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BSN 205 Mobility

Terms in this set (150)

Question 1 of 5
The nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer?
Four
Two
One
None
Two
Question 2 of 5
The nurse is preparing to move a patient from the bed to a stretcher. What will the nurse do first?
Cross the patient's arms over his or her chest.
Lower the side rails of the bed.
Make sure the bed brakes are locked.
Fanfold the draw sheet.
Make sure the bed brakes are locked.
Question 3 of 5
When turning a patient to place a slide board, where do the assistants stand?
At the side of the bed to which the patient will be turned
At the side of the bed from which the patient will be turned
At the head and foot of the bed
At the foot of the bed only
At the side of the bed to which the patient will be turned
Question 4 of 5
The nurse and his or her assistants are using a slide board to move a patient from the bed to a stretcher. The nurse, standing alone on the side of the bed opposite the stretcher, will perform which action during this move?
Hold the slide board stationary.
Pull the draw sheet.
Hold the patient's head stationary.
Lock the brakes on the stretcher.
Hold the slide board stationary.
Question 5 of 5
After moving a patient from the bed to a stretcher, the nurse raises the head of the stretcher. What will the nurse do next?
Lock the wheels on the stretcher.
Cover the patient with a blanket
Raise the side rails on the stretcher.
Unlock the wheels of the bed.
Raise the side rails on the stretcher.
Question 1 of 3
What bone is considered irregular?
Femur
Carpal
Skull
Vertebrae
Vertebrae
Vertebrae are considered irregular.
Question 2 of 3
Which component serves the purpose of connecting bone to cartilage?
Muscles
Tendons
Ligaments
Cartilage
Ligaments
Bones are connected to cartilage by ligaments.
Question 3 of 3
Which term is used to describe a slightly movable joint?
Patellar
Fibrous
Cartilaginous
Synovial
Cartilaginous
A cartilaginous joint is slightly movable.
Question 1 of 3
Posture and gait are controlled by which system?
Musculoskeletal
Nervous
Cardiovascular
Lymphatic
Nervous
The nervous system controls voluntary movement, posture, balance, and gait.
Question 2 of 3
The cerebellum and inner ear are responsible for what?
Balance
Posture
Voluntary movement
Gait
Balance
Balance depends on the inner ear and cerebellum.
Question 3 of 3
Match the component to the function.
Voluntary movement Regulated by the=cerebral cortex
Posture and gait=Controlled by the nervous system
Equilibrium=Dependent on the cerebellum and inner ear
...
Question 1 of 3
What are the primary responsibilities of the cardiopulmonary system?
Select all that apply.
Control posture and gait
Provide framework for movement
Circulate blood throughout the body
Supply tissues with oxygen nutrients
Provide essential fluid for cell function
Circulate blood throughout the body
The cardiopulmonary system circulates blood throughout the body.

Supply tissues with oxygen nutrients
The cardiopulmonary system supplies bones, muscles and tissues with oxygen.

Provide essential fluid for cell function
The cardiopulmonary system supplies fluids that are essential for normal cell function.
What will inadequate circulation and oxygenation impact?
Select all that apply.
Movement
Exercise
Proprioception
Equilibrium
Posture
Movement
Lack of adequate circulation and oxygenation will impact movement.

Exercise
Lack of adequate circulation and oxygenation will impact exercise.
Question 3 of 3
What is the result of significant decrease in circulation and oxygenation?
Increased mobility
Decreased nitrogen balance
Loss of range of motion
Increased exercise tolerance
Decreased nitrogen balance
A significant decrease in circulation and oxygenation compromises nitrogen balance
Question 1 of 15
The nurse is caring for a patient who has suffered multiple fractures after a motor vehicle accident. What assessment finding would be most critical?
Respiratory distress
Elevated heart rate
Pain
Decreased mobility
Respiratory distress
Respiratory distress following multiple fractures would be the most critical finding, particularly if there are rib fractures, as the ribs protect vital organs.
Question 2 of 15
Match the component to the function.
Tendons-Connect bone to muscle
Ligaments-Connect bone to cartilage
Cartilage-Cushion joints
Joints-Assist movement
...
Question 3 of 15
The nurse is caring for a patient in the emergency department. The health care provider has ordered antibiotics for a positive fluid specimen of the synovial joint. Which joint is infected?
Rib
Skull
Knee
Vertebrae
NOT SURE
Knee
The knee is considered a synovial or movable joint.
Question 4 of 15
Which mineral is stored in bone and assists with maintenance of phosphorous?
Potassium
Sodium
Chloride
Calcium
NOT SURE
Calcium
Calcium is stored in the bone and assists with maintenance of phosphorous.
Question 5 of 15
Which portion of the musculoskeletal system contains both flat bones and immobile joints?
Skull
Vertebrae
Rib cage
Femur
NOT SURE
Skull
The skull contains both flat bones and fibrous or immobile joints.
Question 6 of 15
A nurse is caring for a patient with nervous system impairment. What symptoms may be associated?
Select all that apply.
Poor balance
Circulatory stasis
Involuntary movement
Decreased muscle tone
Tissue ischemia
NOT SURE
Poor balance
Nervous system impairment may result in poor balance.
Involuntary movement
Nervous system disturbance may result in involuntary movements.
Question 7 of 15
A nurse is caring for a patient with complaints of balance problems. What could be the source of this abnormal finding?
Eye infection
Sinus infection
Inner ear infection
Tonsillitis is an infection
Inner ear infection
Balance depends on the cerebellum and inner ear.
Question 8 of 15
Electrical impulses from nerves to muscles are communicated by what?
Motor fibers
Neurotransmitters
Ligaments
Proprioceptors
NOT SURE
Neurotransmitters
Neurotransmitters communicate electrical impulses from nerves to muscles.
Question 9 of 15
The nurse is caring for a patient who is being treated for an inner ear infection. What is an expected assessment finding?
Headache
Visual disturbance
Numbness of fingers
Dizziness
NOT SURE
Dizziness
Equilibrium is related to the cerebellum and inner ear so an infection may cause the person to feel dizzy.
Question 10 of 15
Which complication associated with immobility affects the neurologic system?
Decreased physical exercise
Compromised cardiac function
Damage to the cerebrum of the brain
Chronic obstructive pulmonary disease
NOT SURE
Damage to the cerebrum of the brain
Damage to the cerebrum of the brain directly affects the ability to ambulate and control movement, and affects the neurologic system.
Question 11 of 15
The nurse is caring for a patient with cerebellar damage related to traumatic brain injury. What are expected side effects of this condition?
Select all that apply.
Uncoordinated movement
Poor balance
Ability to walk
Inability to remain upright
Unsteady gait
NOT SURE
Uncoordinated movement
Coordination is controlled by the cerebellum and damage would cause uncoordinated movement.

Poor balance
The cerebellum is responsible for equilibrium. Cerebellar damage would interfere with balance.

Inability to remain upright
Cerebellar damage may interfere with the body's ability to maintain posture.

Unsteady gait
Cerebellar damage may cause unsteady gait.
Question 12 of 15
A patient complains of feeling that the room is spinning when she turns her head to the side, even though she is in a prone position. What is the suspected source of this complaint?
Low blood sugar
Low heart rate
Inner ear fluid
Nasal congestion
NOT SURE
Inner ear fluid
Inner ear fluid would cause balance disturbance when the head is moved quickly
Question 13 of 15
The cardiopulmonary system is responsible for supplying the rest of the body with what?
Select all that apply.
Nutrients
Chemicals
Fluids
Neurotransmitters
Cartilage
Nutrients
The cardiopulmonary system supplies the body with oxygen and nutrients.

