Question 1

The nurse is assessing body alignment for a patient who is immobilized.What must the nurse do?

Accepted Answer

For a patient who is immobilized or bedridden,body alignment is assessed with the patient in the lateral position,not supine.The nurse should remove all positioning support from the bed,except for the pillow under the patient's head.

Question 2

Immobilized patients frequently have hypercalcemia,which increases their risk for what?

Accepted Answer

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.Osteoporosis is caused by accelerated bone loss.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.

Question 3

A patient has been on prolonged bed rest,and the nurse is observing for signs associated with immobility.While assessing the patient,the nurse is alert to which of the following signs?

Accepted Answer

Immobility disrupts the normal functioning of the gastrointestinal system,which results in decreased appetite and slowed peristalsis.In the immobilized patient,circulating fluid volume decreases,blood pools in the lower extremities,and autonomic response decreases.These factors result in decreased venous return,followed by a decrease in cardiac output,which is reflected by a decline in blood pressure.Recumbency increases cardiac workload and results in an increased pulse rate.Fluid intake can diminish with immobility,and this,combined with other causes,such as fever,increases the risk of dehydration.Urinary output may decline on or about the fifth or sixth day after immobilization,and the urine is often highly concentrated.

Question 4

Patients on bed rest or otherwise immobile are at risk for what condition?

Accepted Answer

Immobility disrupts normal metabolic functioning: decreasing the metabolic rate;altering the metabolism of carbohydrates,fats,and proteins (nutritional function);causing fluid,electrolyte,and calcium imbalances;and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.

Question 5

When assessing the body alignment of a patient while he or she is standing,the nurse is aware of which of the following?

Accepted Answer

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.

Question 6

The nurse is caring for an older patient with the diagnosis of urinary tract infection (UTI).The patient is confused and agitated.It is important for the nurse to realize that confusion in older people is which of the following?

Accepted Answer

Acute confusion in older persons is not normal;a thorough nursing assessment is the priority.Abrupt changes in personality often have a physiological cause such as surgery,a medication reaction,a pulmonary embolus,or an acute infection.For example,the primary symptom of compromised older patients with an acute urinary tract infection or fever is confusion.Identifying confusion is an important component of the nurse's assessment.

Question 7

The nurse is caring for a patient who has suffered a stroke.As part of her ongoing care,what should the nurse do?

Accepted Answer

Nurses should encourage the 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.Anorexia and insufficient assistance with eating lead to malnutrition.

Question 8

The nurse is aware that patients who are immobile are at increased risk of developing deep vein thromboses (DVTs).Because of this,what action does the nurse take?

Accepted Answer

The nurse measures bilateral calf circumference and records it daily as an assessment for deep vein thrombosis (DVT).Homans's sign,or calf pain on dorsiflexion of the foot,should not be assessed in patients when a DVT is suspected;it is no longer considered a reliable indicator in assessing for DVT,and it is present in other conditions.The patient's elastic stockings or sequential compression devices,or both,should be removed every 8 hours and the calves observed for redness,warmth,and tenderness.Bilateral calf (not ankle)circumferences should be measured daily to detect unilateral increases that may be an early indication of thrombosis.

Question 9

The patient has sequential compression stockings in place.The nurse evaluates that the stockings have been implemented appropriately by the new staff nurse when the nurse observes what?

Accepted Answer

Inflation pressure averages 40 mm Hg.Initial measurement is made around the largest part of the patient's thigh.A protective stockinette is placed over the patient's leg.Then the stocking is wrapped around the leg,starting at the ankle,with the opening over the patella.Stockings are not removed every hour.For optimal results,sequential compression or intermittent pneumatic compression devices are used as soon as possible and maintained until the patient becomes fully ambulatory.The stockings should be removed periodically to assess the condition of the patient's skin.

Question 10

Immobility is a major risk factor for pressure ulcers.In caring for the patient who is immobilized,the nurse needs to be aware of which of the following?

Accepted Answer

Immobility is a major risk factor for pressure ulcers.Any break in the integrity of the skin is difficult to heal.Preventing a pressure ulcer is much less expensive than treating one;therefore,preventive nursing interventions are imperative.A 30-degree lateral position is recommended for patients at risk for pressure ulcers.Tissue metabolism depends on the supply of oxygen and nutrients to and the elimination of metabolic wastes from the blood.Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation.

Question 11

The patient with torticollis would exhibit

Accepted Answer

Torticollis is inclining of the head to the affected side,in which the sternocleidomastoid muscle is contracted.Lordosis is an exaggeration of the lumbar spine curvature.Kyphosis is an increased convexity in the curvature of the thoracic spine.Kyphoscoliosis is an abnormal anteroposterior and lateral curvature of the spine.

