Exam 12: Immobility

A patient complains that his "bottom" is sore.The nurse assesses the area and finds an open area on the sacrum that appears blistered.What action should the nurse implement?

What should the nurse instruct a patient in a wheelchair to do to decrease risk for pressure ulcers?

A nurse evaluates the effectiveness of the treatment for a stage III pressure ulcer as satisfactory when the bed of the ulcer is pink, indicating the presence of ______, which is an indicator of tissue perfusion.

A nurse is planning the care of a patient who is immobile.Why should the nurse consider this patient to be at risk for urinary tract infection?

A patient is complaining to the nurse that he feels the need to have a bowel movement but has not been able to defecate.He has had cramping and even a small amount of brown watery stool.What should the nurse recognize these symptoms as?

A nurse is talking with a patient who recently became paraplegic as a result of a cervical spinal cord injury.When some home equipment is discussed, the patient becomes angry and says, "I don't need to worry about any kind of home equipment." What is the best response by the nurse?

What action should the nurse implement when positioning an immobile patient?

A nurse is instructing a patient on performing isometric exercises.What instruction should the nurse include?

What should the nurse be aware is the best prevention of immobility-related disorders?

What is the classification of incontinence in older adults related to the inability to get to the bathroom in time?

What should a nurse document when assessing a new pressure ulcer? (Select all that apply.)

When bacteria are localized at the site of a stage III pressure ulcer, it is said to be ______.

The care plan of an older adult patient states that the patient should be monitored while in the bathroom because of a history of vasovagal reflex.What should the nurse assess with this patient?

What negative effects does immobilization have on the musculoskeletal system?

Which are characteristics of a stage I pressure ulcer? (Select all that apply.)

A patient in traction with a fractured hip is diagnosed with a stage I pressure ulcer.She asks the nurse how a pressure ulcer could occur after only 2 days of immobility.On what knowledge should the nurse base a response?

What therapeutic reasons exist that explain why a patient might become immobile? (Select all that apply.)

During the shift report, a nurse is told that a patient she will be caring for has a stage II pressure ulcer.What should the nurse expect to visualize during the dressing change?

The negative impact of immobilization on a patient depends on the duration, degree, and type of ______.

A nurse assesses a patient's risk for developing a pressure ulcer using the Norton scale.The patient's score is 18.What nursing action should be implemented?