Chemicals
The cardiopulmonary system supplies the body with chemicals that are essential for normal cell function.

Fluids
The cardiopulmonary system supplies the body with fluids that are essential for normal cell function.
Question 14 of 15
A patient in the telemetry unit is preparing for discharge after suffering an acute myocardial infarction. What does the nurse tell the patient about his expected level of activity after discharge?
The patient should expect to resume all previous activity.
The patient should begin an aggressive physical fitness plan.
The patient should be on complete bed rest for two weeks.
The patient should expect that previous levels of activity will take time to rebuild.
NOT SURE
The patient should expect that previous levels of activity will take time to rebuild.
After an acute myocardial event, the patient cannot expect to resume all previous levels of activity because movement and exercise may be compromised.
Question 15 of 15
A male adult who previously enjoyed running 5-6 miles per day now complains of a "grinding" sensation in the knee when he runs. He states that this has been a gradual problem which seems to be increasing in frequency. What could be responsible for this problem?
Muscle
Tendon
Ligament
Cartilage
NOT SURE
Cartilage
Cartilage is within the joint to provide cushion. Lack of cartilage would create a "grinding" sensation as there is no cushion in the joint space.
Match the nursing diagnosis with the patient assessment.
Altered mobility secondary to stroke-Risk for Falls
Decreased peristalsis related to immobility-Constipation
Strict bed rest restriction-Impaired Skin Integrity
Evidence of shortness of breath and increased heart rate with activity-Activity Intolerance
...
Question 2 of 3
Omar collected both objective and subjective data about his patient Tyson. What other possible nursing diagnosis could be formulated from that data?
CASE STUDY DETAILS
Constipation
Impaired Skin Integrity
Social Isolation
Impaired Wheelchair Mobility
Impaired Wheelchair Mobility
Tyson requires assistance with mobility in the wheelchair and is not independent with its use therefore he has impaired wheelchair mobility.
Question 3 of 3
What must the nurse do before writing an appropriate nursing diagnosis?
Collaborate with a multidisciplinary team.
Assess the patient with both subjective and objective data.
Develop an effective care plan with measureable outcomes.
Review orders written by the doctor.
Assess the patient with both subjective and objective data.
Fully assessing a patient allows the nurse to examine the problems the patient is having and thereby formulate an appropriate nursing diagnosis.
Question 1 of 5
For the primary nurse taking care of a patient, what becomes the focus after patient-centered nursing diagnoses have been selected?
Planning
Assessment
Documentation
Evaluation
Planning
After selecting nursing diagnoses the primary nurse must determine which diagnosis has the highest priority and plan to address that problem first.
Question 2 of 5
To which other member of a multidisciplinary team would the primary nurse delegate the task of moving an immobile patient every two hours to maintain skin integrity?
Dietitian
Speech therapist
Unlicensed assistive personnel
Health care provider
NOT SURE
Unlicensed assistive personnel
Unlicensed assistive personnel provide hands-on care for patients as directed by the primary supervising nurse.
Question 3 of 5
What could a nurse plan as part of collaborative care related to movement and immobility of a new post-op total knee patient?
Patient's discharge
Patient's family coming to visit
Physical therapy consult
Pain management
NOT SURE
Physical therapy consult
The physical therapist would come and evaluate the patient so the nurse and therapist could work together to find the best patient-centered care plan to begin recovery.
Question 4 of 5
Creating nursing diagnoses related to movement and mobility helps the nurse with which of the following actions?
Charting effectively.
Planning patient-centered care.
Educating family about the patient's care.
Observing patient movement.
NOT SURE
Planning patient-centered care.
Nurses plan patient care based on assessments and the nursing diagnoses formulated from the assessments.
Question 5 of 5
What is the definition of activity intolerance?
Patient experiences limitation between two nearby surfaces.
Patient has shortness of breath and oxygen saturation below 90%.
Patient is at risk for deterioration of body systems.
Patient movement limited due to pain from a post-surgical site.
Patient has shortness of breath and oxygen saturation below 90%.
Shortness of breath and oxygen saturation below 90% demonstrates Activity Intolerance.
Question 1
The RN has just received a post-surgical hip patient from the PACU who is restricted to bed rest. The patient is lying supine in the bed and reports pain 8/10, for which the nurse medicates the patient with narcotic pain medication. What types of nursing diagnoses should the nurse assign based on this initial assessment?
Select all that apply.
Impaired Physical Mobility
At Risk for Constipation
Impaired Skin Integrity
Social Isolation
Impaired Ambulation
Impaired Physical Mobility
The patient is restricted to bed rest at this time so he or she is not at a baseline status of performing movement independently, and demonstrates pain with movement and limited range of motion.

At Risk for Constipation
The patient is receiving narcotic pain medication, which places the patient at high risk for constipation.

