Question 1

A nurse is assessing the skin of an immobilized patient. What will the nurse do?

Accepted Answer

A)  Assess the skin every 4 hours. 
B)  Limit the amount of fluid intake. 
C)  Use a standardized tool such as the Braden Scale. 
D)  Have special times for inspection so as to not interrupt routine care.

Question 2

A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take?

Accepted Answer

A)  Moves patient's arm in a full circle 
B)  Moves patient's arm cross the body as far as possible 
C)  Moves patient's arm behind body, keeping elbow straight 
D)  Moves patient's arm until thumb is upward and lateral to head with elbow flexed

Question 3

A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?

Accepted Answer

A)  Hypostatic pneumonia 
B)  Renal calculi 
C)  Pressure ulcers 
D)  Thrombus formation

Question 4

The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to make this procedure safe?

Accepted Answer

A)  Place the pillow under the patient's head and shoulders. 
B)  Do by self if the bed is in the flat position. 
C)  Place the side rails in the up position. 
D)  Use a friction-reducing device.

Question 5

A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal?

Accepted Answer

A)  When observed laterally, the spinal curves align in a reversed "S" pattern. 
B)  When observed posteriorly, the hips and shoulders form an "S" pattern. 
C)  The arms should be crossed over the chest or in the lap. 
D)  The feet should be close together with toes pointed out.

Question 6

Upon assessment a nurse discovers that a patient has erythema. Which actions will the nurse take? (Select all that apply.)

Accepted Answer

A)  Consult a dietitian. 
B)  Increase fiber in the diet. 
C)  Place on chest physiotherapy. 
D)  Increase frequency of turning. 
E)  Place on pressure-relieving mattress.

Question 7

The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding?

Accepted Answer

A)  The edge of the seat is in contact with the popliteal space. 
B)  Both feet are supported on the floor with ankles flexed. 
C)  The body weight is directly on the buttocks only. 
D)  The arms hang comfortably at the sides.

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. Which device will the nurse use to help prevent injury secondary to this rotation?

Accepted Answer

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

Question 9

The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?

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)  Coordinate with occupational therapy for gait training. 
D)  Place the patient on bed rest to prevent fatigue.

Question 10

The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient?

Accepted Answer

A)  Thick, tenacious pulmonary secretions 
B)  Low-molecular-weight heparin doses 
C)  SCDs wrapped around the legs 
D)  Elastic stockings (TED hose)

Question 11

A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the NAP to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?

Accepted Answer

A)  Patient is lying on side. 
B)  Patient is lying on back. 
C)  Patient is lying semiprone. 
D)  Patient is lying on abdomen.

Question 12

The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend?

Accepted Answer

A)  High protein, high calorie 
B)  High carbohydrate, low fat 
C)  High vitamin A, high vitamin E 
D)  Fluid restricted, bland

Question 13

The patient is being admitted to the neurological unit with a diagnosis of stroke. When will the nurse begin discharge planning?

Accepted Answer

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

Question 14

The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient's nursing diagnosis is 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 nursing intervention is most appropriate for this patient?

Accepted Answer

A)  Obtain assistance and physically transfer the patient to the chair. 
B)  Assist with ambulation and measure how far the patient walks. 
C)  Give pain medication after ambulation so the patient will have a clear mind. 
D)  Bring the patient to the cafeteria for group instruction on ambulation.

Exam 28: Immobility