Homework Lance
1. A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the client, the nurse is alert to a(n):
1.
Increased blood pressure
2.
Decreased heart rate
3.
Increased urinary output
4.
Decreased peristalsis
ANS: 4
Immobility causes gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. In the immobilized client, decreased circulating fluid volume, pooling of blood in the lower extremities, and decreased autonomic response occur. These factors result in decreased venous return, followed by a decrease in cardiac output, which is reflected by a decline in blood pressure. Recumbency increases cardiac workload and results in an increased pulse rate. Fluid intake can diminish with immobility, and this combined with other causes, such as fever, increases the risk for dehydration. Urinary output may decline on or about the fifth or sixth day after immobilization, and the urine is often highly concentrated.
PTS: 1 DIF: A REF: 1225 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
2. A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident (stroke). In planning care for this client, the nurse implements which one of the following as an appropriate intervention?
1.
Encourage an even gait when walking in place.
2.
Assess the extremities for unilateral swelling and muscle atrophy.
3.
Encourage holding the breath frequently to hyperinflate the client’s lungs.
4.
Teach the use of a two-point crutch technique for ambulation.
ANS: 2
Because edema moves to dependent body regions, assessment of the immobilized client should include the sacrum, legs, and feet. Unilateral increases in calf diameter can be an early indication of thrombosis. The client who has suffered a cerebrovascular accident with left-sided paralysis may not be capable of an even gait. To prevent stasis of pulmonary secretions, the client’s position should be changed every 2 hours, and fluids should be increased to 2000 mL, if not contraindicated. The client should deep breathe and cough every 1 to 2 hours to promote chest expansion. The client would most likely ambulate safely with a walker, or a cane. If crutches are used, the client should use a three-point support.
PTS: 1 DIF: A REF: 1238 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
3. Two nurses are standing on opposite sides of the bed to move the client up in bed with a drawsheet. Where should the nurses be standing in relation to the client’s body as they prepare for the move?
1.
Even with the thorax
2.
Even with the shoulders
3.
Even with the hips
4.
Even with the knees
ANS: 2
The nurses should be standing even with the client’s shoulders when they prepare to move the client up in bed.
PTS: 1 DIF: A REF: 1253 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
4. A client is leaving for surgery and because of preoperative sedation needs complete assistance to transfer from the bed to the stretcher. Which of the following should the nurse do first?
1.
Elevate the head of the bed.
2.
Explain the procedure to the client.
3.
Place the client in the prone position.
4.
Assess the situation for any potentially unsafe complications.
ANS: 4
Before transferring the client from the bed to the stretcher, the nurse should assess the situation for any potentially unsafe complications. The sedated client is transferred most easily in the supine position, unless contraindicated. The head of the bed should be at the same level as the head of the stretcher. This client has had preoperative sedation, which may impair his or her cognition. The nurse should simplify instructions when explaining the procedure to the client, but this should be done immediately before transferring the client.
PTS: 1 DIF: C REF: 1268 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
5. A client has sequential compression stockings in place. The nurse evaluates that they are implemented appropriately by the new staff nurse when the:
1.
Initial measurement is made around the client’s calves
2.
Intermittent pressure is set at 40 mm Hg
3.
Stockings are wrapped directly over the leg from ankle to knee
4.
Stockings are removed every hour during application
ANS: 2
Inflation pressures average 40 mm Hg. Initial measurement is made around the largest part of the client’s thigh. A protective stockinette is placed over the client’s leg; then the stocking is wrapped around the leg, starting at the ankle, with the opening over the patella. For optimal results, sequential compression devices (SCDs) or intermittent pneumatic compression (IPC) are used as soon as possible and maintained until the client becomes fully ambulatory. Stockings are not removed every hour but should be removed periodically to assess the condition of the client’s skin.
PTS: 1 DIF: A REF: 1238 OBJ: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
6. The nurse assesses that the client has torticollis and that this may adversely influence the client’s mobility. This individual has a(n):
1.
Exaggeration of the lumbar spine curvature
2.
Increased convexity of the thoracic spine
3.
Abnormal anteroposterior and lateral curvature of the spine
4.
Contracture of the sternocleidomastoid muscle with a head incline
ANS: 4
Torticollis is inclining of the head to the affected side, in which the sternocleidomastoid muscle is contracted. Lordosis is an exaggeration of the lumbar spine curvature. Kyphosis is an increased convexity in the curvature of the thoracic spine. Kyphoscoliosis is an abnormal anteroposterior and lateral curvature of the spine.
PTS: 1 DIF: A REF: 1224 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
7. An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as:
1.
Harsh crackles
2.
Wheezing on inspiration
3.
Diminished breath sounds
4.
Bronchovesicular whooshing
ANS: 3
Atelectasis is the collapse of alveoli. In atelectasis, secretions block a bronchiole or a bronchus, and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. If the client were suspected of having atelectasis, the nurse would expect diminished breath sounds in the area of hypoventilation. Harsh crackles indicate excessive airway secretion. Wheezing on inspiration indicates narrowing of the lumen of a respiratory passageway. Bronchovesicular sounds are a mixture of bronchial and vesicular sounds. Bronchovesicular whooshing would not be an expected sound indicating atelectasis.
PTS: 1 DIF: A REF: 1226 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
8. The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to:
1.
Measure the calf and thigh circumferences
2.
Attempt to elicit Homans’ sign
3.
Palpate the temperature of the feet
4.
Observe for a loss of hair and skin turgor in the lower legs
ANS: 1
Calf and thigh circumferences should be measured daily. Unilateral increases in calf or thigh circumference can be an early indication of thrombosis. Homans’ sign is not always positive in the presence of thrombosis. Assessing the temperature of the feet is not the best approach to determine the presence of thrombosis. Observing for hair loss and skin turgor of the lower legs is not the best approach to determine the presence of thrombosis. A lack of hair may indicate a chronic lack of oxygen. Skin turgor is a measure of hydration.
PTS: 1 DIF: A REF: 1238 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
9. A client is getting up for the first time after a period of bed rest. The nurse should first:
1.
Assess respiratory function
2.
Obtain a baseline blood pressure
3.
Assist the client with sitting at the edge of the bed
4.
Ask the client if he or she feels light-headed
ANS: 2
When getting the client up for the first time after a period of bed rest, the nurse should document orthostatic changes. The nurse first obtains a baseline blood pressure. Assessing the client’s respiratory function is not the nurse’s first intervention when getting a client up for the first time after prolonged bed rest. After the nurse assesses the client’s blood pressure, the nurse can assist the client to a sitting position at the side of the bed. After the client is in the sitting position at the side of the bed, the nurse should ask the client if he or she feels light-headed.
PTS: 1 DIF: C REF: 1238 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
10. To promote respiratory function in the immobilized client, the nurse should:
1.
Change the client’s position every 4 to 8 hours
2.
Encourage deep breathing and coughing every hour
3.
Use oxygen and nebulizer treatments regularly
4.
Suction the client’s secretions every hour
ANS: 2
The nurse should actively work with the immobilized client to deep breathe and cough every 1 to 2 hours to promote chest expansion. The client’s position should be changed every 2 hours to reduce stagnation of secretions. The health care provider must order oxygen and nebulizer treatments, which are primarily used to treat the client who is experiencing an impaired air exchange, not to promote respiratory function in the immobilized client. The client’s secretions should only be suctioned as needed.
PTS: 1 DIF: A REF: 1247 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
11. Antiembolic stockings (thromboembolic device [TED] hose) are ordered for the client on bed rest following surgery. The nurse explains to the client that the primary purpose for the TEDs is to:
1.
Keep the skin warm and dry
2.
Prevent abnormal joint flexion
3.
Apply external pressure
4.
Prevent bleeding
ANS: 3
The primary purpose of antiembolic stockings is to maintain external pressure on the muscles of the lower extremities and thus promote venous return. Antiembolic stockings are not primarily used to prevent bleeding but are used to prevent clot formation caused by venous stasis.
PTS: 1 DIF: C REF: 1248 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
12. To provide for the psychosocial needs of an immobilized client, an appropriate statement by the nurse is which of the following?
1.
“The staff will limit your visitors so that you will not be bothered.”
2.
“A roommate can be a real bother. You’d probably rather have a private room.”
3.
“Let’s discuss the routine to see if there are any changes we can make.”
4.
“I think you should have your hair done and put on some makeup.”
