Exam 21: Immobility

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.The nurse knows that she should assess for:

When planning the care of a patient who is immobile,the nurse should remember that the patient will be at risk for urinary tract infection because the:

The nurse takes into consideration that many therapeutic reasons exist that explain why a patient might become immobile,and these include:

The nurse takes into consideration that immobilization has negative effects on the musculoskeletal system such as:

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.The nurse's response is based on her knowledge that:

The nursing assistant is bathing a patient who has a stage I pressure ulcer on the right shoulder.The nurse reminds the nursing assistant that the tissue could become more damaged if she:

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

On a newly discovered pressure ulcer,the nurse should document which of the following?

The nurse is instructing a patient relative to the characteristics of a stage I pressure ulcer,which are:

When a bacteria is localized at the site of a Stage III pressure ulcer,it is said to be_____________.

The nurse assesses a patient's risk for developing a pressure ulcer using the Norton scale.The patient's score is 18.The nurse should:

The nurse instructing a patient on performing isometric exercises should instruct the patient to:

The nurse knows that the best prevention of immobility-related disorders is:

A discharge order for the patient with left-sided weakness after having a stroke is to teach the patient to perform range-of-motion exercises on the affected extremities.The patient asks why she needs to do range-of-motion exercises.The nurse's best response would be:

The nurse instructs a patient in a wheelchair that the risk for pressure ulcers can be diminished if the patient will:

The nurse takes into consideration that such emotions as worry,anxiety and depression can contribute to the common nutritional problem of ______.

The nurse is providing discharge instructions to the family of an older adult patient who is unable to get out of bed.The nurse should instruct the family that the most effective way to prevent urinary incontinence associated with immobility is to:

When the nurse's assessment reveals an area of erythema on an immobilized patient's sacrum,the first step should be to:

The 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.The nurse recognizes these symptoms as:

The nurse points out that the National Pressure Ulcer Advisory Panel prefers to refer to skin breakdown as: