47 mobility review questions

40 terms by nursecait11

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1. A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the client, the nurse is alert to a(n):
1. Increased blood pressure
2. Decreased heart rate
3. Increased urinary output
4. Decreased peristalsis

Decreased peristalsis

2. A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident (stroke). In planning care for this client, the nurse implements which one of the following as an appropriate intervention?
1. Encourage an even gait when walking in place.
2. Assess the extremities for unilateral swelling and muscle atrophy.
3. Encourage holding the breath frequently to hyperinflate the client's lungs.
4. Teach the use of a two-point crutch technique for ambulation.

Assess the extremities for unilateral swelling and muscle atrophy.

3. Two nurses are standing on opposite sides of the bed to move the client up in bed with a drawsheet. Where should the nurses be standing in relation to the client's body as they prepare for the move?
1. Even with the thorax
2. Even with the shoulders
3. Even with the hips
4. Even with the knees

Even with the shoulders

4. A client is leaving for surgery and because of preoperative sedation needs complete assistance to transfer from the bed to the stretcher. Which of the following should the nurse do first?
1. Elevate the head of the bed.
2. Explain the procedure to the client.
3. Place the client in the prone position.
4. Assess the situation for any potentially unsafe complications.

Assess the situation for any potentially unsafe complications.

5. A client has sequential compression stockings in place. The nurse evaluates that they are implemented appropriately by the new staff nurse when the:
1. Initial measurement is made around the client's calves
2. Intermittent pressure is set at 40 mm Hg
3. Stockings are wrapped directly over the leg from ankle to knee
4. Stockings are removed every hour during application

Intermittent pressure is set at 40 mm Hg

6. The nurse assesses that the client has torticollis and that this may adversely influence the client's mobility. This individual has a(n):
1. Exaggeration of the lumbar spine curvature
2. Increased convexity of the thoracic spine
3. Abnormal anteroposterior and lateral curvature of the spine
4. Contracture of the sternocleidomastoid muscle with a head incline

Contracture of the sternocleidomastoid muscle with a head incline

7. An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as:
1. Harsh crackles
2. Wheezing on inspiration
3. Diminished breath sounds
4. Bronchovesicular whooshing

Diminished breath sounds

8. The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to:
1. Measure the calf and thigh circumferences
2. Attempt to elicit Homans' sign
3. Palpate the temperature of the feet
4. Observe for a loss of hair and skin turgor in the lower legs

Measure the calf and thigh circumferences

9. A client is getting up for the first time after a period of bed rest. The nurse should first:
1. Assess respiratory function
2. Obtain a baseline blood pressure
3. Assist the client with sitting at the edge of the bed
4. Ask the client if he or she feels light-headed

Obtain a baseline blood pressure

10. To promote respiratory function in the immobilized client, the nurse should:
1. Change the client's position every 4 to 8 hours
2. Encourage deep breathing and coughing every hour
3. Use oxygen and nebulizer treatments regularly
4. Suction the client's secretions every hour

Encourage deep breathing and coughing every hour

11. Antiembolic stockings (thromboembolic device [TED] hose) are ordered for the client on bed rest following surgery. The nurse explains to the client that the primary purpose for the TEDs is to:
1. Keep the skin warm and dry
2. Prevent abnormal joint flexion
3. Apply external pressure
4. Prevent bleeding

Apply external pressure

12. To provide for the psychosocial needs of an immobilized client, an appropriate statement by the nurse is which of the following?
1. "The staff will limit your visitors so that you will not be bothered."
2. "A roommate can be a real bother. You'd probably rather have a private room."
3. "Let's discuss the routine to see if there are any changes we can make."
4. "I think you should have your hair done and put on some makeup."

"Let's discuss the routine to see if there are any changes we can make."

