Homework Lance
1.An elderly patient was admitted to the hospital after falling in the nursing home. The patient has a fractured right femur and is awaiting surgery. The surgeon orders bed rest. The patient asks the nurse what this means. What is the nurse’s best explanation?
a.
“You are to be immobile.”
b.
“You cannot move.”
c.
“You need restraints.”
d.
“You have to remain in bed.”
ANS: D
A patient’s mobility can be restricted for therapeutic reasons, such as when bed rest is ordered. Therapeutic reasons for bed rest include decreasing the body’s oxygen needs, reducing cardiac workload, reducing pain, and allowing the debilitated or ill patient to rest. The duration of bed rest depends on the type and nature of the illness or injury and the patient’s prior state of health. Bed rest does not mean immobile, cannot move, or that restraints are needed.
PTS:1DIF:Cognitive Level: Applying (Application)
REF:1035OBJ:Describe mobility and immobility.
TOP:Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
2.The patient is recovering from a cerebrovascular accident (stroke). The patient is having problems with balance and coordination. The patient asks the nurse what part of the brain has been damaged. How should the nurse respond?
a.
The hypothalamus has been damaged.
b.
The cerebellum has been damaged.
c.
The thalamus has been damaged.
d.
The medulla oblongata has been damaged.
ANS: B
Damage to the cerebellum causes problems with balance, and motor impairment is directly related to the amount of destruction of the motor strip. The hypothalamus controls temperature. The thalamus controls the five senses: hearing, seeing, taste, smell, and touch. The medulla oblongata is part of the brainstem and controls breathing, heart rate, and digestion.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:1033
OBJ: Describe common physical and physiological changes associated with immobility.
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
3.A student nurse is caring for a young adult patient who is immobile with a back injury. On auscultation, the student nurse hears rhonchi in the lower lobes. The student nurse reports this symptom because the patient is developing which complication?
a.
Increased lung expansion
b.
Hypostatic pneumonia
c.
Aspiration pneumonia
d.
Increased diuresis
ANS: B
Decreased, not increased, lung expansion, generalized respiratory muscle weakness, and dependent stasis of secretions occur with immobility. These conditions often contribute to the development of atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Aspiration pneumonia results from aspiration, not from immobility. Diuresis is increased urine excretion.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:1035
OBJ: Describe common physical and physiological changes associated with immobility.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
4.A young adult patient was involved in a motorcycle accident. The patient was in the intensive care unit of the hospital for 2 months with immobility and was just discharged to a rehabilitation hospital. The patient asks the nurse, “Why am I so weak?” What is the bestresponse from the nurse?
a.
“When you are in bed for a long time, your body begins to break down its own protein.”
b.
“When you don’t use it, you lose it.”
c.
“You haven’t eaten much for the past couple of months.”
d.
“Your body has spent energy trying to heal itself by increasing the metabolic rate.”
ANS: A
Immobility disrupts normal metabolic functioning, decreasing the metabolic rate and altering the metabolism of carbohydrates, proteins, and fats. A patient’s basal metabolic rate (BMR) decreases in response to reduced cellular energy because of the body’s decreased ability to produce insulin and metabolize glucose. The body then begins to breakdown its protein stores for energy resulting in a negative nitrogen balance and increased oxygen demands. However, in the presence of an infection, immobilized patients have an increased BMR. It is the immobility that has caused the weakness, not what was eaten. Not using it leads to losing it is a cliché and should be avoided. The metabolic rate is decreased in immobility not increased.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF: 1035 OBJ: Identify changes in metabolic rate associated with immobility.
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
5.Patients on prolonged bed rest are at risk for a deep vein thrombosis. Which information indicates the nurse needs more teaching about the factors in Virchow’s triad?
a.
One of the factors is loss of integrity of the vessel wall.
b.
One of the factors is abnormalities of blood flow.
c.
One of the factors is alterations in blood constituents.
d.
One of the factors is atrophy of the muscles.
ANS: D
Three factors contribute to venous thrombus formation: (1) loss of integrity of the vessel wall (e.g., injury), (2) abnormalities 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 referred to as Virchow’s triad. Disuse, atrophy, and shortening of muscle fibers and surrounding joint tissues cause joint contracture, not deep vein thrombosis.
PTS:1DIF:Cognitive Level: Applying (Application)
REF:1036
OBJ: Describe common physical and physiological changes associated with immobility.
TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity
6.An elderly nursing home resident fell 2 weeks ago and has been on bed rest. The patient has become increasingly fatigued during activities of daily living (ADLs). The family is concerned about the patient’s declining condition. The best explanation that the nurse can give the family is that the patient’s fatigue is caused by which of the following?
a.
Decreased muscle endurance caused by immobility
b.
Advanced age
c.
Increased metabolism
d.
Urinary stasis
ANS: A
The body loses muscle strength when muscles are inactive. The rate of muscle decline varies with the degree of immobility, but it is rapid while mobility and weight bearing are restricted. These effects are devastating to patients who are marginally functional with their ADLs. This fatigue is a result of the bed rest, not from advanced age or urinary stasis. Reduced metabolism, not increased, leads to a loss of muscle and body mass, causing fatigue with prolonged activity. Urinary stasis does not affect activity level, but can lead to urinary tract infections.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:1035 | 1036
OBJ: Describe common physical and physiological changes associated with immobility.
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
7.Which patient is at greatest risk for developing a pressure ulcer?
a.
Young adult paraplegic with pneumonia
b.
Middle age adult that can turn by self in bed
c.
Teenager with a sprained ankle on crutches
d.
Middle-age adult with breast cancer
ANS: A
The paraplegic (paralyzed) is most at risk. The direct effect of pressure on the skin by immobility is compounded by metabolic changes. Older adult patients and patients with paralysis have a greater risk for developing pressure ulcers. A breast cancer patient is mobile as is the teenager on crutches, which decreases their risk. The middle-age adult is turning, decreasing the risk of pressure ulcers.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF: 1049 OBJ: Discuss factors that contribute to pressure ulcer formation.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
8.Which patient is most at risk for developing a urinary tract infection?
a.
Teenage comatose patient on a ventilator lying supine
b.
Middle-age adult after abdominal surgery sitting in a chair
c.
Elderly adult with Alzheimer disease who is wandering at night
d.
Middle-age adult postcardiac catheterization being discharged home
ANS: A
The patient most at risk is the teenage comatose patient on a ventilator lying supine. When the patient is in bed, the kidneys and ureters move toward a more level plane, and urine tries to move from the kidney to the bladder against gravity. Because the peristaltic contractions of the ureters are not strong enough to overcome gravity when the patient is reclining, the renal pelvis fills before urine enters the ureters, which increases the patient’s risk for urinary tract infection (UTI) and renal calculi. The elderly adult with Alzheimer and the middle-age adult post cardiac catheterization are both upright, which decreases chance for UTI. The middle-age adult after abdominal surgery is sitting in a chair, which decreases chance for UTI because gravity is helping the ureters drain.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:1050
OBJ: Describe common physical and physiological changes associated with immobility.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
9.The nurse working with a new nursing assistive personnel (NAP), is explaining about the importance of repositioning immobile patients to prevent pressure ulcers. At a minimum, the nurse tells the NAP to reposition patients how often?
a.
Every 2 hours
b.
Every 3 hours
c.
Every 4 hours
d.
Once every shift
ANS: A
Immobilized patients require vigilant nursing care, such as repositioning at least every 2 hours, to avoid physical complications. Every 3 or 4 hours or once every shift is too long.
PTS:1DIF:Cognitive Level: Applying (Application)
REF: 1049 OBJ: Discuss factors that contribute to pressure ulcer formation.
TOP:Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
10.Which patient is most likely to have developmental effects due to prolonged immobility?
a.
Toddler patient in traction for a congenital skeletal anomaly
b.
Young adult patient with burns on the hands
c.
Teenage patient with a bacterial infection in isolation
d.
Middle-age adult patient with a fractured ankle on crutches
ANS: A
The toddler would be most affected because of the prolonged immobility. Developmental effects of immobility more commonly affect the very young and the older adult. When the infant, toddler, or preschooler is immobilized, it is usually because of trauma or the need to correct a congenital skeletal abnormality. Prolonged immobilization delays the child’s motor skill and intellectual development. The immobilized young or middle-age adult experiences few, if any, developmental changes. The young and middle adult patients are mobile, not immobile. The teenage patient may have developmental effects due to the isolation but the question asked for prolonged immobility, which this patient does not have.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:1050
OBJ: Describe psychosocial and developmental effects of immobilization.
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
11.The nurse is observing a patient’s posture while sitting, standing, and assessing gait. What is the rationale for the nurse’s assessment?
a.