ANS: 3
To meet the psychosocial needs of immobilized clients, the nurse should encourage clients to be involved in their care whenever possible. Asking the client if there are changes the staff can make in routine care is an appropriate question. Visitors should not be limited for the immobilized client. The client needs socialization throughout the day. If possible, the client should be placed in a room with others who are mobile and interactive. Clients should be encouraged to wear their glasses or artificial teeth and to shave or apply makeup. These are activities through which people maintain their body image. The nurse provides for the psychosocial needs of an immobilized client by having the client perform as much self-care as possible.
PTS: 1 DIF: A REF: 1229 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
13. To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse should implement the use of a:
1.
Footboard
2.
Trochanter roll
3.
Trapeze bar
4.
Bed board
ANS: 2
A trochanter roll prevents external rotation of the hips when the client is in a supine position. The footboard prevents footdrop by maintaining the feet in dorsiflexion. The trapeze bar allows the client to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises. A bed board is used to increase back support and alignment, especially with a soft mattress.
PTS: 1 DIF: A REF: 1251 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
14. To reduce the chance of plantar flexion (footdrop) in a client on prolonged bed rest, the nurse should implement the use of:
1.
Trapeze bars
2.
High-top sneakers
3.
Trochanter rolls
4.
Thirty-degree lateral positioning
ANS: 2
High-top tennis shoes or an ankle-foot orthotic may be used to help maintain dorsiflexion and prevent footdrop. A trapeze bar is used to assist the client in mobility. A trochanter roll prevents external rotation of the hips when the client is in a supine position. Thirty-degree lateral positioning may be used for clients at risk for pressure ulcers.
PTS: 1 DIF: A REF: 1254 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
15. Which of the following is the most important to consider when assisting the client in passive range-of-motion exercises?
1.
Flex the joint to the point of discomfort.
2.
Work from the proximal joints to the distal joints.
3.
Quickly work through the range of motion.
4.
Support the distal joints while performing range-of-motion exercises.
ANS: 4
While performing range-of-motion exercises, support should be provided for the distal joints. The joint should be flexed to the point of resistance, not to the point of discomfort. When performing range-of-motion exercises, begin at distal joints and work toward proximal joints. Joints should be moved slowly through their range of motion. Quick movement could cause injury.
PTS: 1 DIF: A REF: 1274 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
16. Which of the following clients is most at risk for losing his or her balance?
1.
A woman who is 9 months pregnant walking down a flight of stairs
2.
A 16-year-old skate boarding down a 15-degree slope
3.
A 45-year-old taking hypertensive medication
4.
A 4-year-old riding a tricycle
ANS: 1
Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility also affect balance. Impaired balance is a major threat to physical safety and contributes to a fear of falling and self-imposed restrictions on activity. Although all the options represent a risk, the situation of the pregnant woman places her at greatest risk.
PTS: 1 DIF: C REF: 1220 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
17. It has been determined that all of the following clients are at risk for falling. Which one requires the nurse’s priority for ambulation?
1.
A 16-year-old with a sprained ankle being discharged from the emergency department
2.
A 54-year-old who has taken the initial dose of an antihypertensive medication
3.
A 45-year-old postoperative client up for the first time since knee surgery
4.
An 81-year-old who is asthmatic and had a hip replaced 18 months ago
ANS: 3
Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility also affect balance. Although all the options represent a potential risk for falling, the postoperative client has both prolonged immobility and physical injury (surgery) and so is at greatest risk.
PTS: 1 DIF: C REF: 1220 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
18. Which of the following statements made by ancillary staff reflects the most informed knowledge regarding the benefit of having a client assist with his or her own activities of daily living (ADLs) to that client’s activity tolerance?
1.
“The more he does for himself, the more he will be able to do for himself.”
2.
“He doesn’t like washing and dressing himself, but it makes him stronger.”
3.
“Doing for himself makes him tired, but in the long run he has more energy and strength when he does.”
4.
“By washing and dressing himself he is building muscle strength that lets him actually walk a little better.”
ANS: 4
Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. ADLs require muscle action and help maintain muscle tone. When a client is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone decrease. The remaining options do not explain the reason for the additional activity tolerance as does the answer.
