Question 1

The nurse must assess the patient for hazards of immobility by performing a head-to-toe physical assessment.When assessing the respiratory system,the nurse should

Accepted Answer

A)  Assess the patient at least every 4 hours. 
B)  Inspect chest wall movements during the expiratory cycle only. 
C)  Auscultate the entire lung region to assess lung sounds. 
D)  Focus auscultation on the upper lung fields. 
A)  Assess the patient at least every 4 hours. 
B)  Inspect chest wall movements during the expiratory cycle only. 
C)  Auscultate the entire lung region to assess lung sounds. 
D)  Focus auscultation on the upper lung fields. C

Question 2

When creating a plan of care for a patient who is experiencing alterations in mobility,the nurse

Accepted Answer

A)  Cannot delegate interventions to nursing assistive personnel. 
B)  Is solely responsible for modifying ADLs. 
C)  Consults other health care team members to help plan therapy. 
D)  Consults wound care specialists only when wounds are apparent. 
A)  Cannot delegate interventions to nursing assistive personnel. 
B)  Is solely responsible for modifying ADLs. 
C)  Consults other health care team members to help plan therapy. 
D)  Consults wound care specialists only when wounds are apparent. C

Question 3

Joints are the connections between bones.The joint that is freely movable is known as the _____ joint.

Accepted Answer

A)  Synostotic 
B)  Cartilaginous 
C)  Fibrous 
D)  Synovial 
A)  Synostotic 
B)  Cartilaginous 
C)  Fibrous 
D)  Synovial D

Question 4

Correct body alignment reduces strain on musculoskeletal structures and contributes to balance.Balance control is attained by

Accepted Answer

A)  Keeping the body's center of gravity high. 
B)  Maintaining a wide base of support. 
C)  Keeping the body's center of gravity low. 
D)  Maintaining correct body posture. 
E)  Maintaining immobility to prevent falls. 
A)  Keeping the body's center of gravity high. 
B)  Maintaining a wide base of support. 
C)  Keeping the body's center of gravity low. 
D)  Maintaining correct body posture. 
E)  Maintaining immobility to prevent falls.

Question 5

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.

Question 6

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 7

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 8

The nurse is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine.To help prevent injury secondary to this rotation,the nurse can use

Accepted Answer

A)  A trochanter roll. 
B)  The trapeze bar. 
C)  Hand rolls. 
D)  Hand-wrist splints. 
A)  A trochanter roll. 
B)  The trapeze bar. 
C)  Hand rolls. 
D)  Hand-wrist splints.

Question 9

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.

Question 10

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 11

The nurse is aware that patients who are immobile are at increased risk of developing deep vein thromboses (DVTs).Because of this,the nurse should

Accepted Answer

A)  Make sure that elastic stockings are not removed. 
B)  Measure the calf circumference of both legs. 
C)  Dorsiflex the foot while assessing for patient discomfort. 
D)  Measure both ankles to determine size. 
A)  Make sure that elastic stockings are not removed. 
B)  Measure the calf circumference of both legs. 
C)  Dorsiflex the foot while assessing for patient discomfort. 
D)  Measure both ankles to determine size.

Question 12

The nurse needs to transfer the patient from the bed to the chair.The nurse should

Accepted Answer

A)  Avoid using a transfer or gait belt around the patient's waist prior to transfer. 
B)  Not allow the patient to help in any way because resistance can lead to injury. 
C)  Assess for the need of a mechanical lift and help. 
D)  Ensure that the patient has stockings on his feet for transfer. 
A)  Avoid using a transfer or gait belt around the patient's waist prior to transfer. 
B)  Not allow the patient to help in any way because resistance can lead to injury. 
C)  Assess for the need of a mechanical lift and help. 
D)  Ensure that the patient has stockings on his feet for transfer.

Question 13

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 14

During voluntary movement,impulses descend from the motor strip to the spinal cord.Impulses stimulate muscles by way of

Accepted Answer

A)  Ligaments. 
B)  Tendons. 
C)  Neurotransmitters. 
D)  Cartilage. 
A)  Ligaments. 
B)  Tendons. 
C)  Neurotransmitters. 
D)  Cartilage.

Question 15

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 16

The nurse is admitting a patient who has been diagnosed as having had a stroke.The physician writes orders for "ROM as needed." The nurse understands that

Accepted Answer

A)  The nurse will have to move all the patient's extremities. 
B)  The patient is unable to move his extremities. 
C)  Further assessment of the patient is needed. 
D)  The patient needs to restrict his mobility as much as possible. 
A)  The nurse will have to move all the patient's extremities. 
B)  The patient is unable to move his extremities. 
C)  Further assessment of the patient is needed. 
D)  The patient needs to restrict his mobility as much as possible.

Question 17

The nurse needs to reposition a 300-lb patient.Which of the following strategies is most likely to prevent back injury?

Accepted Answer

A)  Turn the patient alone using the lift pad and applying pillows. 
B)  Put the bed in Trendelenburg and pull from the head of the bed. 
C)  Assess and obtain the number of people needed to help. 
D)  Bend at the waist and pull the lift pad using the arms. 
A)  Turn the patient alone using the lift pad and applying pillows. 
B)  Put the bed in Trendelenburg and pull from the head of the bed. 
C)  Assess and obtain the number of people needed to help. 
D)  Bend at the waist and pull the lift pad using the arms.

Question 18

The director of a nursing home has decided to institute ergonomic programs in the facility because these programs increase employee satisfaction and have been shown to

Accepted Answer

A)  Be ineffective in reducing injury. 
B)  Be cost neutral in budgeting. 
C)  Enhance recruitment. 
D)  Decrease retention rates. 
A)  Be ineffective in reducing injury. 
B)  Be cost neutral in budgeting. 
C)  Enhance recruitment. 
D)  Decrease retention rates.

Question 19

While performing passive ROM exercises,the nurse stands at the side of the bed closest to the joint being exercised and

Accepted Answer

A)  Forces the joint just a bit beyond the point of resistance. 
B)  Moves the joint until the patient complains of pain. 
C)  Repeats each movement twice. 
D)  Carries out movements slowly and smoothly. 
A)  Forces the joint just a bit beyond the point of resistance. 
B)  Moves the joint until the patient complains of pain. 
C)  Repeats each movement twice. 
D)  Carries out movements slowly and smoothly.

Question 20

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.

Exam 92: Mobility and Immobility

The nurse must assess the patient for hazards of immobility by performing a head-to-toe physical assessment.When assessing the respiratory system,the nurse should

When creating a plan of care for a patient who is experiencing alterations in mobility,the nurse

Joints are the connections between bones.The joint that is freely movable is known as the _____ joint.

Correct body alignment reduces strain on musculoskeletal structures and contributes to balance.Balance control is attained by

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

Patients on bed rest or otherwise immobile are at risk for

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 with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine.To help prevent injury secondary to this rotation,the nurse can use

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

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

The nurse is aware that patients who are immobile are at increased risk of developing deep vein thromboses (DVTs).Because of this,the nurse should

The nurse needs to transfer the patient from the bed to the chair.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

During voluntary movement,impulses descend from the motor strip to the spinal cord.Impulses stimulate muscles by way of

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 admitting a patient who has been diagnosed as having had a stroke.The physician writes orders for "ROM as needed." The nurse understands that

The nurse needs to reposition a 300-lb patient.Which of the following strategies is most likely to prevent back injury?

The director of a nursing home has decided to institute ergonomic programs in the facility because these programs increase employee satisfaction and have been shown to

While performing passive ROM exercises,the nurse stands at the side of the bed closest to the joint being exercised and

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

Health and Wellness

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