13. To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse should implement the use of a:
1. Footboard
2. Trochanter roll
3. Trapeze bar
4. Bed board

Trochanter roll

14. To reduce the chance of plantar flexion (footdrop) in a client on prolonged bed rest, the nurse should implement the use of:
1. Trapeze bars
2. High-top sneakers
3. Trochanter rolls
4. Thirty-degree lateral positioning

High-top sneakers

15. Which of the following is the most important to consider when assisting the client in passive range-of-motion exercises?
1. Flex the joint to the point of discomfort.
2. Work from the proximal joints to the distal joints.
3. Quickly work through the range of motion.
4. Support the distal joints while performing range-of-motion exercises.

Support the distal joints while performing range-of-motion exercises.

16. Which of the following clients is most at risk for losing his or her balance?
1. A woman who is 9 months pregnant walking down a flight of stairs
2. A 16-year-old skate boarding down a 15-degree slope
3. A 45-year-old taking hypertensive medication
4. A 4-year-old riding a tricycle

A woman who is 9 months pregnant walking down a flight of stairs

17. It has been determined that all of the following clients are at risk for falling. Which one requires the nurse's priority for ambulation?
1. A 16-year-old with a sprained ankle being discharged from the emergency department
2. A 54-year-old who has taken the initial dose of an antihypertensive medication
3. A 45-year-old postoperative client up for the first time since knee surgery
4. An 81-year-old who is asthmatic and had a hip replaced 18 months ago

A 45-year-old postoperative client up for the first time since knee surgery

18. Which of the following statements made by ancillary staff reflects the most informed knowledge regarding the benefit of having a client assist with his or her own activities of daily living (ADLs) to that client's activity tolerance?
1. "The more he does for himself, the more he will be able to do for himself."
2. "He doesn't like washing and dressing himself, but it makes him stronger."
3. "Doing for himself makes him tired, but in the long run he has more energy and strength when he does."
4. "By washing and dressing himself he is building muscle strength that lets him actually walk a little better."

"By washing and dressing himself he is building muscle strength that lets him actually walk a little better."

19. Which of the following statements regarding physical activity and its effect on activity tolerance made by a client shows the most informed knowledge regarding the connection between the two?
1. "I know I need to walk more if I want to get stronger."
2. "I don't like walking, but I do it because I know it will make me stronger."
3. "I try to walk a little farther each afternoon so I can dance at my grandson's wedding."
4. "I walk with my son three evenings a week because it's good for his weight and for my bones."

"I try to walk a little farther each afternoon so I can dance at my grandson's wedding."

20. A client recovering from hip surgery tells the nurse that she wants to get better so she can walk down the aisle to her seat at her granddaughter's wedding. Which of the following nursing interventions will have the greatest impact on achieving that goal?
1. Informing physical therapists that the client has expressed that goal
2. Reminding the ancillary staff to offer to walk with the client after her bath
3. Regularly praising the client for the efforts she is making to reach her goal
4. Walking with the client to and from the dining room where she eats her meals

Walking with the client to and from the dining room where she eats her meals

21. An infant born via cesarean section because of a breech presentation is diagnosed with bilateral congenital hip dysplasia. The primary nursing intervention directed toward this diagnosis is:
1. Assessing the infant frequently to determine abduction of the thighs
2. Maintaining the infant in the position of continuous abduction of both hips
3. Educating the parents about the importance of positioning the infant so that the head of the femurs are in alignment with the hip sockets
4. Providing pain management so that the infant is comfortable in the therapeutic position required

Maintaining the infant in the position of continuous abduction of both hips

22. A 16-year-old had a full leg cast for 4 months, and it is being removed today. Which of the following statements made by the client shows the most informed understanding of the effects of immobilization of a muscle on its strength and stamina?
1. "I'm hoping to be back at soccer practice in 3 weeks."
2. "Walking and riding my bike will help regain the muscle."
3. "I'll practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring."
4. "There was a good bit of muscle and strength loss, but I'll work at getting it back like it was before the break."

"I'll practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring."