PTS: 1 DIF: C REF: 1250 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
19. Which of the following statements regarding physical activity and its effect on activity tolerance made by a client shows the most informed knowledge regarding the connection between the two?
1.
“I know I need to walk more if I want to get stronger.”
2.
“I don’t like walking, but I do it because I know it will make me stronger.”
3.
“I try to walk a little farther each afternoon so I can dance at my grandson’s wedding.”
4.
“I walk with my son three evenings a week because it’s good for his weight and for my bones.”
ANS: 3
Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. The better the muscle tone, the more stamina the client will experience. The remaining options do not state the connection between activity and stamina as well as the answer.
PTS: 1 DIF: C REF: 1244 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
20. A client recovering from hip surgery tells the nurse that she wants to get better so she can walk down the aisle to her seat at her granddaughter’s wedding. Which of the following nursing interventions will have the greatest impact on achieving that goal?
1.
Informing physical therapists that the client has expressed that goal
2.
Reminding the ancillary staff to offer to walk with the client after her bath
3.
Regularly praising the client for the efforts she is making to reach her goal
4.
Walking with the client to and from the dining room where she eats her meals
ANS: 4
Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. ADLs require muscle action and help maintain muscle tone. When a client is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone decrease. The better the muscle tone, the more stamina the client will experience. Although all the interventions are appropriate, actually walking with the client will have the greatest impact on her ability to achieve the goal.
PTS: 1 DIF: B REF: 1241 OBJ: Application
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
21. An infant born via cesarean section because of a breech presentation is diagnosed with bilateral congenital hip dysplasia. The primary nursing intervention directed toward this diagnosis is:
1.
Assessing the infant frequently to determine abduction of the thighs
2.
Maintaining the infant in the position of continuous abduction of both hips
3.
Educating the parents about the importance of positioning the infant so that the head of the femurs are in alignment with the hip sockets
4.
Providing pain management so that the infant is comfortable in the therapeutic position required
ANS: 2
Maintenance of continuous abduction of the thigh so that the head of the femur presses into the center of the acetabulum is critical in the care and treatment of this infant. Although the other options are appropriate, they are not primary interventions in this scenario.
PTS: 1 DIF: C REF: 1224 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
22. A 16-year-old had a full leg cast for 4 months, and it is being removed today. Which of the following statements made by the client shows the most informed understanding of the effects of immobilization of a muscle on its strength and stamina?
1.
“I’m hoping to be back at soccer practice in 3 weeks.”
2.
“Walking and riding my bike will help regain the muscle.”
3.
“I’ll practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring.”
4.
“There was a good bit of muscle and strength loss, but I’ll work at getting it back like it was before the break.”
ANS: 3
Even this temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. When a client is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone decrease. Appropriate general exercise and specific exercise of the atrophied muscle will increase both muscle tone and overall stamina. Although the remaining options are not incorrect, the answer shows the greatest insight because it provides both a plan and a time line for recovery.
PTS: 1 DIF: C REF: 1223 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
23. A staff member experienced a shoulder injury while assisting with a client transfer. The nurse manager’s most therapeutic response to this situation is to:
1.
Thoroughly review the accident report filed by the injured personnel to determine the factors that contributed to the injury
2.
Have a nonpunitive meeting with all the involved staff to discuss correcting the factors that resulted in the injury
3.
Require that mechanical lifts be used in the transfer of all clients incapable of assisting with the transfer
4.
Implement new policies and procedures to correct the factors that resulted in the injury
ANS: 2
An “after-action review” allows the health care team to apply knowledge about safe client moving to the situation to identify safety factors contributing to the problem and make suggestions for the implementation of strategies to minimize risk to both client and staff.
PTS: 1 DIF: C REF: 1225 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
24. Which of the following statements made by a nurse caring for a client who experienced a myocardial infarction 8 hours ago shows the greatest insight as to the purpose for keeping the client on bed rest?
1.
“This has been exhausting; she needs a period of uninterrupted rest.”
2.
“The pain she experienced is exhausting; it’s imperative that she rest.”
3.
“Keeping her on bed rest decreases the need her body has for oxygen”
4.
“She needs complete rest; she is really very ill, especially her heart.”
ANS: 3
Although all of the options are correct, the primary reason for bed rest in this scenario is to minimize the need for oxygen to both the heart and the body in general.