Impaired Skin Integrity
Impaired Skin Integrity is related to bed rest restriction.
Question 2 of 14
The nurse would assign which nursing diagnosis to a patient with an unsteady gait?
Impaired Bed Mobility
Impaired Ambulation
Impaired Wheelchair Mobility
Sedentary Lifestyle
Impaired Ambulation
Patients with Impaired Ambulation would have an unsteady gait.
Question 3 of 14
What nursing diagnosis would be directly related to the goal, "Patient will experience no falls during hospital stay"?
Impaired Physical Mobility
Imbalanced Nutrition
Risk for Falls
Activity Intolerance
NOT SURE
Risk for Falls
The staff monitors a patient who is at a high risk for falls closely, and a common goal for this type of patient would be to not experience a fall during the hospital stay.
Question 4 of 14
Miranda is a new patient on the orthopedic floor. She is currently on post-op day three from a total knee replacement. Physical therapy and nursing staff have been encouraging Miranda to walk frequently, but she is still rating her pain 7/10 with movement. Her nurse has written a care plan and reevaluated based on today's assessment. Which nursing diagnosis fits Miranda's current situation most accurately?
Imbalanced Nutrition
Constipation
Activity Intolerance
Impaired Mobility Related to Pain
Impaired Mobility Related to Pain
Miranda is experiencing pain, which is deterring her from progressing on her physical rehabilitation, which would increase her ability to move independently.
Question 5 of 14
Sarah is a post-op total hip replacement patient. She is receiving very good care by a team of professionals in the hospital. Ultimately, which provider is primarily responsible for this patient's care?
Chaplain
Her sister
Primary nurse
Health care provider
Primary nurse
The primary nurse assigned to this patient has ultimate responsibility for the coordination of care for this patient.
Question 6 of 14
Which professionals would be involved in the collaboration of care for a patient with decreased movement and immobility needs?
Select all that apply.
Dietitian
Physical therapist
Nurse
Unlicensed assistive personnel
Housekeeping
NOT SURE
Physical therapist
The physical therapist helps the patient in gaining strength and using correct positions to maximize recovery.
Nurse
The nurse works with the physical therapist and unlicensed assistive personnel to coordinate a care and rehabilitation schedule that maximizes the patient's recovery.
Unlicensed assistive personnel
Unlicensed assistive personnel provide hands-on bedside care moving the patient and assisting the patient with ADLs.
Question 7 of 14
Tom is being discharged from the hospital after a fall at home, and the nurse is providing education for Tom before he leaves. What reminders should the nurse include in his education?
Select all that apply.
The home should be free from clutter.
Make sure the windows are open.
Do not get up to walk right away if you are dizzy.
Make sure to maintain a nutritious diet.
Make sure to perform activities independently while recovering.
The home should be free from clutter.
Keeping the home free from clutter will decrease the risk of falling again at home.
Do not get up to walk right away if you are dizzy.
Making sure the patient understands the need to be steady on his feet and have a steady gait will decrease the risk of him falling at home.
Correct
Make sure to maintain a nutritious diet.
Maintaining a nutritious diet will ensure proper strength during recovery.
Question 8 of 14
The primary nurse is advocating for the patient. In order to properly evaluate and treat a nursing diagnosis of impaired mobility, the nurse would contact the provider and ask for which order?
Dietitian consults to evaluate nutritional needs.
Speech therapy consults to evaluate swallowing.
Physical therapy consults to evaluate and treat mobility.
Chaplain for spiritual guidance.
NOT SURE
Physical therapy consults to evaluate and treat mobility.
A physical therapist manages mobility and would be able to properly conduct an evaluation and then work with the nurse to come up with a patient-centered treatment plan.
Question 9 of 14
Bill was in a car accident over a week ago and is currently on life support. As one of his nursing diagnoses he has impaired physical mobility. To whom would the nurse most likely delegate care such as turning the patient every two hours to maintain skin integrity and range of motion?
Unlicensed assistive personnel
Speech therapist
Health care provider
Dietitian
...
Question 10 of 14
The nurse is just coming on shift and is getting the report on a bed-ridden patient. Upon entering the room, the nurse sees the patient in bed and family visiting. What type of movement and immobility nursing diagnosis could the nurse identify for this patient?
Pain
Constipation
Impaired Bed Mobility
Social Isolation
NOT SURE
Impaired Bed Mobility
Impaired Bed Mobility can be identified because the patient is unable to get out of the bed.
Question 11 of 14
A post-surgical patient has been out of bed once. The patient experienced increased heart rate and increased oxygen requirements. What nursing diagnosis would the primary nurse identify for this patient?
Social Isolation
Risk for Falls
Imbalanced Nutrition
Activity Intolerance
NOT SURE
Activity Intolerance
The patient is exhibiting signs of deconditioning as a result of bed rest after surgery, such as pulse rate above 100 with activity, increased oxygen requirements, and shortness of breath.
Question 12 of 14
The RN comes on shift and goes in to do primary assessment on the patient. The nurse assesses the patient with a history of multiple sclerosis lying in bed and notices a wheelchair at the bedside. The patient reports tiredness from physical therapy. Which nursing diagnoses could be identified from this assessment?
Select all that apply.
Impaired Physical Mobility
Impaired Skin Integrity
Pain
Activity Intolerance
Constipation
NOT SURE
Impaired Physical Mobility
The patient is restricted to the bed and requires assistance out of bed and with movement. The patient is also wheelchair-dependent when out of bed.
Impaired Skin Integrity
The patient is always in bed or in a wheelchair with constant pressure on the coccyx, and is therefore at risk for pressure ulcers
Question 13 of 14
Why is it important for the nurse to have nursing diagnoses when assessing patients for movement and immobility issues?
To plan, collaborate, and evaluate patient-centered care plans
To evaluate if their daily medications are effective
To educate families about the patients' care plans
To plan for patients' discharges
NOT SURE
To plan, collaborate, and evaluate patient-centered care plans
Nursing diagnoses related to movement and immobility help the nurse identify and determine measureable patient-centered goals, track the patient's progress, and adjust plans if needed.
Question 14 of 14
Which is an example of a goal with a measurable outcome for the nursing diagnosis Pain Related to Immobility?
Patient will be free from falls during hospital stay.
Patient will be pain-free during hospital stay.
Patient will tolerate a regular diet after surgery.
Patient will maintain a tolerable pain level of 2/10 during hospital stay.
Patient will maintain a tolerable pain level of 2/10 during hospital stay.
This goal has a measureable quantity (2/10) and can be tracked in the patient record. It can be audited for the duration of the hospital stay.
Question 1 of 3
Match the type of exercise with an example.
Isotonic-Walking
Isometric-Kegel exercises
Aerobic-Repeated stair-climbing
Anaerobic-Heavy weight-lifting
NOT SURE
...
Question 2 of 3
What ambulation aid provides a base of stability for patients with weakness or balance problems?
Select all that apply.
Walker
Crutches
Canes
Transfer belts
Knee walker
NOT SURE
Walker
A walker provides a base of stability for patients with weakness or balance problems, allowing the patient to lean heavily on the walker to avoid falls.
Canes
A cane provides a point of stability for patients with weakness or balance problems.
Question 3 of 3
When a patient is in the supine position, where should a pillow be placed?
Between the legs
Under the calves
Between the arms
Under the scapula
Under the calves
When a patient is in the supine position a pillow should be placed under the calves to alleviate pressure on the heels, preventing pressure ulcers.
When is the best time to teach deep-breathing techniques to a surgical patient?
The day after surgery.
Immediately after surgery.
Prior to surgery.
Either before or after surgery.
Prior to surgery.
The best time to teach deep breathing techniques is prior to surgery to maximize the patient's understanding while not impaired by the effects of medication.
Question 2 of 3
In which position should the patient be placed to perform coughing, deep-breathing, and incentive spirometry?
Right side-lying
Left side-lying
Supine
Upright
NOT SURE
Upright
The best position is upright as it allows for increased lung expansion by relieving pressure on the diaphragm and chest wall
Question 3 of 3
When instructing a patient on incentive spirometry, what is the last step of the procedure?
Perform 2 controlled coughs.
Exhale through pursed lips.
Exhale through the mouthpiece.
Take 2 deep breaths.
NOT SURE
Perform 2 controlled coughs.
After using the incentive spirometer the patient should be instructed to perform 2 controlled coughs.
Question 1 of 3
The risk for developing a deep vein thrombosis is highest in what part of body?
Upper extremities
Lower extremities
Pulmonary artery
Lungs
Lower extremities
The risk of developing a deep vein thrombosis is highest in the lower extremities, due to pooling of blood in the veins particularly in patients with limited mobility.
Question 2 of 3
What nursing action should be included in the plan of care for a patient with sequential compression devices?
Ensure the fit of the sleeves is tight.
Roll the sleeves inside out to apply them.
Monitor the patient's toes for impaired circulation.
Activate the heating function once a shift.
NOT SURE
Monitor the patient's toes for impaired circulation.
As sequential compression devices can impair circulation if too tight, it's important to check the patient's circulation to the toes.
Question 3 of 3
Which statement best describes the evidence supporting the use of antiembolism stockings and sequential compression devices (SCDs)?
Thigh-length stockings are a better prevention measure for deep vein thromboses than knee-length stockings.
A major reason SCDs do not prevent deep vein thromboses is that the devices often fail to function properly.
Thigh-length antiembolism stockings are more comfortable and cost less than knee-length stockings.
A major reason SCDs fail to prevent deep vein thromboses is improper use by the staff.
NOT SURE
A major reason SCDs fail to prevent deep vein thromboses is improper use by the staff.
Evidence show that improper staff use of SCDs is a major reason they fail to prevent deep vein thromboses.
Question 1 of 3
Patients who are on prolonged bed rest should be encouraged to make what dietary choices?
Include lean protein in their diet.
Eat two large meals a day.
Eat more polyunsaturated fats.
Include more fats in their diet.
Include lean protein in their diet.
Patients who are on prolonged bed rest should be encouraged to include lean protein in their diet.
Question 2 of 3
The Dietary Guidelines for Americans recommend that the daily intake of protein be________gram per kilogram of ideal body weight.
0.8
The Dietary Guidelines for Americans recommend that the daily intake of protein be 0.8 gram per kilogram of ideal body weight
Question 3 of 3
Increasing the fiber in a patient's diet helps prevent what problem?
Deep vein thrombosis
Loss of muscle mass
Constipation
Urinary stasis
Constipation
Increasing the fiber in a patient's diet helps prevent constipation.
Question 1 of 3
What intervention facilitates early identification of pressure ulcers?
Turn and reposition the patient frequently.
Maintain clean, dry, wrinkle free bed linens.
Ensure patient has adequate nutritional intake.
Assess the patient's skin with a skin assessment tool.