23. A staff member experienced a shoulder injury while assisting with a client transfer. The nurse manager's most therapeutic response to this situation is to:
1. Thoroughly review the accident report filed by the injured personnel to determine the factors that contributed to the injury
2. Have a nonpunitive meeting with all the involved staff to discuss correcting the factors that resulted in the injury
3. Require that mechanical lifts be used in the transfer of all clients incapable of assisting with the transfer
4. Implement new policies and procedures to correct the factors that resulted in the injury

Have a nonpunitive meeting with all the involved staff to discuss correcting the factors that resulted in the injury

24. Which of the following statements made by a nurse caring for a client who experienced a myocardial infarction 8 hours ago shows the greatest insight as to the purpose for keeping the client on bed rest?
1. "This has been exhausting; she needs a period of uninterrupted rest."
2. "The pain she experienced is exhausting; it's imperative that she rest."
3. "Keeping her on bed rest decreases the need her body has for oxygen"
4. "She needs complete rest; she is really very ill, especially her heart."

"Keeping her on bed rest decreases the need her body has for oxygen"

25. The nurse recognizes that a client who is inactive is at a risk for decreased muscle mass as a result of increased muscle atrophy and:
1. Decrease metabolic rate
2. Catabolic tissue breakdown
3. Inactivity-induced depression
4. Anorexia caused by decreased peristalsis

Catabolic tissue breakdown

26. A 78-year-old inactive client diagnosed with acute renal failure is at risk for which of the following skeletal maladies?
1. Rickets
2. Osteomyelitis
3. Pathological fractures of long bones
4. Compression fractures of the spinal column

Pathological fractures of long bones

28. The nurse is providing ancillary personnel with instructions regarding the performance of passive range-of-motion (ROM) exercises for a client experiencing paralysis from the waist down (paraplegia) as a result of an automobile accident. Which of the following statements made by the ancillary personnel reflects the greatest insight regarding the frequency with which the intervention should be provided for this client?
1. "I will do a whole body range of motion as I complete her daily bath."
2. "Bath time, bedtime, after lunch, and at least once more; she can pick when."
3. "It works well with her bath and when she is being prepared for bed at night."
4. "I'll ask her when she wants me to exercise her joints in addition to bath time."

"Bath time, bedtime, after lunch, and at least once more; she can pick when."

29. The nurse is discussing joint mobility exercises with a client who experienced a stroke and now has left-sided weakness. Which of the following statements made by the client reflects the greatest insight regarding the best method for him to maintain mobility of the joints on his left side?
1. "My wife knows how to do those exercises for the joints on my left side."
2."Physical therapy really exercises my left side when I go there every afternoon."
3. "I'll remind the staff to exercise my left side when they come to help me with my bath and getting dressed."
4. "I will do those passive range of motion exercises you taught me to my left side at least 3 times a day."

"I will do those passive range of motion exercises you taught me to my left side at least 3 times a day."

30. The nurse caring for a 38-year-old female client with multiple fractures in the trauma intensive care unit knows that this client is at high risk for pulmonary complications such as atelectasis from her immobility. One of the interventions that the nurse can do to help prevent this from occurring is to:
1. Keep the PaO2 level at or above 94%
2. Instruct the client to deep breathe and cough every hour while awake
3. Turn the client every 2 hours
4. Keep the client on the ventilator as long as possible

Instruct the client to deep breathe and cough every hour while awake

31. The nurse is caring for a 48-year-old male client who was involved in a motor vehicle accident and had a fractured pelvis, a ruptured spleen, and multiple contusions. The client has been in the hospital for 5 days on bed rest. The nurse knows that this client is at risk for venous thrombus formation because of prolonged bed rest, potential damage to vessel walls during surgery, and the platelets he received in the trauma unit. These three factors are also known as:
1. Trigeminy
2. Virchow's triad
3. Trigone
4. Hutchinson's triad

Virchow's triad

32. The nurse caring for a 73-year-old female client who has been hospitalized with a stroke instructs the client's daughter to continue to do passive range-of-motion exercises with her mother on her affected side to prevent contractures. The nurse explains to the daughter that this is very important in an immobile older adult client because contractures can form in as little as:
1. 8 hours
2. 24 hours
3. 1 week
4. 1 month