PTS: 1 DIF: C REF: 1224 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
25. The nurse recognizes that a client who is inactive is at a risk for decreased muscle mass as a result of increased muscle atrophy and:
1.
Decrease metabolic rate
2.
Catabolic tissue breakdown
3.
Inactivity-induced depression
4.
Anorexia caused by decreased peristalsis
ANS: 2
Weight loss, decreased muscle mass, and weakness result from tissue catabolism (tissue breakdown).
PTS: 1 DIF: A REF: 1227 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
26. A 78-year-old inactive client diagnosed with acute renal failure is at risk for which of the following skeletal maladies?
1.
Rickets
2.
Osteomyelitis
3.
Pathological fractures of long bones
4.
Compression fractures of the spinal column
ANS: 3
Immobility causes the release of calcium into the circulation, where normally the kidneys excrete the excess calcium. If the kidneys are unable to respond appropriately, hypercalcemia results. Pathological fractures occur if calcium reabsorption continues as the client remains on bed rest or continues to be immobile. Bed rest is not a direct causative factor for the other options.
PTS: 1 DIF: A REF: 1228 OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
27. Prevention of plantar flexion (footdrop) through the application of high-topped shoes is a primary intervention for which of the following mobility-impaired clients?
1.
A 54-year-old diagnosed with osteoarthritis in all lower extremity joints
2.
A 25-year-old with a fractured pelvis as a result of a motorcycle accident
3.
A 78-year-old who has experienced left-sided paralysis resulting from a cerebral vascular accident (CVA)
4.
A 15-year-old who has been comatose for 2 years as a result of a head injury sustained from a fall off a roof
ANS: 2
The client who has suffered a CVA with resulting left-sided paralysis (hemiplegia) is at risk for footdrop. In two of the options, the client would not damage the nerve necessary to cause the condition, and the remaining option is not the correct answer because there is little chance this client will ever be capable of mobility.
PTS: 1 DIF: C REF: 1254 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
28. The nurse is providing ancillary personnel with instructions regarding the performance of passive range-of-motion (ROM) exercises for a client experiencing paralysis from the waist down (paraplegia) as a result of an automobile accident. Which of the following statements made by the ancillary personnel reflects the greatest insight regarding the frequency with which the intervention should be provided for this client?
1.
“I will do a whole body range of motion as I complete her daily bath.”
2.
“Bath time, bedtime, after lunch, and at least once more; she can pick when.”
3.
“It works well with her bath and when she is being prepared for bed at night.”
4.
“I’ll ask her when she wants me to exercise her joints in addition to bath time.”
ANS: 2
If the client is unable to move part or all of the body, perform passive ROM exercises for all immobilized joints while bathing the client and at least 2 or 3 more times a day.
PTS: 1 DIF: C REF: 1249 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
29. The nurse is discussing joint mobility exercises with a client who experienced a stroke and now has left-sided weakness. Which of the following statements made by the client reflects the greatest insight regarding the best method for him to maintain mobility of the joints on his left side?
1.
“My wife knows how to do those exercises for the joints on my left side.”
2.
“Physical therapy really exercises my left side when I go there every afternoon.”
3.
“I’ll remind the staff to exercise my left side when they come to help me with my bath and getting dressed.”
4.
“I will do those passive range of motion exercises you taught me to my left side at least 3 times a day.”
ANS: 4
If one extremity is paralyzed, teach the client to put each joint independently through its ROM.
PTS: 1 DIF: C REF: 1261 OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
30. The nurse caring for a 38-year-old female client with multiple fractures in the trauma intensive care unit knows that this client is at high risk for pulmonary complications such as atelectasis from her immobility. One of the interventions that the nurse can do to help prevent this from occurring is to:
1.
Keep the PaO2 level at or above 94%
2.
Instruct the client to deep breathe and cough every hour while awake
3.
Turn the client every 2 hours
4.
Keep the client on the ventilator as long as possible
ANS: 2
In atelectasis, secretions block a bronchiole or a bronchus, and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. The site of the blockage affects the severity of atelectasis. Sometimes an entire lung lobe or a whole lung collapses. At some point in the development of these complications, there is a proportional decline in the client’s ability to cough productively. Turning the client is an excellent way to help prevent the accumulation of mucus in the dependent regions of the airways causing hypostatic pneumonia. Mucus is an excellent place for bacteria to grow. Keeping a client on a ventilator longer than necessary has the potential to cause multiple other complications and is not the best choice.
