Question 1

A young adult was involved in a motor vehicle accident and suffers from brain trauma.The patient has decrease mobility in all joints.The nurse should assess for which common,debilitating contracture?

Accepted Answer

One common and debilitating contracture is footdrop.When footdrop occurs,the foot is permanently in plantar flexion.Patients are no longer able to walk when this occurs.Lordosis is the exaggeration of the anterior convex curve of the lumbar spine caused by a congenital condition or a temporary condition such as pregnancy.Bowlegs (genu varum)is one or both legs bent outward at the knee,which is normal until 2 to 3 years of age and is caused by a congenital condition or rickets.Kyphosis is the increased convexity in curvature of thoracic spine for a congenital condition,rickets,osteoporosis,or tuberculosis of the spine.

Question 2

Immobilized patients often become depressed.A nurse can best combat this effect of immobilization by doing which of the following? (Select all that apply.)

Accepted Answer

Involve patients in their care whenever possible.For example,have the patient determine when the bed should be made.Some patients rest better during the night when fresh sheets are put on in the evening rather than in the morning.Keep hygiene and grooming articles within easy reach.Encourage patients to wear their glasses or artificial teeth and to shave or apply makeup.These are normal activities to enhance body image,thus improving the patient's outlook.If possible,place the patient in a room with others who are mobile and interactive.If a private room is required,ask staff members to visit throughout the shift to provide meaningful interaction.Limiting visitors is not beneficial.

Question 3

When completing the assessment of an immobilized patient,the most likely place for the nurse to assess edema includes which of the following? (Select all that apply.)

Accepted Answer

Because edema moves to dependent body regions as a result of gravity,assessment of the immobilized patient includes the sacrum,legs,and feet.Face and abdomen are not dependent areas.

Question 4

The patient was involved in a motor vehicle accident.The patient has a fractured right hip and is on bed rest.Because of the prolonged immobility the nurse is concerned about complications such as which of the following? (Select all that apply.)

Accepted Answer

Physiological outcomes from immobility include: decreased nutrients/fluids,decreased lung expansion,increased (not decreased)pooling of lung secretions,and increased disuse osteoporosis.Decreased (not increased)gastrointestinal motility occurs.

Question 5

A patient has decrease mobility in all joints.Because of the lack of mobility,the nurse expects the health care provider to order what medication to prevent venous thromboembolisms that will reduce the side effect of hemorrhage?

Accepted Answer

Newer low-molecular-weight (LMW)heparins such as ardeparin and enoxaparin are being prescribed in place of older forms of unfractionated heparin.The LMW heparins have a more predictable anticoagulant effect.Low-molecular-weight heparin compared with unfractionated heparin reduces the occurrence of major hemorrhage as a side effect.
Heparin is an anticoagulant that suppresses clot formation.This therapy requires a health care provider's order.Aspirin and oral anticoagulants increase the risk for hemorrhage.

Quiz 36: Immobility

A young adult was involved in a motor vehicle accident and suffers from brain trauma.The patient has decrease mobility in all joints.The nurse should assess for which common,debilitating contracture?

Immobilized patients often become depressed.A nurse can best combat this effect of immobilization by doing which of the following? (Select all that apply.)

When completing the assessment of an immobilized patient,the most likely place for the nurse to assess edema includes which of the following? (Select all that apply.)

The patient was involved in a motor vehicle accident.The patient has a fractured right hip and is on bed rest.Because of the prolonged immobility the nurse is concerned about complications such as which of the following? (Select all that apply.)

A patient has decrease mobility in all joints.Because of the lack of mobility,the nurse expects the health care provider to order what medication to prevent venous thromboembolisms that will reduce the side effect of hemorrhage?