Exam 21: Immobility

The nurse takes into consideration that many therapeutic reasons exist that explain why a patient might become immobile,and these include: (Select all that apply.)

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

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

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:

The 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." The best response by the nurse would be:

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

The home health nurse instructs a family about boosting the patient in bed so that a ____________________ type of skin injury will not occur.

A nurse caring for a patient who has been prescribed bedrest for 1 week notices a reddened area on the patient's left hip.The skin is intact but,when the nurse presses on the area,the redness does not fade.The nurse recognizes this pressure ulcer as:

During the shift report,the nurse is told that the patient she will be caring for has a stage II pressure ulcer.During the dressing change,the nurse would expect to see a(n):

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

The most effective intervention to prevent constipation in a patient who recently suffered a fractured femur and is currently in traction is to:

The 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.

Incontinence in older adults,which is related to the inability to get to the bathroom in time,is classified as:

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

On a newly discovered pressure ulcer,the nurse should document which of the following? (Select all that apply.)

When positioning an immobile patient,the nurse should:

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