Question 1

The nurse is evaluating the body alignment of a patient in the sitting position.In this position,how is the body aligned?

Accepted Answer

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

Question 2

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

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. C

Question 3

The nurse is assessing the way the patient walks.The manner of walking is known as what?

Accepted Answer

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

Question 4

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

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.

Question 5

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

Accepted Answer

A)  That nurses are at low risk for back injury.
B)  That nurses are especially at risk for upper back injuries.
C)  That nurses should be aware of agency policies.
D)  That nurses should not need to use assistive devices.

Question 6

In preparing to create a nursing diagnosis for a patient who is immobile,what is important for the nurse to understand?

Accepted Answer

A)  Physiological issues should be the major focus.
B)  Psychosocial issues should be the major focus.
C)  Developmental issues should be the major focus.
D)  All dimensions are important to health.

Question 7

Two nurses are standing on opposite sides of the bed to move the patient up in bed with a drawsheet.Which of the following describes the correct position for the nurses in order to safely position the patient?

Accepted Answer

A)  The nurses should face the patient.
B)  The nurses should face the direction of movement.
C)  The nurses should face each other.
D)  The nurses should face opposite the direction of movement.

Question 8

The nurse is caring for an older patient with the diagnosis of urinary tract infection (UTI).The patient is confused and agitated.It is important for the nurse to realize that confusion in older people is which of the following?

Accepted Answer

A)  Not a normal expectation.
B)  Purely psychological in origin.
C)  Not a common manifestation with UTIs.
D)  Acceptable and needs no further assessment.

Question 9

The patient is unable to move himself and needs to be pulled up in bed.For this repositioning to be done safely,what must the nurse understand?

Accepted Answer

A)  The procedure can be done by one person if the bed is in the flat position.
B)  Side rails should be in the up position to prevent the patient from falling out.
C)  The pillow should be placed under the patient's head and shoulders.
D)  Assistive devices or additional nurses should be used.

Question 10

Patients on bed rest or otherwise immobile are at risk for what condition?

Accepted Answer

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

Question 11

The patient has suffered a spinal cord injury and needs to be repositioned through the log-rolling technique to keep the spinal column in straight alignment.Which of the following is the proper technique for nurses to perform log-rolling?

Accepted Answer

A)  Obtaining assistance from at least two or three other people.
B)  Having the patient reach for the opposite side rail when turning.
C)  Moving the top part of the patient's torso,then the bottom part.
D)  Not using pillows after turning because the softness causes misalignment.

Question 12

A 61-year-old patient recently had left-sided paralysis from a cerebrovascular accident (CVA;also known as stroke).In planning care for this patient,the nurse would do which of the following?

Accepted Answer

A)  Encourage an even gait when walking in place.
B)  Assess the extremities for unilateral swelling and muscle atrophy.
C)  Encourage holding the breath frequently to hyperinflate the lungs.
D)  Teach the use of a two-point crutch technique for ambulation.

Question 13

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,what can the nurse use?

Accepted Answer

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

Question 14

The nurse expects to maintain the patient's legs in abduction after total hip replacement surgery with the use of which of the following?

Accepted Answer

A)  Foot boot.
B)  Wedge pillow.
C)  Trochanter roll.
D)  Sandbag.

Question 15

A patient has been on prolonged bed rest,and the nurse is observing for signs associated with immobility.While assessing the patient,the nurse is alert to which of the following signs?

Accepted Answer

A)  Increased blood pressure.
B)  Decreased heart rate.
C)  Increased urinary output.
D)  Decreased peristalsis.

Question 16

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

Accepted Answer

A)  Set goals that are a little beyond the capabilities of the patient.
B)  Use his or her judgement 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 17

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)  Sequential compression devices wrapped around the legs to prevent DVT formation.
D)  Elastic stockings (thromboembolic disease [TED] hose) to promote venous return.

Question 18

The nurse is caring for a patient who has suffered a stroke.As part of her ongoing care,what should the nurse do?

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 because energy needs are decreased.

Question 19

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.What is one strategy that the nurse could use?

Accepted Answer

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

Question 20

A patient is admitted to the medical unit after a CVA.There is evidence of left-sided hemiparesis,and the nurse will be following up on range-of-motion (ROM)and other exercises performed in physiotherapy.Which of the following principles of ROM exercises does the nurse correctly teach the patient and family members?

Accepted Answer

A)  Flex the joint to the point of discomfort.
B)  Work from proximal to distal joints.
C)  Move the joints quickly.
D)  Provide support to the extremity.

Exam 45: Mobility and Immobility