To determine type of assistance with anthropometric measurements
b.
To determine type of assistance with joint mobility
c.
To determine type of assistance with range of motion (ROM)
d.
To determine type of assistance with ambulation
ANS: D
Observing the patient’s posture while sitting and standing and assessing gait helps to determine the type of assistance the patient requires for ambulation or transfer. Assessment of ROM is important as a baseline measurement to compare and evaluate whether loss in joint mobility has occurred. Anthropometric measurements are for nutrition, not for mobility. Anthropometric measurements include height, weight, mid upper-arm circumference, and triceps skinfold measurements.
PTS:1DIF:Cognitive Level: Applying (Application)
REF:1038
OBJ: Discuss the appropriate decision-making process when choosing equipment needed for safe patient handling and movement. TOP: Nursing Process: Assessment
MSC:Client Needs: Physiological Integrity
12.Which action should the nurse implement to help prevent thrombus formation in postsurgical patients?
a.
Maintain complete bed rest.
b.
Place tight clothing on the legs and waist.
c.
Put pillows under the knees.
d.
Position properly with use of antiembolic stockings.
ANS: D
Proper positioning used with other therapies (e.g., anticoagulants and antiembolic stockings) helps reduce thrombus formation. When positioning patients, use caution to prevent pressure on the posterior knee and deep veins in the lower extremities. Teach patients to avoid crossing the legs, sitting for prolonged periods of time, wearing tight clothing that constricts the legs or waist, putting pillows under the knees, and massaging the legs. Complete bed rest increases the chance for thrombus formation.
PTS:1DIF:Cognitive Level: Applying (Application)
REF:1042 | 1049
OBJ:List appropriate nursing interventions for an immobilized patient.
TOP:Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
13.A nurse is caring for an immobile patient. What is the most appropriate nursing intervention to implement?
a.
Turn the patient every 4 hours.
b.
Apply an abdominal binder while the patient is lying in bed.
c.
Encourage the regular use of incentive spirometry while awake.
d.
Maintain the patient’s maximum fluid intake of 1000 mL daily.
ANS: C
You can also promote lung expansion through regular deep breathing exercises, use of an incentive spirometer, and forceful coughing. Changing the position of the patient at least every 2 hours, not 4, allows the dependent lung regions to re-expand, maintains the elastic recoil property of the lungs, and clears the dependent lung regions of pulmonary secretions. Your assessment will determine if patients need more frequent position changes. An application of an abdominal binder will restrict chest expansion. Make sure that the immobile patient has a fluid intake of at least 2000 mL per day, if not contraindicated, to help keep mucociliary clearance intact.
PTS:1DIF:Cognitive Level: Applying (Application)
REF:1048
OBJ:List appropriate nursing interventions for an immobilized patient.
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
14.A nurse notes a typical cardiovascular change in an immobilized postoperative patient. Which of the following did the nurse find upon assessment?
a.
Atelectasis
b.
Negative nitrogen balance
c.
Orthostatic hypotension
d.
Bleeding
ANS: C
Orthostatic hypotension, a common cardiovascular response, occurs in patients on bed rest and after prolonged sitting. Orthostatic hypotension is an increase in heart rate of more than 15% and a drop of 15 mm Hg or more in systolic blood pressure or a decrease of 10 mm Hg in diastolic blood pressure when the patient rises from a lying or sitting position to a standing position. Respiratory changes, not cardiovascular, include decreased lung expansion, generalized muscle weakness, and stasis of secretions. These conditions are consistent with the development of atelectasis. Three factors contribute to thrombus formation (not bleeding), which include loss of integrity of vessel wall, abnormalities of blood flow, and changes in clotting factors/increased platelet activity.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:1035 | 1036
OBJ: Describe common physical and physiological changes associated with immobility.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
15.A nurse is caring for a patient in Buck’s traction on bed rest for a fracture of the femur. Which action should the nurse take to help preserve skin integrity?
a.
Provide meticulous skin care.
b.
Use pain medication to prevent excessive movement.
c.
Limit range of joint motion so the patient is not disturbed.
d.
Reduce the amount of protein intake so renal function can be preserved.
