Chapter 28 Imobility

Question 1

An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the pt has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply)

1. B/P = 128/84
2. Respirations 26/min on room air
3. HR 114
4. Crackles over lover lobe heard on auscultation
5. Pain reported as 3 on scale of 0 to 10 after medication

Answer 1

2. Respirations 26/min on room air
3. HR 114
4. Crackles over lover lobe heard on auscultation

Question 2

A pt has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility:

1. Decreased peristalsis
2. Decreased HR
3. Increased B/P
4. Increased urinary output

Answer 2

1. Decrease peristalsis

Question 3

The nurse puts elastic stockings on a pt following major abdominal surgery. The nurse teaches the pt that the stockings are used after a surgical procedure to:

Answer 3

Promote venous return to the heart

Question 4

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply)

1. “I usually go swimming with my family at the YMCA 3 times a week”
2. “I need to ask my doctor if I should have a bone mineral density check this year”
3. “If I don’t drink my milk at dinner, I’ll eat broccoli or cabbage to get the calcium that I need in my diet”
4. “I’ll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill”
5. “My lactose intolerance should not be a concern when considering my calcium intake”

Answer 4

1. “I usually go swimming with my family at the YMCA 3 times a week”
2. “I need to ask my doctor if I should have a bone mineral density check this year”
3. “If I don’t drink my milk at dinner, I’ll eat broccoli or cabbage to get the calcium that I need in my diet

Question 5

A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the nursing measures will best facilitate the resumption of activities of daily living for this patient?

1. Encouraging use of an overhead trapeze for positioning and transfer
2. Frequent family visits
3. Assisting the patient to a wheelchair one per day
4. Ensuring that there is an order for physical therapy

Answer 5

1. Encouraging use of an overhead trapeze for positioning and transfer

Question 6

An older-adult pt has been bedridden for 2 weeks. Which of the following complaints by the pt indicates to the nurse that he or she is developing a complication of immobility?

1. Loss of appetite
2. Gum soreness
3. Difficulty swallowing
4. Left ankle joint stiffness

Answer 6

4. Left ankle joint stiffness

Question 7

A pt is receiving 5000 units of heparin subQ every 12 hrs while on prolonged bed rest to prevent thrombophelbitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the pt for the following signs of bleeding: (Select all that apply)

1. Bruising
2. Pale yellow urine
3. Bleeding gums
4. Coffee ground-like vomitus
5. Light brown stool

Answer 7

1. Bruising
2. Bleeding gums
3. Coffee ground-like vomitus

Question 8

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend?

1. Cream of broccoli soup with whole wheat cracker, cheese, and tapioca pudding for dessert
2. Hotdog on whole wheat bun with a side salad and a apple for dessert
3. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert
4. Turkey salad on toast with tomato and lettuce and honey bun for dessert

Answer 8

1. Cream of broccoli soup with whole wheat cracker, cheese, and tapioca pudding for dessert

Question 9

The nurse evaluates that the NAP has applied a patients sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply)

1. Initial pt measurement is made around the calves
2. Inflation pressure averages 40 mm Hg
3. Pts leg placed in SCD sleeve with back of knee aligned with politeal opening on the sleeve
4. Stockings are removed every 2 hours during application
5. Yellow light indicates SCD device is functioning

Answer 9

2. Inflation pressure averages 40 mm Hg

3. Pts leg placed in SCD sleeve with back of knee aligned with politeal opening on the sleeve

Question 10

A pt on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventative measures are not taken?

1. Myoclonus
2. Pathological fractures
3. Pressure ulcers
4. Pruritus

Answer 10

3. Pressure ulcers

Question 11

The effects of immobility on the cardiac system include which of the following? (Select all that apply)

1. Thrombus formation
2. Increased cardiac workload
3. Weak peripheral pulses
4. Irregular heartbeat
5. Orthostatic hypotension

Answer 11

1. Thrombus formation
2. Increased cardiac workload
3. Orthostatic hypotension

Question 12

To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a pt who has had abdominal surgery?

1. Turn, cough, and deep breathe every 30 minutes while awake
2. Ambulated patient to chair in the hall
3. Passive range of motion 4 times a day
4. Immobility is not a concern the first postoperative day

Answer 12

2. Ambulated patient to chair in the hall

Question 13

Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?

1. Isometric exercises
2. Administration of low-dose heparin
3. Suctioning every 4 hours
4. Use of incentive spirometer every 2 hours while awake

Answer 13

4. Use of incentive spirometer every 2 hours while awake

Question 14

Place the following options in the order in which elastic stockings should be applied:

1. Identify patient using two identifiers
2. Smooth any creases or wrinkles
3. Slide the remainder of the stocking over the pts heel and up the leg
4. Turn the stocking inside out until heel is reached
5. Assess the condition of the patients skin and circulation of the legs
6. Place toes into foot of the stocking
7. Use tape measure to measure pts legs to determine proper stocking size

Answer 14

1. Identify patient using two identifiers
2. Assess the condition of the patients skin and circulation of the legs
3. Use tape measure to measure pts legs to determine proper stocking size
4. Turn the stocking inside out until heel is reached
5. Place toes into foot of the stocking
6. Slide the remainder of the stocking over the pts heel and up the leg
7. Smooth any creases or wrinkles

Question 15

Which of the following are physiological outcomes of immobility?

1. Increased metabolism
2. Reduced cardiac workload
3. Decreased lung expansion
4. Decreased oxygen demand

Answer 15

3. Decreased lung expansion