PTS: 1 DIF: A REF: 1220 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
31. The nurse is caring for a 48-year-old male client who was involved in a motor vehicle accident and had a fractured pelvis, a ruptured spleen, and multiple contusions. The client has been in the hospital for 5 days on bed rest. The nurse knows that this client is at risk for venous thrombus formation because of prolonged bed rest, potential damage to vessel walls during surgery, and the platelets he received in the trauma unit. These three factors are also known as:
1.
Trigeminy
2.
Virchow’s triad
3.
Trigone
4.
Hutchinson’s triad
ANS: 2
There are three factors that contribute to venous thrombus formation: (1) damage to the vessel wall (e.g., injury during surgical procedures), (2) alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity. These three factors are sometimes referred to as Virchow’s triad
PTS: 1 DIF: A REF: 1260 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
32. The nurse caring for a 73-year-old female client who has been hospitalized with a stroke instructs the client’s daughter to continue to do passive range-of-motion exercises with her mother on her affected side to prevent contractures. The nurse explains to the daughter that this is very important in an immobile older adult client because contractures can form in as little as:
1.
8 hours
2.
24 hours
3.
1 week
4.
1 month
ANS: 1
Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. When a contracture occurs, the joint cannot obtain full ROM. Contractures sometimes leave a joint or joints in a nonfunctional position, as seen in clients who are permanently curled in a fetal position. Early prevention of contractures is key; they can begin to form after only 8 hours of immobility in the older adult client.
PTS: 1 DIF: B REF: 1225 OBJ: Application
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
33. The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in an immobile client is to:
1.
Keep the skin dry
2.
Provide range of motion every shift
3.
Use lift equipment when transferring a client
4.
Turn the client a minimum of every 2 hours
ANS: 4
Implement a comprehensive skin care program to prevent skin breakdown in all clients, from neonates to older adults. Effective skin care programs include accurate and consistent assessment and documentation as well as interventions to protect the skin (e.g., turn the client at least every 2 hours). Keeping the skin dry is very important in preventing skin breakdown, range-of-motion exercises will help prevent contractures from occurring, lift equipment will help decrease harm to both clients and staff, but turning the client will best help prevent pressure ulcers.
PTS: 1 DIF: B REF: 1225 OBJ: Application
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
34. The nurse caring for a 78-year-old male client recovering from hip replacement surgery is assessing for signs of improvement of the client’s activity tolerance. The nurse determined a baseline for ongoing assessments by:
1.
Determining how much time it takes the client to recover from an activity
2.
Assessing how much the client can do at one time
3.
Determining the level of pain experienced by the client during the activity
4.
Asking the client how much the client feels like doing
ANS: 1
When the client experiences decreased activity tolerance, carefully assess how much time the client needs to recover. Decreasing recovery time indicates improving activity tolerance. Pain should not be an assessment of activity tolerance. Asking the client how much he feels like doing before an activity will not tell the nurse if he is improving over time. The client may be able to do more (or less) than he thinks he is capable of doing before an activity.
PTS: 1 DIF: A REF: 1225 OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
35. The nurse and a nursing assistive personnel (NAP) are going to move an older adult client up in bed. Before moving the client, the nurse explains to the NAP that they will need to lift the client off the bed with an assistive device instead of using the drawsheet. The most important reason for using the assistive device is:
1.
To avoid frightening the client
2.
To avoid shearing the client’s skin
3.
To avoid getting “written up” for not following lift procedures
4.
Because the nurse is tired
ANS: 2
The greater the surface area of the object that is moved, the greater the friction. A larger object produces greater resistance to movement. To decrease surface area and reduce friction when clients are unable to assist with moving up in bed, nurses use an ergonomic assistive device, such as a full body sling. It mechanically lifts the client off the surface of the bed, thereby preventing friction, tearing, or shearing of the client’s delicate skin. The client may also be frightened by the use of the equipment. It is important to explain what will be going on and what the client can expect to experience when using any piece. Lift policies are put in place to protect both clients and staff; however, the nurse should not be as concerned with being “written up” as with protecting himself or herself, the NAP, and the client from harm. The most important reason for using the lift equipment is to protect the client and staff from harm.
