Question 1

It has been determined that each of the following patients is at risk for falling.Which one requires the nurse's priority for ambulation?

Accepted Answer

A) A 16-year-old with a sprained ankle being discharged from the emergency department. 
B) A 54-year-old who has taken the initial dose of an antihypertensive medication. 
C) A 45-year-old postoperative patient up for the first time since knee surgery. 
D) An 81-year-old who is asthmatic and had a hip replaced 18 months ago.

Question 2

The nurse is caring for a patient who has had a stroke that caused total paralysis of the right side.To help maintain joint function and to prevent contractures,passive ROM exercises will be initiated.When should therapy begin?

Accepted Answer

A) After the acute phase of the disease has passed. 
B) As soon as the ability to move is lost. 
C) Once the patient enters the rehabilitation unit. 
D) No ROM exercise is needed.

Question 3

The patient is being admitted to the neurological unit with the diagnosis of stroke.When should 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.

Question 4

The patient is getting up for the first time after a period of bed rest.What is the initial nursing action?

Accepted Answer

A) Assess respiratory function. 
B) Obtain a baseline blood pressure. 
C) Assist the patient to sit at the edge of the bed. 
D) Ask the patient if he or she feels lightheaded.

Question 5

In caring for a patient who is immobile,what is important for the nurse to understand?

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.

Question 6

The nurse is admitting a patient who has had a stroke.The physician writes orders for "ROM as needed." What does the nurse understand about this situation?

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.

Question 7

The nurse is caring for a patient who has had a recent stroke and is paralyzed on his left side.He has no respiratory or cardiac issues,but he cannot walk.He becomes extremely frustrated when he cannot button his shirt and cannot feed himself because he was left-handed.He has shown no signs of dysphagia,but he has been eating very little and has lost 0.9 kg (2 pounds).He asks the nurse,"How can I go home like this? I'm not getting better.I can't ask my wife to take care of me like a baby." Of the following list of health care team members,which member would the nurse need to consult? (Select all that apply. )

Accepted Answer

A) Physiotherapy. 
B) Occupational therapy. 
C) Respiratory therapy. 
D) Cardiac rehabilitation. 
E) Psychology services.

Question 8

The nurse needs to reposition a 136.1 kg (300-pound)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 the Trendelenburg position 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 9

Correct body alignment reduces strain on musculoskeletal structures and contributes to balance.Balance control is attained by which of the following? (Select all that apply. )

Accepted Answer

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

Question 10

When the nurse is preparing a plan of care for an immobilized patient,what should the nurse keep in mind?

Accepted Answer

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

Question 11

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

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.

Question 12

Immobilized patients frequently have hypercalcemia,which increases their risk for what?

Accepted Answer

A) Osteoporosis. 
B) Renal calculi. 
C) Pressure ulcers. 
D) Thrombus formation.

Question 13

When assessing the body alignment of a patient while he or she is standing,the nurse is aware of which of the following?

Accepted Answer

A) When observed posteriorly,the hips and shoulders form an S pattern. 
B) When observed laterally,the spinal curves align in a reversed 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 14

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

Accepted Answer

A) Breaks in skin integrity are easy to heal. 
B) Preventing a pressure ulcer is more expensive than treating one. 
C) A 30-degree lateral position is recommended 
D) Pressure ulcers are caused by a sudden influx of oxygen to the tissue.

Question 15

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

Accepted Answer

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

Question 16

The nurse is caring for a patient with the nursing diagnosis of Impaired physical mobility.The nurse needs to be alert for which of the following potential complications? (Select all that apply. )

Accepted Answer

A) Pulmonary emboli. 
B) Pneumonia. 
C) Impaired skin integrity. 
D) Somnolence. 
E) Increased socialization.

Question 17

Many patients who experience an alteration in mobility have one or more nursing diagnoses.For whom would the nurse would use the diagnosis of Impaired physical mobility?

Accepted Answer

A) A patient who is not completely immobile. 
B) A patient who is completely immobile. 
C) A patient who is at risk for multisystem problems. 
D) A patient who is at risk for single-system involvement.

Question 18

When a patient with impaired physical mobility is in the recumbent position,what angle of lateral position is recommended?

Accepted Answer

A) 15 degrees. 
B) 30 degrees. 
C) 45 degrees. 
D) 90 degrees.

Question 19

Of the following nursing goals,which is the most appropriate for a patient who has had a total hip replacement?

Accepted Answer

A) The patient will walk 305 m (1000 feet),using her walker,by the time of discharge. 
B) The patient will ambulate by the time of discharge. 
C) The patient will ambulate briskly on the treadmill by the time of discharge. 
D) The nurse will assist the patient to ambulate in the hall.

Question 20

The patient with torticollis would exhibit

Accepted Answer

A) Exaggeration of the lumbar spine curvature. 
B) Increased convexity of the thoracic spine. 
C) Abnormal anteroposterior and lateral curvature of the spine. 
D) Contracture of the sternocleidomastoid muscle with a head incline.

Exam 45: Mobility and Immobility