Question 1

In applying for a job on a nursing unit that requires frequent patient positioning,the nurse should be aware that nurses

Accepted Answer

A)  Are at low risk for back injury. 
B)  Are especially at risk for high back injuries. 
C)  Should be aware of agency policies. 
D)  Should not need to use assistive devices. 
A)  Are at low risk for back injury. 
B)  Are especially at risk for high back injuries. 
C)  Should be aware of agency policies. 
D)  Should not need to use assistive devices. C

Question 2

The patient is being admitted to the neurological unit with the diagnosis of stroke.The nurse should begin discharge planning

Accepted Answer

A)  At the time of admission. 
B)  The day before the patient is to be discharged. 
C)  As soon as the patient's discharge destination is known. 
D)  When outpatient therapy will no longer be needed. 
A)  At the time of admission. 
B)  The day before the patient is to be discharged. 
C)  As soon as the patient's discharge destination is known. 
D)  When outpatient therapy will no longer be needed. A

Question 3

In caring for immobile patients,the nurse understands that back injuries occur

Accepted Answer

A)  Only when lifting patients. 
B)  Only when transferring patients. 
C)  Only when providing direct patient care. 
D)  With many clinical activities. 
A)  Only when lifting patients. 
B)  Only when transferring patients. 
C)  Only when providing direct patient care. 
D)  With many clinical activities. D

Question 4

When assessing the skin of an immobilized patient,the nurse should

Accepted Answer

A)  Assess the skin at least every 4 hours. 
B)  Use a standardized tool such as the Braden Scale. 
C)  Use nursing instinct instead of a standardized tool. 
D)  Have special times for inspection so as to not interrupt routine care. 
A)  Assess the skin at least every 4 hours. 
B)  Use a standardized tool such as the Braden Scale. 
C)  Use nursing instinct instead of a standardized tool. 
D)  Have special times for inspection so as to not interrupt routine care.

Question 5

Patients on bed rest or otherwise immobile are at risk for

Accepted Answer

A)  Increased metabolic rate. 
B)  Increased diarrhea (peristalsis). 
C)  Altered metabolic function. 
D)  Increased appetite. 
A)  Increased metabolic rate. 
B)  Increased diarrhea (peristalsis). 
C)  Altered metabolic function. 
D)  Increased appetite.

Question 6

The patient who is experiencing an alteration in mobility often has one or more nursing diagnoses.The nurse would use the diagnosis of Impaired physical mobility for a patient who is

Accepted Answer

A)  Not completely immobile. 
B)  Completely immobile. 
C)  At risk for multisystem problems. 
D)  At risk for single-system involvement. 
A)  Not completely immobile. 
B)  Completely immobile. 
C)  At risk for multisystem problems. 
D)  At risk for single-system involvement.

Question 7

The nurse is assessing body alignment for a patient who is immobilized.To do this,the nurse must

Accepted Answer

A)  Place the patient in the supine position. 
B)  Remove the pillow from under the patient's head. 
C)  Insert positioning supports to help the patient. 
D)  Place the patient in a lateral position. 
A)  Place the patient in the supine position. 
B)  Remove the pillow from under the patient's head. 
C)  Insert positioning supports to help the patient. 
D)  Place the patient in a lateral position.

Question 8

The nurse is caring for a patient who has been diagnosed with a stroke.As part of her ongoing care,the nurse should

Accepted Answer

A)  Encourage the patient to perform as many self-care activities as possible. 
B)  Provide a complete bed bath to promote patient comfort. 
C)  Place the patient on bed rest to prevent fatigue. 
D)  Understand that the patient will not eat owing to a decreased energy need. 
A)  Encourage the patient to perform as many self-care activities as possible. 
B)  Provide a complete bed bath to promote patient comfort. 
C)  Place the patient on bed rest to prevent fatigue. 
D)  Understand that the patient will not eat owing to a decreased energy need.