PTS: 1 DIF: B REF: 1220 OBJ: Application
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
36. The nurse understands that using metabolic functioning, measures of height, weight, and skinfold thickness, to evaluate muscle atrophy in an immobilized client is known as:
1.
Anthropometric measurements
2.
Anhydrous measurements
3.
Balke test
4.
Calorimetry
ANS: 1
When assessing metabolic functioning, use anthropometric measurements (measures of height, weight, and skinfold thickness) to evaluate muscle atrophy. Anhydrous means without water, the Balke test determines maximum oxygen utilization, and calorimetry is the determination of heat loss or gain.
PTS: 1 DIF: A REF: 1247 OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
MULTIPLE RESPONSE
1. The nurse recognizes that facilitating correct body alignment for a dependent client may well result in which of the following positive client outcomes? (Select all that apply.)
1.
A comfortable night’s sleep
2.
Minimized activity intolerance
3.
Muscle tone that promotes ambulation
4.
Reduction of falls caused by general weakness
5.
Minimal strain placed on the spinal column
6.
Increased socialization, resulting in peace of mind
ANS: 1, 2, 3, 4, 5
Correct body alignment reduces strain on musculoskeletal structures, aids in maintaining adequate muscle tone, promotes comfort, and contributes to balance and conservation of energy. Although a client experiencing the benefits of proper body alignment and thus experiencing the positive outcomes may well experience increased peace of mind, there is not a clear connection between the two.
PTS: 1 DIF: C REF: 1227 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
2. The nurse chooses to use a mechanical lift to move an obese immobile client. The nurse recognizes that the positive outcomes for both the client and the staff resulting from this intervention will be: (Select all that apply.)
1.
Less of the client’s body will be dragged along the sheets during the transfer
2.
There will be less chance of injuring the skin on the client’s elbows and buttocks
3.
The staff involved in the transfer will have less likelihood of self-injury
4.
The staff will have a greater degree of control over the move
5.
The client will feel physically safer during the transfer
6.
The move will be accomplished more quickly
ANS: 1, 2, 3, 4
Mechanical lifts raise the client off the surface of the bed, thereby preventing friction, tearing, or shearing of the client’s delicate skin; it also protects the nurse and other staff from injury. There is no guarantee that the move will be quicker or that the client will feel safer.
PTS: 1 DIF: C REF: 1228 OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
3. A 16-year-old has had a full leg cast in place for 2 months, and it is being removed today. Which of the following assessment findings would be expected following the removal of the cast? (Select all that apply.)
1.
Popliteal pulse equal in both legs
2.
Slight footdrop noted on affected leg
3.
Swelling noted at ankle on affected leg
4.
Weight bearing less stable on affected leg
5.
Calf circumference greater in unaffected leg
6.
Greater range of motion of knee of unaffected leg
ANS: 1, 4, 5, 6
Even this temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Pulses should be equal, and there should not be swelling or footdrop on either foot.
PTS: 1 DIF: C REF: 1229 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
4. Which of the following factors has an impact on the severity of physical impairment a client will experience from a period of immobility? (Select all that apply.)
1.
The client’s age
2.
Prior overall health
3.
Length of immobility
4.
The degree of immobility
5.
Situation requiring the inactivity
6.
Client’s mental attitude about the limitations
ANS: 1, 2, 3, 4
The severity of the impairment depends on the client’s overall health, degree and length of immobility, and age. The resulting effects are not dictated by situation or attitude.
PTS: 1 DIF: C REF: 1236 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
5. A client who experienced a myocardial infarction has been placed on bed rest. The nurse caring for the client recognizes that the inactivity will result in certain assessment findings that include: (Select all that apply.)
1.
Lethargy
2.
Confusion
3.
Depression
4.
Poor appetite
5.
Hypoactive bowel sounds
6.
Decrease in baseline respiratory rate
ANS: 1, 4, 5, 6
Immobility disrupts normal metabolic functioning; decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. Cognitive and psychological alterations are not directly caused by the inactivity.
PTS: 1 DIF: C REF: 1238 OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Mobility/Immobility
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