8 hours

33. The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in an immobile client is to:
1. Keep the skin dry
2. Provide range of motion every shift
3. Use lift equipment when transferring a client
4. Turn the client a minimum of every 2 hours

Turn the client a minimum of every 2 hours

34. The nurse caring for a 78-year-old male client recovering from hip replacement surgery is assessing for signs of improvement of the client's activity tolerance. The nurse determined a baseline for ongoing assessments by:
1. Determining how much time it takes the client to recover from an activity
2. Assessing how much the client can do at one time
3. Determining the level of pain experienced by the client during the activity
4. Asking the client how much the client feels like doing

Determining how much time it takes the client to recover from an activity

35. The nurse and a nursing assistive personnel (NAP) are going to move an older adult client up in bed. Before moving the client, the nurse explains to the NAP that they will need to lift the client off the bed with an assistive device instead of using the drawsheet. The most important reason for using the assistive device is:
1. To avoid frightening the client
2. To avoid shearing the client's skin
3. To avoid getting "written up" for not following lift procedures
4. Because the nurse is tired

To avoid shearing the client's skin

36. The nurse understands that using metabolic functioning, measures of height, weight, and skinfold thickness, to evaluate muscle atrophy in an immobilized client is known as:
1. Anthropometric measurements
2. Anhydrous measurements
3. Balke test
4. Calorimetry

Anthropometric measurements

1. The nurse recognizes that facilitating correct body alignment for a dependent client may well result in which of the following positive client outcomes? (Select all that apply.)
1. A comfortable night's sleep
2. Minimized activity intolerance
3. Muscle tone that promotes ambulation
4. Reduction of falls caused by general weakness
5. Minimal strain placed on the spinal column
6. Increased socialization, resulting in peace of mind

1. A comfortable night's sleep
2. Minimized activity intolerance
3. Muscle tone that promotes ambulation
4. Reduction of falls caused by general weakness
5. Minimal strain placed on the spinal column

2. The nurse chooses to use a mechanical lift to move an obese immobile client. The nurse recognizes that the positive outcomes for both the client and the staff resulting from this intervention will be: (Select all that apply.)
1. Less of the client's body will be dragged along the sheets during the transfer
2. There will be less chance of injuring the skin on the client's elbows and buttocks
3. The staff involved in the transfer will have less likelihood of self-injury
4. The staff will have a greater degree of control over the move
5. The client will feel physically safer during the transfer
6. The move will be accomplished more quickly

1. Less of the client's body will be dragged along the sheets during the transfer
2. There will be less chance of injuring the skin on the client's elbows and buttocks
3. The staff involved in the transfer will have less likelihood of self-injury
4. The staff will have a greater degree of control over the move

3. A 16-year-old has had a full leg cast in place for 2 months, and it is being removed today. Which of the following assessment findings would be expected following the removal of the cast? (Select all that apply.)
1. Popliteal pulse equal in both legs
2. Slight footdrop noted on affected leg
3. Swelling noted at ankle on affected leg
4. Weight bearing less stable on affected leg
5. Calf circumference greater in unaffected leg
6. Greater range of motion of knee of unaffected leg

1. Popliteal pulse equal in both legs
4. Weight bearing less stable on affected leg
5. Calf circumference greater in unaffected leg
6. Greater range of motion of knee of unaffected leg

4. Which of the following factors has an impact on the severity of physical impairment a client will experience from a period of immobility? (Select all that apply.)
1. The client's age
2. Prior overall health
3. Length of immobility
4. The degree of immobility
5. Situation requiring the inactivity
6. Client's mental attitude about the limitations

1. The client's age
2. Prior overall health
3. Length of immobility
4. The degree of immobility

5. A client who experienced a myocardial infarction has been placed on bed rest. The nurse caring for the client recognizes that the inactivity will result in certain assessment findings that include: (Select all that apply.)
1. Lethargy
2. Confusion
3. Depression
4. Poor appetite
5. Hypoactive bowel sounds
6. Decrease in baseline respiratory rate

1. Lethargy
4. Poor appetite
5. Hypoactive bowel sounds
6. Decrease in baseline respiratory rate

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