Assess the patient's skin with a skin assessment tool.
Using a skin assessment tool regularly can facilitate the early identification of the development of a pressure ulcer.
Question 2 of 3
Which intervention can be used to prevent heel pressure as well as keep the ankle and foot in proper alignment?
PRAFO boots
Foot boards
Splints
Heel protectors
PRAFO boots
Pressure-relief ankle-foot orthotic (PRAFO) boots can be used to prevent pressure on the heels.
Evidence demonstrates that patients should spend
_______hour(s) or less in a chair without pressure relief.
2
Evidence demonstrates that patients should spend 2 hours or less in a chair without pressure relief.
What nursing intervention can assist the patient with maintaining a normal sleep-wake cycle?
Encouraging contact with family and friends.
Providing a clock in the patient's room.
Opening the window blinds during the day.
Allowing access to the radio.
NOT SURE
Opening the window blinds during the day.
Opening the window blinds during the day can assist the patient with maintaining a normal sleep-wake cycle.
Question 2 of 3
A nursing care plan to promote the immobilized patient's involvement in his or her care includes what nursing action?
Encourage the patient to read a book.
Encourage family and friends to visit.
Offer spiritual support.
Explain all procedures to the patient.
Explain all procedures to the patient.
Explaining all procedures to the patient will promote the patient's involvement in his or her care, and help with coping
Question 3 of 3
Which is a physiological as well as psychological response to sleep pattern disturbance?
Immunosuppression
Depression
Pressure ulcers
Deep vein thrombosis
Immunosuppression
A physiologic response to sleep pattern disturbance is immunosuppression. Sleep naturally promotes the production of cytokines, which helps a person sleep and also helps with inflammation and infection. Sleep deprivation may decrease the production of cytokines.
Question 1 of 15
A nurse is discussing the advantages of exercise with a patient with limited mobility. What benefit should the nurse include in the discussion to help facilitate normal movement?
Exercise promotes muscle strength.
Exercise minimizes joint flexibility.
Exercise stimulates bone reabsorption.
Exercise improves mood.
NOT SURE
Exercise promotes muscle strength.
Exercise promotes muscle strength and helps prevent the negative impacts of immobility. This is the most important aspect to include in the discussion.
Question 2 of 15
A nurse is encouraging an immobile patient to turn in bed as a form of isotonic exercise. The patient asks how isotonic exercises work. What is the nurse's best response?
Isotonic exercises build power and body mass.
Isotonic exercises involve active movement with constant muscle contraction.
Isotonic exercises require tension and relaxation of muscles without joint movement.
Isotonic exercises require oxygen metabolism to produce energy.
NOT SURE
Isotonic exercises involve active movement with constant muscle contraction.
Isotonic exercises involve moving joints and muscles rhythmically and repetitively through their ranges of motion using low resistance.
Question 3 of 15
The nurse is working with a patient who has a history of falls and is displaying generalized weakness and requires some assistance with ambulation. The patient has not used an ambulation aid in the past. Which aid would be the best choice for the nurse to use with this patient at this time?
Gait belt
Cane
Walker
Crutches
NOT SURE
Gait belt
A gait belt provides a grasp point for caregivers to support ambulation of a patient with an unsteady gait or generalized weakness, and would be appropriate for use with this patient.
Question 4 of 15
A patient has a paralyzed right upper extremity and will be undergoing physical rehabilitation. What device would be appropriate to keep the wrist in a functional position?
Trochanter roll
Hand roll
Splint
Arm board
NOT SURE
Splint
A custom-made splint would be the most appropriate device to maintain long-term proper alignment of the hand and wrist.
Question 5 of 15
Following surgery to repair a fractured femur, a patient is asking for something to help with repositioning in bed. Which device would be the most appropriate for this patient?
Transfer board
Friction-reducing sheet
Mechanical lift
Trapeze bar
NOT SURE
Trapeze bar
A trapeze bar would allow the patient to assist with repositioning, as the patient can grasp the bar to pull his own weight up when repositioning.
Question 6 of 15
The health care team is discussing safe patient handling. A team member asks about available evidence on the subject. Which statement would most accurately reflect current available evidence on safe patient handling?
When moving patients, colleague assistance can reduce nurse injuries.
Proper body mechanics prevents injury during patient transfers.
Nurses should use assistive devices when lifting patients over 50 lbs.
The use of lift equipment has not be shown to reduce staff injuries.
NOT SURE
When moving patients, colleague assistance can reduce nurse injuries.
Maximizing assistance when moving patients in can drastically reduce transfer- or lift-related injuries to the staff.
Question 7 of 15
The nurse is teaching a patient coughing techniques. What instruction should be part of that education?
Take two deep breaths in and out to start.
Inhale through the nose as deeply as possible.
Inhale slowly through the mouthpiece of the spirometer.
Fully exhale between coughs.
NOT SURE
Take two deep breaths in and out to start.
Taking two deep breaths in and out is part of the instructions for teaching coughing techniques.
Question 8 of 15
A patient asks the nurse how often deep breathing exercises should be performed. What is the appropriate response from the nurse?
Perform 5 to 12 deep breaths in a row and repeat them every hour.
Perform 3 to 5 deep breaths in a row and repeat them 10 times per hour.
Perform 2 to 3 deep breaths in a row and repeat them every 2 hours.
Perform 10 deep breaths in a row and repeat them 5 times per hour.
NOT SURE
Perform 3 to 5 deep breaths in a row and repeat them 10 times per hour.Deep breathing exercises should be performed 3 to 5 times in a row and repeated 10 times per hour.
Incorrect
Question 9 of 15
A nurse is caring for a patient on bed rest. The patient does not wish to wear the sequential compression sleeves and asks the nurse why they are so important. What should the nurse say to the patient?
"You need to wear them because the practitioner ordered them."
"You don't have to wear them all the time, just when you are sleeping to prevent leg cramps."
"They help prevent blood clots in your legs, which puts you at risk for a pulmonary embolism."
"They prevent clots from traveling to your pulmonary artery, which is fatal."
NOT SURE
"They help prevent blood clots in your legs, which puts you at risk for a pulmonary embolism."
This is the correct statement. Sequential compression sleeves help prevent deep vein thromboses from forming in the legs and decrease the risk of a pulmonary embolism.
Question 10 of 15
A nurse is teaching a student nurse how to put on antiembolism stockings. Which action would indicate the student nurse understood the teaching?
The student nurse bunches up the stockings and pulls them up the patient's leg.
The student nurse makes sure the stockings are big enough to slip two fingers between the stocking and the leg.
The student nurse leaves wrinkles behind the patient's knee to allow the patient to bend the leg.
The student nurse checks the circulation in the patient's toes once the stockings have been applied.
NOT SURE
The student nurse checks the circulation in the patient's toes once the stockings have been applied.
The circulation in the patient's toes should be checked after the stockings are applied, and then routinely thereafter, to ensure the stockings are not constricting blood flow to the extremity.
Question 11 of 15
The nurse is caring for patient on prolonged bed rest who is refusing to eat. The patient states he has no appetite. What modification should the nurse make to the plan of care to address this issue?
Change the patient to a soft diet.
Offer the patient smaller, more frequent meals.
Call the practitioner and obtain an order for tube feedings.
Encourage the patient to include more whole grains with their meals.
NOT SURE
Offer the patient smaller, more frequent meals.Patients with a decreased appetite should be offered smaller, more frequent meals.
Question 12 of 15
A bedridden patient is refusing to drink any fluids because of the fear they will have to use the bedpan. What should the nurse say to the patient?
"I understand you don't like using the bedpan; however, if you don't drink anything, I will have to put an IV catheter in you."
"I understand you don't like using the bedpan; however, drinking fluids helps prevent urinary tract infections and constipation."
"I understand you don't like using the bedpan; however, drinking fluids is really important to prevent blood from pooling in your legs and clots from forming."
"I understand you don't like using the bedpan, so let's see if you can use a bedside commode."
NOT SURE
"I understand you don't like using the bedpan; however, drinking fluids helps prevent urinary tract infections and constipation."
Acknowledging the patient's dislike of the bedpan is important, and explaining why the fluid is necessary allows the patient to make a better informed decision about drinking the fluids.
Question 13 of 15
The nurse is caring for a comatose patient who is at high risk for skin breakdown. The practitioner orders PRAFO boots for the patient. The patient's spouse asks what a PRAFO boot is. What is an appropriate response from the nurse?
It is a tubular shaped boot made of foam used to cushion the heels.
It is a cloth-covered boot made of sheepskin used to prevent friction between the patient's heels and the bed sheets.
It is rigid aluminum-framed boot, lined with sheepskin, and used to prevent pressure on the heels.
It is a rigid aluminum-framed lower leg boot that keeps the knee, ankle, and foot in proper alignment.
NOT SURE
It is rigid aluminum-framed boot, lined with sheepskin, and used to prevent pressure on the heels.
A PRAFO boot is a rigid aluminum-framed boot, lined with sheepskin, and used to prevent pressure on the heels.
Question 14 of 15
A stuff nurse is interested in participating in a unit research study regarding the use of nursing interventions to decrease the patient's risk for impaired skin integrity. Based on the current review of the literature, which should be the focus of the research in the prevention of pressure ulceration?
Select all that apply.
Using transfer gait belts appropriately
Determining the most effective positions
Managing the use of transfer-assist devices
Teaching the proper use of positioning devices
Establishing protocol for the frequency of repositioning
NOT SURE
Determining the most effective positions
A review of the literature indicates the need to determine the most effective positions to decrease the patient risk for impaired skin integrity.
Establishing protocol for the frequency of repositioning
A review of the literature indicates the need for establishing protocols for the frequency of repositioning to decrease the patient risk for impaired skin integrity.
Question 15 of 15
The nurse initiates a variety of interventions to decrease a patient's stress level before undergoing a series of surgical procedures. The nurse knows this is important because stress places the patient at risk for which complication?
Delayed wound healing
Immobility
Pulmonary embolism
Pressure ulcers
NOT SURE
Delayed wound healing
The evidence indicates that stress places the patient at risk for infection and delayed wound healing.
Question 1 of 4
What happens to the musculoskeletal system when injury or disease occurs?
Select all that apply.
Increased lung capacity
Increased flexibility
Impaired mobility
Decreased capacity for exercise
Coordinated body movement
Impaired mobility
When injury or disease occurs to the musculoskeletal system, it can lead to impaired mobility.