ANS: A
Interventions aimed at prevention of pressure ulcers are positioning, skin care, and the use of pressure-relief devices. Change the immobilized patient’s position according to the patient’s activity level, perceptual ability, status of peripheral circulation, treatment protocols, and daily routines. A patient needs adequate, not reduced, protein intake to ensure wound healing and tissue growth and to prevent a negative nitrogen balance. Patients whose mobility is restricted require ROM to reduce the hazards of immobility; ROM should not be limited. Pain medication is to relieve pain, not to prevent excessive movement.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:1042
OBJ:List appropriate nursing interventions for an immobilized patient.
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
16.Nurses implement therapeutic immobilization for patients to achieve which result?
a.
Reducing pain
b.
Restraining an unstable patient in bed
c.
Increasing active movement of the body
d.
Strengthening joints and muscles
ANS: A
Therapeutic reasons for bed rest include decreasing the body’s oxygen needs, reducing cardiac workload, reducing pain, and allowing the debilitated or ill patient to rest. Restraining an unstable patient in bed is not a reason for therapeutic immobilization. Restraining is a last resort. The body loses muscle strength when muscles are inactive; therapeutic immobilization does not strengthen joints and muscles. Bed rest is to limit active movement of the body, not to increase it.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:1035
OBJ: Describe common physical and physiological changes associated with immobility.
TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity
17.Which assessment finding should the nurse expect to observe on an immobilized patient?
a.
Increased serum glucose levels
b.
Decreased urine excretion
c.
Positive nitrogen balance
d.
Increased serum potassium levels
ANS: A
A patient’s basal metabolic rate (BMR) decreases in response to reduced cellular energy because of the body’s decreased ability to produce insulin and metabolize glucose. In the immobilized patient, a major shift in blood volume occurs, which causes diuresis (increased urine excretion). Diuresis causes the body to lose electrolytes, such as potassium and sodium. When the body is unable to metabolize glucose, it begins to break down protein stores for energy, resulting in negative nitrogen balance, not positive.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF: 1035 OBJ: Identify changes in metabolic rate associated with immobility.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
18.While planning care for an immobilized patient, which physiological process will the nurse consider about the patient’s musculoskeletal system?
a.
Increased muscle mass
b.
Decreased rate of bone resorption
c.
Muscle atrophy
d.
Bone tissue density elevated
ANS: C
During immobility, the muscle atrophies, and the size of the muscle decreases. As immobility progresses and muscles are not exercised, muscle mass continues to decrease, not increase. Immobilization increases (not decreases) the rate of bone resorption, which results in reduced (not elevated) bone tissue density.
PTS:1DIF:Cognitive Level: Applying (Application)
REF:1036
OBJ: Describe common physical and physiological changes associated with immobility.
TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity
19.A patient is recovering from an abdominal aortic bypass graft. To reduce the effects of orthostatic hypotension, what is the most appropriate action for the nurse to take?
a.
Encourage moving positions slowly.
b.
Perform isometric exercises.
c.
Decrease the number of ankle pumps.
d.
Participate in chest physiotherapy.
ANS: A
Moving positions slowly will help with orthostatic hypotension by allowing the body to adapt. Orthostatic hypotension is an increase in heart rate of more than 15% and a drop of 15 mm Hg or more in systolic blood pressure or a decrease of 10 mm Hg in diastolic blood pressure when the patient rises from a lying or sitting position to a standing position. Isometric exercises, which are activities that involve muscle tension without muscle shortening, do not have any effect on preventing orthostatic hypotension, but improve activity tolerance. Ankle pumps help to prevent deep vein thrombosis. Participating in chest physiotherapy assists patients with decreasing effects of pulmonary complications.
PTS:1DIF:Cognitive Level: Applying (Application)
REF: 1035 | 1036 | 1045
OBJ:List appropriate nursing interventions for an immobilized patient.
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
20.A nurse has finished preoperative teaching for a surgical patient. Which statement by the patient indicates teaching was successful about the use of elastic stockings?
a.
“I do not have to worry about wrinkles.”
b.
“I can roll them no lower than my calf.”
c.
“I will massage my legs regularly.”
d.
“I should remove and reapply them every 8 hours.”
ANS: D
Remove and reapply elastic stockings at least every 8 hours. Elastic stocking aid in maintaining pressure on the muscles of the lower extremities and promote venous return. Rolled-down stockings constrict the vessels and impede venous return. The elastic stocking should be smooth, not wrinkled. The legs should not be massaged.
PTS:1DIF:Cognitive Level: Applying (Application)
REF: 1042 | 1053 OBJ: Evaluate nursing care for the immobilized patient.
TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity
21.A young adult was involved in a motor vehicle accident and suffers from brain trauma. The patient has decrease mobility in all joints. The nurse should assess for which common, debilitating contracture?
a.
Lordosis
b.
Bowlegs
c.
Footdrop
d.
Kyphosis
ANS: C
One common and debilitating contracture is footdrop. When footdrop occurs, the foot is permanently in plantar flexion. Patients are no longer able to walk when this occurs. Lordosis is the exaggeration of the anterior convex curve of the lumbar spine caused by a congenital condition or a temporary condition such as pregnancy. Bowlegs (genu varum) is one or both legs bent outward at the knee, which is normal until 2 to 3 years of age and is caused by a congenital condition or rickets. Kyphosis is the increased convexity in curvature of thoracic spine for a congenital condition, rickets, osteoporosis, or tuberculosis of the spine.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:1034 | 1036
OBJ: Describe common physical and physiological changes associated with immobility.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
22.A patient has decrease mobility in all joints. Because of the lack of mobility, the nurse expects the health care provider to order what medication to prevent venous thromboembolisms that will reduce the side effect of hemorrhage?
a.
Oral anticoagulant
b.
Aspirin
c.
Low-molecular-weight heparin
d.
Unfractionated heparin
ANS: C
Newer low-molecular-weight (LMW) heparins such as ardeparin and enoxaparin are being prescribed in place of older forms of unfractionated heparin. The LMW heparins have a more predictable anticoagulant effect. Low-molecular-weight heparin compared with unfractionated heparin reduces the occurrence of major hemorrhage as a side effect.
Heparin is an anticoagulant that suppresses clot formation. This therapy requires a health care provider’s order. Aspirin and oral anticoagulants increase the risk for hemorrhage.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:1052
OBJ:List appropriate nursing interventions for an immobilized patient.
TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity
MULTIPLE RESPONSE
1.When completing the assessment of an immobilized patient, the most likely place for the nurse to assess edema includes which of the following? (Select all that apply.)
a.
Face
b.
Feet
c.
Sacrum
d.
Abdomen
e.
Legs
ANS: B, C, E
Because edema moves to dependent body regions as a result of gravity, assessment of the immobilized patient includes the sacrum, legs, and feet. Face and abdomen are not dependent areas.
PTS:1DIF:Cognitive Level: Applying (Application)
REF: 1042 OBJ: Complete a nursing assessment of an immobilized patient.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2.Immobilized patients often become depressed. A nurse can best combat this effect of immobilization by doing which of the following? (Select all that apply.)
a.
Limiting visitors so the patient is not bothered
b.
Involving the patient in planning time for care and activities
c.
Placing the patient in a private room to reduce the interruptions by a roommate
d.
Encouraging the patient to comb hair, wear make-up, and/or use cologne if appropriate
e.
Having the patient in a room with another patient who is interactive.
ANS: B, D, E
Involve patients in their care whenever possible. For example, have the patient determine when the bed should be made. Some patients rest better during the night when fresh sheets are put on in the evening rather than in the morning. Keep hygiene and grooming articles within easy reach. Encourage patients to wear their glasses or artificial teeth and to shave or apply makeup. These are normal activities to enhance body image, thus improving the patient’s outlook. If possible, place the patient in a room with others who are mobile and interactive. If a private room is required, ask staff members to visit throughout the shift to provide meaningful interaction. Limiting visitors is not beneficial.
PTS:1DIF:Cognitive Level: Applying (Application)
REF:1042 | 1055 | 1056
OBJ: Describe psychosocial and developmental effects of immobilization.
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
3.The patient was involved in a motor vehicle accident. The patient has a fractured right hip and is on bed rest. Because of the prolonged immobility the nurse is concerned about complications such as which of the following? (Select all that apply.)
a.
Decreased nutrients/fluids
b.
Increased disuse osteoporosis
c.
Increased gastrointestinal motility
d.
Decreased lung expansion
e.
Decreased pooling of lung secretions
ANS: A, B, D
Physiological outcomes from immobility include: decreased nutrients/fluids, decreased lung expansion, increased (not decreased) pooling of lung secretions, and increased disuse osteoporosis. Decreased (not increased) gastrointestinal motility occurs.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF:1035
OBJ: Describe common physical and physiological changes associated with immobility.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
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