Question 9

The term body alignment refers to positioning of the joints,tendons,ligaments,and muscles while standing,sitting,and lying.A term that is similar to body alignment is

Accepted Answer

A)  Weight. 
B)  Posture. 
C)  Friction. 
D)  Body mechanics. 
A)  Weight. 
B)  Posture. 
C)  Friction. 
D)  Body mechanics.

Question 10

Muscles that attach to bones to provide the needed strength to move an object use which of the following to obtain their objective?

Accepted Answer

A)  Posture 
B)  Leverage 
C)  Isometric contraction 
D)  Muscle tone 
A)  Posture 
B)  Leverage 
C)  Isometric contraction 
D)  Muscle tone

Question 11

The nurse is assessing the way the patient walks.The manner of walking is known as the patient's

Accepted Answer

A)  Activity tolerance. 
B)  Body alignment. 
C)  Range of motion. 
D)  Gait. 
A)  Activity tolerance. 
B)  Body alignment. 
C)  Range of motion. 
D)  Gait.

Question 12

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder.This diagnosis means that the nurse should

Accepted Answer

A)  Encourage the patient to do self-care. 
B)  Keep the patient as mobile as possible. 
C)  Encourage the patient to perform ROM. 
D)  Assist the patient with comfort measures. 
A)  Encourage the patient to do self-care. 
B)  Keep the patient as mobile as possible. 
C)  Encourage the patient to perform ROM. 
D)  Assist the patient with comfort measures.

Question 13

The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair.The nurse opts to use a mechanical lift (Hoyer lift).The nurse understands that when this lift is used,the

Accepted Answer

A)  Straps need to be removed before lowering the patient to the chair. 
B)  Horseshoe-shaped base should be on the opposite side from the chair. 
C)  Longer straps hook to the bottom of the sling. 
D)  Short straps are hooked to the bottom of the sling. 
A)  Straps need to be removed before lowering the patient to the chair. 
B)  Horseshoe-shaped base should be on the opposite side from the chair. 
C)  Longer straps hook to the bottom of the sling. 
D)  Short straps are hooked to the bottom of the sling.

Question 14

Immobility is a major risk factor for pressure ulcers.In caring for the patient who is immobilized,the nurse needs to be aware that

Accepted Answer

A)  Breaks in skin integrity are easy to heal. 
B)  Preventing a pressure ulcer is more expensive than treating one. 
C)  Immobilized patients can develop skin breakdown within 3 hours. 
D)  Pressure ulcers are caused by a sudden influx of oxygen to the tissue. 
A)  Breaks in skin integrity are easy to heal. 
B)  Preventing a pressure ulcer is more expensive than treating one. 
C)  Immobilized patients can develop skin breakdown within 3 hours. 
D)  Pressure ulcers are caused by a sudden influx of oxygen to the tissue.

Question 15

The patient is immobilized after undergoing hip replacement surgery.Which of the following would place the patient at risk for hemorrhage?

Accepted Answer

A)  Thick, tenacious pulmonary secretions 
B)  Low-molecular-weight heparin doses to prevent DVT 
C)  SCDs wrapped around the legs to prevent DVT formation 
D)  Elastic stockings (TED hose) to promote venous return 
A)  Thick, tenacious pulmonary secretions 
B)  Low-molecular-weight heparin doses to prevent DVT 
C)  SCDs wrapped around the legs to prevent DVT formation 
D)  Elastic stockings (TED hose) to promote venous return

Question 16

The patient is admitted to a skilled care unit for rehabilitation 10 days after the surgical procedure of fixation of a fractured left hip and has a nursing diagnosis of Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement.The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair.Which of the following nursing interventions is most appropriate for this patient?

Accepted Answer

A)  Obtain assistance and physically transfer the patient to the chair. 
B)  Assist the patient with ambulation and measure how far she walks. 
C)  Withhold pain medication so that she can ambulate with a clear mind. 
D)  Bring the patient to the cafeteria for group instruction on ambulation. 
A)  Obtain assistance and physically transfer the patient to the chair. 
B)  Assist the patient with ambulation and measure how far she walks. 
C)  Withhold pain medication so that she can ambulate with a clear mind. 
D)  Bring the patient to the cafeteria for group instruction on ambulation.