Decreased capacity for exercise
When injury or disease occurs to the musculoskeletal system, it can lead to decreased capacity for exercise.
Question 2 of 4
Decreased physical exercise contributes to what symptoms?
Select all that apply.
Bone fragility
Deterioration
Loss of strength
Hypertonicity
Spasticity
NOT SURE
Bone fragility
Decreased physical exercise and lack of weight-bearing exercise contribute to bone fragility.

Deterioration
Decreased physical exercise and lack of weight-bearing exercise contribute to deterioration.

Loss of strength
Decreased physical exercise and lack of weight-bearing exercise contribute to loss of strength.
Match the risk factor with the musculoskeletal system condition.
Aging-Osteoporosis
Disease-Rheumatoid arthritis
Genetic disorders-Muscular dystrophy
Developmental disorders-Cerebral palsy
...
Question 4 of 4
Which musculoskeletal diseases are more prevalent in the older population?
Select all that apply.
Osteoporosis
Rheumatoid arthritis
Cerebral palsy
Muscular dystrophy
Osteoarthritis
NOT SURE
Osteoporosis
Osteoporosis is a disease in which bones deteriorate, and is a disease that is prevalent in the older adult population.
Osteoarthritis
Osteoarthritis causes cartilage breakdown, and is a disease that is prevalent in the older adult population.
What does paresis mean?
Impaired mobility and movement
Complete loss of movement
Weakness on one side of the body
Lower body paralysis
NOT SURE
Impaired mobility and movement
Impaired mobility and movement is paresis.
Question 2 of 4
What is paralysis of one side of the body known as?
Hemiparesis
Paraplegia
Hemiplegia
Ischemia
Hemiplegia
Hemiplegia is paralysis of one side of the body.
Question 3 of 4
Which of these conditions may result in right-sided hemiplegia?
Right-sided brain injury
Left-sided brain injury
Lower spinal cord trauma
Cervical spinal cord trauma
Left-sided brain injury
Left-sided brain injury results in right-sided hemiparesis or hemiplegia.
Question 4 of 4
What injury is associated with breathing difficulties?
Right-sided brain injury
Left-sided brain injury
Lower spinal cord trauma
Cervical spinal cord trauma
NOT SURE
Cervical spinal cord trauma
Quadriplegia and breathing difficulties are associated with cervical cord trauma.
Question 1 of 3
In which condition is the heart is unable to pump enough blood to meet the body's demand?
Heart failure
Peripheral vascular disease
Chronic obstructive pulmonary disease
Angina
NOT SURE
Heart failure
Heart failure is a complex condition in which the heart is unable to pump enough blood to meet the body's demand.
Question 2 of 3
Which disorders decrease the body's ability to deliver oxygen and nutrients to body organs?
Select all that apply.
Heart failure
Peripheral vascular disease
Chronic obstructive pulmonary disease
Diabetes mellitus
Renal failure
NOT SURE
Heart failure
Heart failure decreases the body's ability to deliver oxygen and nutrients to body organs and tissues.

Peripheral vascular disease
Peripheral vascular disease decreases the body's ability to deliver oxygen and nutrients to body organs and tissues.

Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease decreases the body's ability to deliver oxygen and nutrients to body organs and tissues.
Question 3 of 3
Which condition is related to venous stasis?
Heart failure
Peripheral vascular disease
Chronic obstructive pulmonary disease
Angina
NOT SURE
Peripheral vascular disease
Peripheral vascular disease is a disturbance in the venous system caused by stasis of blood.
Question 1 of 15
A nurse is caring for a patient with neurologic impairment. The health care provider has documented that the patient has lower extremity flaccidity. What does this mean?
Bone fragility
Muscle spasms
Lack of muscle tone
Joint inflammation
NOT SURE
...
Question 1 of 15
A nurse is caring for a patient with neurologic impairment. The health care provider has documented that the patient has lower extremity flaccidity. What does this mean?
Bone fragility
Muscle spasms
Lack of muscle tone
Joint inflammation
NOT SURE
Lack of muscle tone
Flaccidity is a lack of muscle tone.
Question 2 of 15
A nurse is caring for a patient with osteoporosis. In which type of patient is this condition most prevalent?
Adult African-American female
Adult male
Middle-age Caucasian
Older Asian female
Older Asian female
Osteoporosis is more prevalent in the older adult population and in Caucasian and Asian women.
Question 3 of 15
A patient asks the nurse what dietary supplements to take to reduce the chance of developing brittle bones later on in life. What is the best response by the nurse?
Select all that apply.
Vitamin C
Iron
Calcium
Vitamin E
Vitamin D
NOT SURE
Calcium
Calcium is important in the production and maintenance of bone tissue. Inadequate intake of calcium or impaired calcium metabolism increases bone fragility.

