.
High carbohydrate, low fat
c.
High vitamin A, high vitamin E
d.
Fluid restricted, bland
ANS: A
Because the body needs protein to repair injured tissue and rebuild depleted protein stores, give
the immobilized patient a high-protein, high-calorie diet. A high-carbohydrate, low-fat diet is not
beneficial for an immobilized patient. Vitamins B and C are needed rather than A and E. Fluid
restriction can be detrimental to the immobilized patient; this can lead to dehydration. A bland
diet is not necessary for immobilized patients.
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41. The nurse is caring for a patient who has had a stroke causing total paralysis of the right side.
To help maintain joint function and minimize the disability from contractures, passive ROM will
be initiated. When should the nurse begin this therapy?
a.
After the acute phase of the disease has passed
b.
As soon as the ability to move is lost
c.
Once the patient enters the rehab unit
d.
When the patient requests it
ANS: B
Passive ROM exercises should begin as soon as the patient’s ability to move the extremity or
joint is lost. The nurse should not wait for the acute phase to end. It may be some time before the
patient enters the rehab unit or the patient requests it, and contractures could form by then.
42. The nurse is admitting a patient who has been diagnosed as having had a stroke. The health
care provider writes orders for “ROM as needed.” What should the nurse do next?
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a.
Restrict patient’s mobility as much as possible.
b.
Realize the patient is unable to move extremities.
c.
Move all the patient’s extremities.
d.
Further assess the patient.
ANS: D
Further assessment of the patient is needed to determine what the patient is able to perform.
Some patients are able to move some joints actively, whereas the nurse passively moves others.
With a weak patient, the nurse may have to support an extremity while the patient performs the
movement. In general, exercises need to be as active as health and mobility allow.
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43. A nurse is assessing pressure points in a patient placed in the Sims’ position. Which areas
will the nurse observe?
a.
Chin, elbow, hips
b.
Ileum, clavicle, knees
c.
Shoulder, anterior iliac spine, ankles
d.
Occipital region of the head, coccyx, heels
ANS: B
In the Sims’ position pressure points include the ileum, humerus, clavicle, knees, and ankles. The
lateral position pressure points include the ear, shoulder, anterior iliac spine, and ankles. The
prone position pressure points include the chin, elbows, female breasts, hips, knees, and toes.
Supine position pressure points include the occipital region of the head, vertebrae, coccyx,
elbows, and heels.
44. The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of
fixation of a fractured left hip. The patient’s nursing diagnosis is Impaired physical mobility
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related to musculoskeletal impairment from
surgery and pain with movement. The patient is able
to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which
nursing intervention is most appropriate for this patient?
a.
Obtain assistance and physically transfer the patient to the chair.
b. Assist with ambulation and measure how far the patient walks.
c.
Give pain medication after ambulation so the patient will have a clear mind.
d. Bring the patient to the cafeteria for group instruction on ambulation.
ANS: B
Assist with walking and measure how far the patient walks to quantify progress. The nurse
should allow the patient to do as much for self as possible. Therefore, the nurse should observe
the patient transferring from the bed to the chair using the walker and should provide assistance
as needed. The patient should be encouraged to use adequate pain medication to decrease the
effects of pain and to increase mobility. The patient should be instructed on safe transfer and
ambulation techniques in an environment with few distractions, not in the cafeteria.
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45. The patient has been diagnosed with a spinal cord injury and needs to be repositioned using
the logrolling technique. Which technique will the nurse use for logrolling?
a.
Use at least three people.
b.
Have the patient reach for the opposite side rail when turning.
c.
Move the top part of the patient’s torso and then the bottom part.
d.
Do not use pillows after turning.
ANS: A
At least three to four people are needed to perform this skill safely. Have the patient cross the
arms on the chest to prevent injury to the arms. Move the patient as one unit in a smooth,
continuous motion on the count of three. Gently lean the patient as a unit back toward pillows for
support.
MULTIPLE RESPONSE
1. Upon assessment a nurse discovers that a patient has erythema. Which actions will the nurse
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take? (Select all that apply.)
a.
Consult a dietitian.
b.
Increase fiber in the diet.
c.
Place on chest physiotherapy.
d.
Increase frequency of turning.
e.
Place on pressure-relieving mattress.
ANS: A, D, E
If skin shows areas of erythema and breakdown, increase the frequency of turning and
repositioning; place the turning schedule above the patient’s bed; implement other activities per
agency skin care policy or protocol (e.g., assess more frequently, consult dietitian, place patient
on pressure-relieving mattress). Increased fiber will help constipation. Chest physiotherapy is for
respiratory complications.
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2. The nurse is caring for a patient with impaired physical mobility. Which potential
complications will the nurse monitor for in this patient? (Select all that apply.)
a.
Footdrop
b.
Somnolence
c.
Hypostatic pneumonia
d.
Impaired skin integrity
e.
Increased socialization
ANS: A, C, D
Immobility leads to complications such as hypostatic pneumonia. Other possible complications
include footdrop and impaired skin integrity. Interruptions in the sleep-wake cycle and social
isolation are more common complications than somnolence or increased socialization.
3. The nurse is caring for a patient who has had a recent stroke and is paralyzed on the left side.
The patient has no respiratory or cardiac issues but cannot walk. The patient cannot button a shirt
and cannot feed self due to being left-handed
and becomes frustrated very easily. The patient has
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been eating very little and has lost 2 lbs. The patient asks the nurse, “How can I go home like
this? I’m not getting better.” Which health care team members will the nurse need to consult?
(Select all that apply.)
a.
Dietitian
b.
Physical therapist
c.
Respiratory therapist
d.
Cardiac rehabilitation therapist
e.
Occupational therapist
f.
Psychologist
ANS: A, B, E, F
Physical therapists are a resource for planning ROM or strengthening exercises, and occupational
therapists are a resource for planning ADLs that patients need to modify or relearn. Because of
the loss of 2 lbs and eating very little, a dietitian will also be helpful. Referral to a mental health
advanced practice nurse, a licensed social worker, or a physiologist to assist with coping or other
psychosocial issues is also wise. Because the patient exhibits good cardiac and respiratory
function, respiratory therapy and cardiac rehabilitation probably are not needed at this time.
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MATCHING
Upon assessment a nurse discovers postural abnormalities on several patients. Match the
abnormalities to the findings the nurse observed.
a.
Lateral-S- or C-shaped spinal column with vertebral rotation
b.
Legs curved inward so knees come together as person walks
c.
One or both legs bent outward at knee
d.
Inclining of head to affected side
e.
Exaggeration of anterior convex curve of lumbar spine
f.
Increased convexity in curvature of thoracic spine
1. Lordosis
2. Kyphosis
3. Scoliosis
4. Genu valgum
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5. Genu varum
6. Torticollis
1.ANS:E
2.ANS:F
3.ANS:A
4.ANS:B
5.ANS:C
6.ANS:D
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