Question 12

A patient is admitted to the medical unit after a CVA.There is evidence of left-sided hemiparesis,and the nurse will be following up on range-of-motion (ROM)and other exercises performed in physiotherapy.Which of the following principles of ROM exercises does the nurse correctly teach the patient and family members?

Accepted Answer

While the patient is performing ROM exercises,support should be provided to the extremity.The joint should be flexed to the point of resistance,not to the point of discomfort.When performing ROM exercises,the patient should begin at distal joints and work toward proximal joints.Joints should be moved slowly through the ROM.Quick movement could cause injury.

Question 13

A 61-year-old patient recently had left-sided paralysis from a cerebrovascular accident (CVA;also known as stroke).In planning care for this patient,the nurse would do which of the following?

Accepted Answer

Because edema moves to dependent body regions,assessment of the immobilized patient should include observation of the sacrum,legs,and feet.Unilateral increases in calf diameter can be an early indication of thrombosis.The patient who has suffered a CVA with left-sided paralysis may not be capable of an even gait.Having the patient hold his or her breath frequently is not an appropriate nursing intervention.To prevent stasis of pulmonary secretions,the patient's position should be changed every 2 hours,and fluid intake should be increased to 2000 mL,if not contraindicated.The patient should deep breathe and cough every 1 to 2 hours to promote chest expansion.Two-point crutch technique would not be appropriate for the patient with left-sided paralysis.The patient would be more likely to ambulate safely with a walker or a cane.If crutches are used,the patient should use a three-point support.

Question 14

In caring for a patient who is immobile,what is important for the nurse to understand?

Accepted Answer

Many immobilized patients become depressed because of changes in role and self-concept.Every patient responds to immobility differently.Immobility or bed rest frequently affects coping and creates sleep-wake alterations because of changes in routine or in the environment.Because immobilization removes the patient from a daily routine,he or she has more time to worry about disability.Worrying quickly increases the patient's depression,causing withdrawal.Many withdrawn patients do not want to participate in their own care.

Question 15

The nurse is assessing the way the patient walks.The manner of walking is known as what?

Accepted Answer

The term 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 the person is 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.

Question 16

When a patient with impaired physical mobility is in the recumbent position,what angle of lateral position is recommended?

Accepted Answer

When a patient with impaired physical mobility is in the recumbent position,the 30-degree lateral position reduces pressure from the sacral area and reduces the risk of skin breakdown.For a patient in the recumbent position with impaired physical mobility,the correct angle for a patient in the recumbent position with impaired physical mobility is not 15,45,or 90 degrees.

Question 17

The nurse must assess the patient for hazards of immobility by performing a head-to-toe physical assessment.When the respiratory system is assessed,what should the nurse do?

Accepted Answer

The nurse auscultates the entire lung region to identify diminished breath sounds,crackles,or wheezes.A respiratory assessment is performed at least every 2 hours for patients with restricted activity.The nurse inspects chest wall movements during the full inspiratory-expiratory cycle.Auscultation is focused on the dependent lung fields because pulmonary secretions tend to collect in these lower regions.

Question 18

The nurse expects to maintain the patient's legs in abduction after total hip replacement surgery with the use of which of the following?

Accepted Answer

A wedge pillow is a triangular pillow made of heavy foam used to maintain the legs in abduction after total hip replacement surgery.A foot boot maintains feet in dorsiflexion.A trochanter roll prevents external rotation of the hips.Sandbags can be used to shape body contours and immobilize an extremity.

Question 19

The patient is getting up for the first time after a period of bed rest.What is the initial nursing action?

Accepted Answer

When getting a patient up for the first time after a period of bed rest,the nurse should document orthostatic changes.The nurse first obtains a baseline blood pressure.Assessing the patient's respiratory function is not the nurse's first intervention when getting a patient up for the first time after prolonged bed rest.After the nurse assesses the patient's blood pressure,the nurse can assist the patient to a sitting position at the side of the bed.After the patient is in the sitting position at the side of the bed,the nurse should ask the patient if he or she feels lightheaded.

Question 20

The nurse is evaluating the body alignment of a patient in the sitting position.In this position,how is the body aligned?

Accepted Answer

Both feet are supported on the floor,and the ankles are comfortably flexed.With patients of short stature,a footstool is used to ensure that the ankles are comfortably flexed.Body weight is evenly distributed on the buttocks and thighs.A 2.5- to 5.0-cm (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.

Quiz 45: Mobility and Immobility