Vitamin D
Vitamin D is important for the development of bone and tissue formation because of its collaborative efforts with calcium.
Question 4 of 15
What nursing intervention would be most effective in preventing flaccidity in a hospitalized patient?
Early ambulation after surgery
Administering calcium with vitamin D
Coughing and deep breathing exercises
Referring the patient to occupational therapy
Early ambulation after surgery
Ambulation is the most effective intervention to promote maintenance of muscle tone and prevent flaccidity.
Question 5 of 15
The nurse is caring for an older female patient with recent stroke. In the shift report, the nurse learns that the patient has right-sided hemiparesis. What does this mean?
Impaired movement of the right side
No movement of the either side
No movement of the right side
Impaired movement of the left side
Impaired movement of the right side
Right-sided hemiparesis is impaired movement of the right side, and is a result of brain injury of the left side of the brain.
Question 6 of 15
The nurse is caring for a young adult male in the emergency department. The patient was involved in a motorcycle crash and is now unable to move any of his extremities. What is the expected documentation of this condition?
Ischemia
Hemiparesis
Paraplegia
Quadriplegia
NOT SURE
Quadriplegia
Quadriplegia is an inability to move all four extremities.
Question 7 of 15
The rehabilitation nurse is caring for a patient with loss of sensation to the lower extremities. What type of injury is related to this?
Ischemia
Head injury
Lower spinal cord trauma
Cervical spinal cord trauma
NOT SURE
Lower spinal cord trauma
Paraplegia and loss of sensation are most commonly associated with lower spinal cord trauma.
Question 8 of 15
The rehabilitation nurse is caring for a patient with a history of cerebrovascular accident. The MRI revealed that the injury occurred on the right side of the brain. What are the expected impairments?
Right-sided hemiparesis
Left-sided hemiparesis
Lower body paralysis
Inability to move all four extremities
NOT SURE
Left-sided hemiparesis
Right-sided brain injury would cause left-sided hemiparesis.
Question 9 of 15
The rehabilitation nurse is caring for a patient with inability to move all four extremities. What type of injury is related to this?
Ischemia
Head injury
Lower spinal cord trauma
Cervical spinal cord trauma
NOT SURE
Cervical spinal cord trauma
Question 10 of 15
A nurse is caring for a patient in the telemetry unit who is complaining of a recent decrease in her ability to perform activities of daily living (ADLS) and routine exercise. Which conditions are possible contributing factors?
Select all that apply.
Cerebrovascular accident
Heart failure
Peripheral vascular disease
COPD
Renal failure
NOT SURE
Heart failure
Heart failure can create a diminished capacity for exercise.

Peripheral vascular disease
Peripheral vascular disease can create a diminished capacity for exercise.

COPD
COPD can create a diminished capacity for exercise.
Question 11 of 15
A patient has been diagnosed with heart failure. He asks the nurse for clarification on which part of the heart is ineffective. The nurse teaches the patient that heart failure is related to what?
Impaired aorta
Impaired ventricle
Impaired atrium
Impaired arteries
NOT SURE
Impaired ventricle
Heart failure is caused by any heart condition that impairs the ventricle's ability to fill and expel blood.
Question 12 of 15
A nurse is providing patient education on the prevention of osteoporosis. Which important fact should the nurse include in the teaching care plan?
Calcium should be taken with vitamin D to increase calcium absorption.
African American women are more prone to developing osteoporosis than are Asian American women.
Increased phosphorus metabolism may lead to bone fragility.
Aerobic exercise is more advantageous than weight-bearing exercise in preventing osteoporosis.
NOT SURE
Calcium should be taken with vitamin D to increase calcium absorption.
Vitamin D is required for calcium metabolism.
Question 13 of 15
Which cardiopulmonary condition is caused by chronic airway inflammation?
COPD
HF
PVD
DM
NOT SURE
COPD
Question 14 of 15
An older adult male is on prolonged bedrest, related to lower extremity trauma. Which cardiopulmonary condition is a concern in this patient?
COPD
HF
PVD
DM
NOT SURE
PVD
PVD is a disturbance in the venous system caused by venous stasis, immobility, inflammation, and prolonged bedrest.
Question 15 of 15
The nurse is caring for a patient with PVD. Which nursing interventions are expected to be included in the plan of care?
Select all that apply.
Ambulation
Bedrest
Coughing and deep breathing exercises
Lower extremities elevated
Pursed lip breathing
NOT SURE
Lower extremities elevated
Pooling of blood further exacerbates PVD so the patient should have extremities elevated in the sitting position.
Question 1 of 3
What nursing activity starts the assessment of a patient's mobility?
Assessing the patient's sleep patterns
Asking the patient's family about the patient's activities
Asking the patient questions
Observing the patient
Observing the patient
Assessment of the patient's activity level starts with observing the patient.
Question 2 of 3
Which questions should the nurse ask to assess the effect of the patient's activity level on body systems?
Select all that apply.
What is the frequency of bowel movements?
Do you become short of breath when completing your activities of daily living?
Are you experiencing any pain with movement?
What is your appetite?
Do you have any environmental allergies?
What is the frequency of bowel movements?
Asking about the frequency of bowel movements assesses the effects of the patient's activity level on the gastrointestinal system.

Do you become short of breath when completing your activities of daily living?
Asking if the patient becomes short of breath assesses the effect of the patient's activity level on the cardiopulmonary system.

Are you experiencing any pain with movement?
Asking about pain on movement assess the effect of the patient's activity level on the musculoskeletal system.

What is your appetite?
Asking about appetite assesses the effects of the patient's activity level on nutritional intake, which affects all body systems.
Question 3 of 3
What is the main goal of focused questioning of the patient?
To develop a rapport with the patient
To detect alterations due to immobility
To obtain information for the practitioner
To determine the patient's normal activity level
To detect alterations due to immobility
The goal of focused questioning is to detect alterations due to immobility.
Which musculoskeletal conditions does immobility predispose a patient to developing?
Select all that apply.
Weakness
Decreased muscle tone
Decreased muscle mass
Increased bone mass
Decreased joint pain
Weakness
Immobility predisposes a patient to weakness due to inactivity.

Decreased muscle tone
Immobility predisposes a patient to decreased muscle tone, due to inactivity.

Decreased muscle mass
Immobility predisposes a patient to decreased muscle mass, due to inactivity.
Question 2 of 3
Lack of proper body alignment can lead to what condition?
Enhanced coordination
Decreased falls
Unsteady gait
Decreased pain
Unsteady gait
Lack of proper body alignment can lead to an unsteady gait.
Question 3 of 3
In what situation should passive range-of-motion exercises be stopped?
If resistance to movement is felt
If the patient is unable to participate
When joints move freely
When atrophy occurs
If resistance to movement is felt
Range-of-motion exercises are stopped when resistance to movement is experienced.
Question 1 of 3
Which nursing actions should take place immediately prior to ambulation of a patient who has been immobile to prevent injury to the patient?
Select all that apply.
Assess the patient for dizziness.
Perform passive range-of-motion exercises.
Assess the patient's ability to stand unassisted.
Dangle the patient's legs on the side of the bed.
Perform active range-of-motion exercises.
Assess the patient for dizziness.
Immediately prior to standing, the patient should be assessed for dizziness.
Assess the patient's ability to stand unassisted.
Immediately prior to standing, the patient should be assessed for the ability to stand unassisted.

