Test Bank Immobility Potter et al.: Fundamentals of Nursing, 9th Edition,100% CORRECT, Exams of Nursing

Download Test Bank Immobility Potter et al.: Fundamentals of Nursing, 9th Edition,100% CORRECT and more Exams Nursing in PDF only on Docsity! Test Bank Immobility Potter et al.: 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. DIF: Understand (comprehension) REF: 407-408 OBJ: Discuss physiological and pathological influences on mobility. TOP: Assessment MSC: Basic Care and Comfort 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. DIF: Understand (comprehension) REF: 415 OBJ: Compare and contrast active and passive range-of- motion exercises. TOP: Implementation MSC: Basic Care and Comfort 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 b. Elastic stockings c. Blood pressure cuff d. Sequential compression devices 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. DIF: Apply (application) REF: 411 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Assessment MSC: Reduction of Risk Potential 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. DIF: Apply (application) REF: 424 OBJ: Describe interventions for improving or maintaining patients’ mobility. TOP: Implementation MSC: Basic Care and Comfort 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. DIF: Apply (application) REF: 411-412 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Assessment MSC: Physiological Adaptation 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. DIF: Apply (application) REF: 410 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Assessment MSC: Physiological Adaptation 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 ANS: D Loss of hope is a psychosocial aspect. Patients with restricted mobility may 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. DIF: Understand (comprehension) REF: 416 OBJ: Assess for correct and impaired body alignment and mobility. TOP: Assessment MSC: Basic Care and Comfort 14. A nurse is assessing the body alignment of a standing patient. Which finding will the nurse 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. DIF: Apply (application) REF: 417 OBJ: Assess for correct and impaired body alignment and mobility. TOP: Assessment MSC: Health Promotion and Maintenance 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. DIF: Apply (application) REF: 417 OBJ: Assess for correct and impaired body alignment and mobility. TOP: Assessment MSC: Health Promotion and Maintenance 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. 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. DIF: Apply (application) REF: 419 OBJ: Assess for correct and impaired body alignment and mobility. TOP: Implementation MSC: Basic Care and Comfort 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 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. DIF: Apply (application) REF: 419 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Assessment MSC: Physiological Adaptation 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. DIF: Apply (application) REF: 409 OBJ: Discuss physiological and pathological influences on mobility. TOP: Assessment MSC: Physiological Adaptation 22. Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobility for 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. DIF: Understand (comprehension) REF: 420 OBJ: Formulate appropriate nursing diagnoses for patients with impaired mobility. TOP: Diagnosis MSC: Management of Care 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. DIF: Understand (comprehension) REF: 420 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: Basic Care and Comfort 24. A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take? 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. 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. DIF: Analyze (analysis) REF: 421-422 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Planning MSC: Management of Care 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? 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. DIF: Understand (comprehension) REF: 421 OBJ: Describe interventions for improving or maintaining patients’ mobility. TOP: Planning MSC: Health Promotion and Maintenance 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. DIF: Apply (application) REF: 423 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: Health Promotion and Maintenance 30. A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea b. A bedridden patient who has a reddened area on the buttocks who needs to be b. 4, 1, 3, 5, 6, 2 c. 3, 4, 1, 5, 6, 2 d. 5, 6, 3, 1, 4, 2 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. DIF: Understand (comprehension) REF: 433 OBJ: Describe interventions for improving or maintaining patients’ mobility. TOP: Implementation MSC: Basic Care and Comfort 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. 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. DIF: Apply (application) REF: 436 OBJ: Describe interventions for improving or maintaining patients’ mobility. TOP: Implementation MSC: Basic Care and Comfort 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 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. DIF: Understand (comprehension) REF: 428 OBJ: Describe interventions for improving or maintaining patients’ mobility. TOP: Implementation MSC: Basic Care and Comfort 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 This is not a one-person task. Helping a patient move up in bed without help from other co- workers 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. DIF: Apply (application) REF: 433 OBJ: Describe interventions for improving or maintaining patients’ mobility. TOP: Implementation MSC: Basic Care and Comfort 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 maintaining mobility. TOP: Evaluation MSC: Management of Care 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. DIF: Understand (comprehension) REF: 437 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: Management of Care 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. DIF: Understand (comprehension) REF: 423 OBJ: Describe interventions for improving or maintaining patients’ mobility. TOP: Implementation MSC: Basic Care and Comfort 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. DIF: Understand (comprehension) REF: 430 OBJ: Compare and contrast active and passive range-of- motion exercises. TOP: Planning MSC: Basic Care and Comfort 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? 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. DIF: Analyze (analysis) REF: 413-414 | 428 | 431-432 | 438 OBJ: Develop individualized nursing care plans for patients with impaired mobility. TOP: Implementation MSC: Basic Care and Comfort 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. DIF: Apply (application) REF: 437 OBJ: Describe interventions for improving or maintaining patients’ mobility. TOP: Implementation MSC: Basic Care and Comfort MULTIPLE RESPONSE 1. Upon assessment a nurse discovers that a patient has erythema. Which actions will the nurse 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. DIF: Apply (application) REF: 438 OBJ: Describe interventions for improving or maintaining patients’ mobility. TOP: Implementation MSC: Reduction of Risk Potential 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. DIF: Understand (comprehension) REF: 410-411 | 419 OBJ: Identify changes in physiological and psychosocial function associated with immobility. TOP: Assessment MSC: Reduction of Risk Potential 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 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