Question 1

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

Accepted Answer

A)  Set goals that are a little beyond the capabilities of the patient. 
B)  Use his or her judgment 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 2

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients.The nurse is aware that the rate of occupational injury and illness in the hospital setting

Accepted Answer

A)  Is the same as in the private industry sector. 
B)  Is higher than in the nursing home setting. 
C)  Is about 4.4%. 
D)  Has decreased in recent years.

Question 3

To prevent injury,the nurse should not begin a task (e.g.,moving a bed from one room to another,lifting heavy objects)until the task can be completed safely.To prevent injury

Accepted Answer

A)  Keep the weight as far from the body as possible. 
B)  Keep the knees still to prevent loss of balance. 
C)  Tighten abdominal muscles and tuck the pelvis. 
D)  Bend at the waist to move weight forward.

Question 4

What is meant by "concentric tension" of muscles?

Accepted Answer

A)  Increased muscle contraction results in movement. 
B)  The speed and direction of movement are controlled. 
C)  Tension causes no shortening or active movement. 
D)  Tension does not result in isotonic contraction.

Question 5

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.One strategy that the nurse could use is

Accepted Answer

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

Question 6

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 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 7

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

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 8

The nurse is assessing body alignment for a patient who is immobilized.To do this,the nurse must

Accepted Answer

A)  Place the patient in the supine position. 
B)  Remove the pillow from under the patient's head. 
C)  Insert positioning supports to help the patient. 
D)  Place the patient in a lateral position.

Question 9

The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair.The nurse opts to use a mechanical lift (Hoyer lift).The nurse understands that when this lift is used,the

Accepted Answer

A)  Straps need to be removed before lowering the patient to the chair. 
B)  Horseshoe-shaped base should be on the opposite side from the chair. 
C)  Longer straps hook to the bottom of the sling. 
D)  Short straps are hooked to the bottom of the sling.

Question 10

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

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 11

The patient is admitted to a skilled care unit for rehabilitation 10 days after the surgical procedure of fixation of a fractured left hip and has a nursing diagnosis of 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 of the following nursing interventions is most appropriate for this patient?

Accepted Answer

A)  Obtain assistance and physically transfer the patient to the chair. 
B)  Assist the patient with ambulation and measure how far she walks. 
C)  Withhold pain medication so that she can ambulate with a clear mind. 
D)  Bring the patient to the cafeteria for group instruction on ambulation.

Question 12

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

Accepted Answer

A)  Breaks in skin integrity are easy to heal. 
B)  Preventing a pressure ulcer is more expensive than treating one. 
C)  Immobilized patients can develop skin breakdown within 3 hours. 
D)  Pressure ulcers are caused by a sudden influx of oxygen to the tissue.

Question 13

In caring for a patient who is immobile,it is important for the nurse to understand that

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 14

The nurse is caring for a patient with the diagnosis of Impaired physical mobility.The nurse needs to be alert for which of the following potential complications?

Accepted Answer

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

Question 15

When preparing a plan of care for an immobilized patient,the nurse should

Accepted Answer

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

Question 16

The nurse is caring for a patient who has had a stroke causing total paralysis of the right side.To help maintain joint function and to prevent contractures,passive ROM 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 rehab unit 
D)  No ROM is needed.

Question 17

The nurse is assessing the way the patient walks.The manner of walking is known as the patient's

Accepted Answer

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

Question 18

Immobilized patients frequently have hypercalcemia,placing them at risk for

Accepted Answer

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

Question 19

The patient who is experiencing an alteration in mobility often has one or more nursing diagnoses.The nurse would use the diagnosis of Impaired physical mobility for a patient who is

Accepted Answer

A)  Not completely immobile. 
B)  Completely immobile. 
C)  At risk for multisystem problems. 
D)  At risk for single-system involvement.

Question 20

Although isometric contractions do not result in muscle shortening,the nurse understands that isometric contractions

Accepted Answer

A)  Result in decreased energy expenditure. 
B)  Are always desirable regardless of patient condition. 
C)  Are necessary for the active movement of muscles. 
D)  Result in increased energy expenditure.

Exam 92: Mobility and Immobility