Dangle the patient's legs on the side of the bed.
Immediately prior to standing, the patient's legs should be dangled on the side of the bed.
Question 2 of 3
What should the nurse look for in the patient who is having problems with equilibrium?
Inability to sleep
Inability to eat
Difficulties with balance
Stiff joints
Difficulties with balance
Problems with equilibrium affect the patient's ability to balance.
Question 3 of 3
The patient's difficulties with posture are magnified by problems in what part of the brain?
Cerebellum
Pituitary gland
Meninges
Occipital lobe
Cerebellum
Problems with posture are magnified in patients with cerebellar problems, as this part of the brain is responsible for maintaining equilibrium.
Question 1 of 3
Patients on bed rest are at risk for which problems?
Select all that apply.
Increased venous return
Decreased lung expansion
Decreased cardiac workload
Atelectasis
Pneumonia
NOT SURE
Increased venous return
Patients on bedrest are at risk for increased venous return, due to supine positioning.

Decreased lung expansion
Patients on bedrest are at risk for decreased lung expansion, due to pressure on the rib cage.

Atelectasis
Patients on bedrest are at risk for atelectasis, due to dependent positioning and limited lung expansion.

Pneumonia
Patients on bedrest are at risk for pneumonia, due to pooling of secretions in the lungs.
Question 2 of 3
What complication can develop as a result of circulatory stasis and weakened calf muscles?
Edema
Gait disturbances
Permanent plantar flexion
Deep vein thrombosis
Deep vein thrombosis
Circulatory stasis and weakened calf muscles can lead to the development of deep vein thrombosis.
Question 3 of 3
Patient reports shortness of breath and fatigue while performing activities of daily living are indicative of which problem?
Orthostatic hypotension
Deep vein thrombosis
Activity intolerance
Cerebellar problems
NOT SURE
Activity intolerance
Patient reports of shortness of breath and fatigue while performing activities of daily living are signs of activity intolerance.
Question 1 of 3
What nutritional alteration is associated with immobility?
Decreased basal metabolic rate
Positive nitrogen balance
Enhanced appetite
Increased serum albumin levels
Decreased basal metabolic rate
Immobility is associated with a decreased metabolic rate, due to a diminished activity level.
Question 2 of 3
What is the Subjective Global Assessment (SGA) tool used to predict?
Protein calorie needs
Nutrition-related complications
Optimal weight ranges
Body mass index
Nutrition-related complications
The SGA tool predicts nutrition-related complications.
Question 3 of 3
Nursing observations regarding a patient's nutritional needs include which items?
Select all that apply.
Food intake
Food preferences
Changes in weight
Hair analysis
Physical status
NOT SURE
Food intake
Nursing observations regarding a patient's nutritional needs include food intake.

Food preferences
Nursing observations regarding a patient's nutritional needs include food preferences.

Changes in weight
Nursing observations regarding a patient's nutritional needs include changes in weight.

Physical status
Nursing observations regarding a patient's nutritional needs include physical status.

Previous
Question 1 of 3
Inactivity, decreased appetite, and decreased fluid intake can lead to what problem with elimination?
Diarrhea
Urinary frequency
Urinary retention
Constipation
Constipation
Inactivity, decreased appetite, and decreased fluid intake leads to constipation.
Question 2 of 3
Which statements best describes a fecal impaction?
Slowdown of the gastrointestinal tract
Buildup of hardened feces in the lower intestine
Breakdown of muscle protein
Decrease in bowel movement frequency
Buildup of hardened feces in the lower intestine
A fecal impaction is best described as a buildup of hardened feces in the lower intestine.
Question 3 of 3
Monitoring the patient for urinary and gastrointestinal alterations related to immobility includes which observations?
Select all that apply.
Urinary frequency
Fluid intake
Food intake
Bowel frequency
Food allergies
NOT SURE
Urinary frequency
Monitoring for urinary and gastrointestinal alterations related to immobility includes urinary frequency. Assess concentration, odor, and frequency.

Fluid intake
Monitoring for urinary and gastrointestinal alterations related to immobility includes fluid intake. Assess I&O.

Food intake
Monitoring for urinary and gastrointestinal alterations related to immobility includes food intake. Assess intake of dietary fiber.

Bowel frequency
Monitoring for urinary and gastrointestinal alterations related to immobility includes bowel frequency to avoid potential fecal impaction.
Question 1 of 3
Skin that appears darkened or reddened is indicative of what problem?
Reactive hyperemia
Deep vein thrombosis
Tissue ischemia
Tissue blanching
Tissue ischemia
Skin that appears darkened or reddened is indicative of tissue ischemia.
Question 2 of 3
Tissue ischemia related to immobility can lead to the development of what problem?
Contractures
Muscle atrophy
Atelectasis
Pressure ulcers
Pressure ulcers
Tissue ischemia related to immobility can lead to the development of pressure ulcers.
Question 3 of 3
Which areas are at risk for the development of pressure ulcers in the immobile patient?
Select all that apply.
Buttocks
Chest
Coccyx
Heels
Elbows
NOT SURE
Buttocks
Areas at risk for pressure ulcers in the immobile patient include the buttocks, due to pressure when patient is lying in bed.

Coccyx
Areas at risk for pressure ulcers in the immobile patient include the coccyx, due to pressure and shear.

Heels
Areas at risk for pressure ulcers in the immobile patient include the heels, due pressure and friction.

Elbows
Areas at risk for pressure ulcers in the immobile patient include the elbows, due pressure and friction.
Question 1 of 3
What psychosocial alteration is a consequence of bed rest and manifests in the patient becoming lonely or depressed?
Feelings of isolation
Alteration in self-concept
Sensory deprivation
Anxiety
Feelings of isolation
Feelings of isolation are a consequence of bed rest and can manifest in the patient becoming lonely or depressed.
Question 2 of 3
What psychosocial condition is associated with the inability to interact with the environment?
Mood alterations
Alteration in self-concept
Sleep pattern disturbances
Dyssomnia
Alteration in self-concept
Alteration is self-conceptis associated with the inability to interact with the environment.
Question 3 of 3
Monitoring the patient for psychosocial alterations related to immobility includes observing for which changes?
Select all that apply.
Equilibrium
Rest patterns
Mood
Behavior
Sleep patterns
NOT SURE
Rest patterns
Monitoring the patient for psychosocial alterations related to immobility includes observing the patient for changes in rest patterns.

Mood
Monitoring the patient for psychosocial alterations related to immobility includes observing the patient for changes in mood.

Behavior
Monitoring the patient for psychosocial alterations related to immobility includes observing the patient for changes behavior.

Sleep patterns
Monitoring the patient for psychosocial alterations related to immobility includes observing the patient for changes in sleep patterns.
Question 1 of 15
The nurse is asking the patient about how far the patient walks each day. The patient asks the nurse why that information is important. What is the nurse's best response?
"Your practitioner asked me to obtain the information."
"It gives us information about your activity and agility."
"It helps us determine what you will be allowed to do while in the hospital."
"We need to make sure you can walk without assistance."
NOT SURE
"It gives us information about your activity and agility."
The question provides data about a patient's activity and agility.
Question 2 of 15
A patient who has been immobile at home for the last three months is admitted to the hospital. Which problems should the nurse anticipate finding when the patient is examined?
Select all that apply.
Atrophy of the muscles
Contractures
Pain with joint movement
Joint stiffness
Increased range-of-motion
NOT SURE
Atrophy of the muscles
The nurse should anticipate finding atrophy of the muscles as an effect of immobility on the musculoskeletal system.