Question 17

When preparing a plan of care for an immobilized patient,the nurse should

Accepted Answer

A)  Use established expected outcomes to evaluate the patient's response to care. 
B)  Display an air of professional superiority when interventions are not successful. 
C)  Never vary from interventions that have been successful for other patients. 
D)  Use objective data only in determining whether interventions have been successful. 
A)  Use established expected outcomes to evaluate the patient's response to care. 
B)  Display an air of professional superiority when interventions are not successful. 
C)  Never vary from interventions that have been successful for other patients. 
D)  Use objective data only in determining whether interventions have been successful.

Question 18

The nurse is caring for a patient who is immobile and needs to be turned every 2 hours.The patient has poor lower extremity circulation,and the nurse is concerned about irritation of the patient's toes.One strategy that the nurse could use is

Accepted Answer

A)  A foot cradle. 
B)  A trochanter roll. 
C)  The trapeze bar. 
D)  Hand rolls. 
A)  A foot cradle. 
B)  A trochanter roll. 
C)  The trapeze bar. 
D)  Hand rolls.

Question 19

In developing an individualized plan of care for a patient,it is important for the nurse to

Accepted Answer

A)  Set goals that are a little beyond the capabilities of the patient. 
B)  Use his or her judgment and not be swayed by family desires. 
C)  Establish goals that are measurable and realistic. 
D)  Explain that without taking alignment risks, there can be no progress. 
A)  Set goals that are a little beyond the capabilities of the patient. 
B)  Use his or her judgment and not be swayed by family desires. 
C)  Establish goals that are measurable and realistic. 
D)  Explain that without taking alignment risks, there can be no progress.

Question 20

In caring for a patient who is immobile,it is important for the nurse to understand that

Accepted Answer

A)  The effects of immobility are the same for everyone. 
B)  Immobility helps maintain sleep-wake patterns. 
C)  Changes in role and self-concept may lead to depression. 
D)  Immobile patients are often eager to help in their own care. 
A)  The effects of immobility are the same for everyone. 
B)  Immobility helps maintain sleep-wake patterns. 
C)  Changes in role and self-concept may lead to depression. 
D)  Immobile patients are often eager to help in their own care.

Exam 47: Mobility and Immobility

In applying for a job on a nursing unit that requires frequent patient positioning,the nurse should be aware that nurses

The patient is being admitted to the neurological unit with the diagnosis of stroke.The nurse should begin discharge planning

In caring for immobile patients,the nurse understands that back injuries occur

When assessing the skin of an immobilized patient,the nurse should

Patients on bed rest or otherwise immobile are at risk for

The patient who is experiencing an alteration in mobility often has one or more nursing diagnoses.The nurse would use the diagnosis of Impaired physical mobility for a patient who is

The nurse is assessing body alignment for a patient who is immobilized.To do this,the nurse must

The nurse is caring for a patient who has been diagnosed with a stroke.As part of her ongoing care,the nurse should

The term body alignment refers to positioning of the joints,tendons,ligaments,and muscles while standing,sitting,and lying.A term that is similar to body alignment is

Muscles that attach to bones to provide the needed strength to move an object use which of the following to obtain their objective?

The nurse is assessing the way the patient walks.The manner of walking is known as the patient's

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder.This diagnosis means that the nurse should

The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair.The nurse opts to use a mechanical lift (Hoyer lift).The nurse understands that when this lift is used,the

Immobility is a major risk factor for pressure ulcers.In caring for the patient who is immobilized,the nurse needs to be aware that

The patient is immobilized after undergoing hip replacement surgery.Which of the following would place the patient at risk for hemorrhage?

When preparing a plan of care for an immobilized patient,the nurse should

The nurse is caring for a patient who is immobile and needs to be turned every 2 hours.The patient has poor lower extremity circulation,and the nurse is concerned about irritation of the patient's toes.One strategy that the nurse could use is

In developing an individualized plan of care for a patient,it is important for the nurse to

In caring for a patient who is immobile,it is important for the nurse to understand that

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