Contractures
The nurse should anticipate finding contractures as an effect of immobility on the musculoskeletal system. Joint contracture can occur within hours of disuse.

Pain with joint movement
The nurse should anticipate finding pain with joint movement as an effect of immobility on the musculoskeletal system. Pain occurs from moving joints that have not been moved or are contractured.

Joint stiffness
The nurse should anticipate finding joint stiffness.
Question 3 of 15
The nurse is observing a patient ambulate around the room and notes the patient has an unsteady gait. What action should the nurse take next?
Initiate a fall prevention plan for the patient.
Place the patient on complete bed rest.
Start passive range-of-motion exercises twice a day.
Make sure the patient only ambulates with a walker.
NOT SURE
Initiate a fall prevention plan for the patient.
An unsteady gait places the patient at risk for falling, and the nurse should initiate fall preventions measures to ensure the patient's safety.
Question 4 of 15
The nurse is caring for a patient who has been in bed for several days after surgery. The nurse has orders to get the patient out of bed to a chair. What action should the nurse take first?
Stand the patient up with assistance.
Stand the patient up without assistance.
Allow the patient to dangle.
Transfer the patient with a slide board.
NOT SURE
Allow the patient to dangle.
The first action the nurse should take to get the patient out of bed is allow the patient to dangle.
Question 5 of 15
The nurse is caring for a patient with trauma to the cerebellum. What problem should the nurse anticipate when getting the patient out of bed?
Planter flexion contractures of both feet
Muscle atrophy and weakness of the arms
Pathologic bone fractures of the lower legs
Balance and stability issues
NOT SURE
Balance and stability issues
The nurse should anticipate balance and stability issues in the patient with cerebellar problems, as the cerebellum assists with equilibrium.
Question 6 of 15
An immobile patient had been admitted to the unit following a fall out of bed. The patient is coughing up thick secretions. What action should the nurse take next?
Encourage the patient to take deep breaths.
Assess the patient for signs of a deep vein thrombosis.
Notify the health care provider that the patient may have pneumonia.
Place the patient flat in bed.
Notify the health care provider that the patient may have pneumonia.
The nurse should notify the health provider that the patient may have pneumonia as a consequence of prolonged immobility, decreased lung expansion, and pooling of secretions in the lungs.
Question 7 of 15
A nurse is working with a student nurse who asks about orthostatic hypotension. The nurse responds that it occurs when the patient stands up and experiences a sudden change in vital signs. Which changes in vital signs are indicative of orthostatic hypotension?
Select all that apply.
Increase in heart rate of 10 beats/min
Drop in systolic blood pressure of 20 mm Hg
Increase in heart rate of 20 beats/min
Drop in systolic blood pressure of 10 mm Hg
Drop in diastolic pressure of 10 mm Hg
NOT SURE
Drop in systolic blood pressure of 20 mm Hg
A drop in systolic blood pressure of 20 mm Hg when a patient stands is classified as orthostatic hypotension.
Correct
Increase in heart rate of 20 beats/min
An increase in heart rate of 20 beats/min when a patient stands is classified as orthostatic hypotension.
Drop in diastolic pressure of 10 mm Hg
A drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as orthostatic hypotension.
Question 8 of 15
While performing an assessment, the nurse notes that a patient has developed redness, warmth, and swelling in the right lower leg. What complication does this place the patient risk for?
Pulmonary embolism
Pathologic bone fractures
Orthostatic hypotension
Joint damage
NOT SURE
Notify the health care provider that the patient may have pneumonia.
The nurse should notify the health provider that the patient may have pneumonia as a consequence of prolonged immobility, decreased lung expansion, and pooling of secretions in the lungs.
Question 9 of 15
While caring for an immobile patient, the nurse notes the patient has a poor appetite. What action should the nurse take to encourage the patient's nutritional intake?
Monitor the patient's serum albumin.
Assess the patient' nutritional intake.
Interview the patient for food preferences.
Weigh the patient at routine intervals.
NOT SURE
Interview the patient for food preferences.
The nurse should interview the patient for food preferences as this information can be used to adjust the patient's diet more to the patient likes.
Question 10 of 15
While talking about nutrition with a patient who has been on bed rest for several days, the patient states, "I am just not hungry. I don't understand it. I am always hungry." What is the nurse's best response to this statement?
"Don't worry about it, every patient gets that way in the hospital."
"You have been immobile for several days, which can decrease your basal metabolic rate and appetite."
"Your loss of appetite is unusual; I will let your practitioner know."
"Your lack of appetite is your body's way of telling you that bed rest interferes with your body's ability to digest food and not to eat too much."
NOT SURE
"You have been immobile for several days, which can decrease your basal metabolic rate and appetite."
Decreased activity decreases the body's basal metabolic rate (BMR) and appetite.
Question 11 of 15
A nurse is caring for a comatose patient and is concerned that the patient may develop a urinary tract infection. Which items should be included in the nurse's assessment?
Select all that apply.
Fluid intake and output
Peripheral pulses
Concentration and odor of urine
Urinary frequency
Serum albumin levels
NOT SURE
Concentration and odor of urine
Assessment of urinary elimination should include the concentration and odor of urine.
Correct
Urinary frequency
Assessment of urinary elimination should the frequency of urination.
Question 12 of 15
A patient on bed rest is concerned about developing constipation. What actions should the nurse take to prevent this from happening?
Increase the frequency of the patient's active range-of-motion exercises.
Decrease the patient's food intake and increase the patient's fluid intake.
Complete the Mini Nutritional Assessment tool on the patient.
Increase the patient's dietary fiber and fluid intake.
NOT SURE
.Increase the patient's dietary fiber and fluid intake.
The patient's dietary fiber and fluid intake should be increased to prevent constipation in the immobile patient.
Question 13 of 15
While caring for a comatose patient, a nurse asks a new graduate nurse what the Braden Scale is used for. Which response indicates that the new nurse understands the purpose of the Braden scale?
"It is an inexpensive tool that can predict nutrition-related complications."
"It is a standardized tool used to identify protein-energy malnutrition."
"It is a standardized tool used to identify patients at risk for pressure ulcers."
"It is a numerical scale that assists the patient with identifying his or her level of pain."
NOT SURE
"It is a standardized tool used to identify patients at risk for pressure ulcers."
The Braden Scale is a standardized tool used to identify patients at risk for pressure ulcers.
Question 14 of 15
The nurse is caring for an immobile patient who refuses to turn on his side and lays on his back most of the time. Due to the patient's position, the nurse is most concern that this behavior will contribute to the patient's development of what complication?
Edema
Constipation
Pressure ulcer
Deep vein thrombosis
NOT SURE
Pressure ulcer
A patient who lays most of the time on his or her back is at risk for developing pressure ulcers, due to pressure on the bony prominences.
Question 15 of 15
A nurse has been caring for a patient on bed rest for the last several days. The patient has been calm and cooperative. Today, however, the patient is angry and upset about being woken up every night. The nurse suspects the patient may be developing which problem?
Sensory deprivation
Sleep pattern disturbance
Feelings of isolation
Confusion
NOT SURE
Sleep pattern disturbance
The patient is probably developing sleep pattern disturbance, due to disruptions to the patient's sleep for care and treatments at night.
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