Chapter 47 Flashcards
(Potter 1175) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition.
An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate 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 per minute on room air
3 HR 114
4 Crackles heard on auscultation
5 Pain reported as 3 on scale of 0 to 10 after medication.
2, 3,4
Respirations 26 per minute on room air, HR 114, and Crackles heard on auscultation
A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, “It hurts when I try to breathe, and I can’t catch my breath.” Your first action is to:
1 Call the health care provider to report this change in condition.
2 Give the patient a paper bag to breathe into to decrease her anxiety.
3 Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen.
4 Explain that this is normal after such trauma and administer the ordered pain medication.
- Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen
The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to:
1 Prevent varicose veins.
2 Prevent muscular atrophy.
3 Ensure joint mobility and prevent contractures.
4 Promote venous return to the heart.
4.
A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education?
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 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.”
4 “I’ll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill.”
The patient at greatest risk for developing multiple adverse effects of immobility is a:
1 1-year-old child with a hernia repair.
2 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA).
3 51-year-old woman following a thyroidectomy.
4 38-year-old woman undergoing a hysterectomy.
2 80-year old woman who has suffered a hemorrhagic cerebrovascular accident (CVA)
An older adult who was in a car accident and fractured his femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time?
1 Chronic pain
2 Impaired skin integrity
3 Risk for ineffective cerebral tissue perfusion
4 Risk for activity intolerance
4 Risk for activity intolerance
A patient had a left-sided cerebrovascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore nasogastric (NG) tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately?
1 Pale yellow urine
2 Unilateral neglect
3 Slight movement noted on the R side
4 Coffee ground–like aspirate from the feeding tube
- Coffee ground like aspirate from the feeding tube
A home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a quad-cane. Which of the following must be corrected or removed for the patient’s safety? (Select all that apply.)
1 The rubber mat in the walk-in shower
2 The three-legged stool on wheels in the kitchen
3 The braided throw rugs in the entry hallway and between the bedroom and bathroom
4 The night-lights in the hallways, bedroom, and bathroom
5 The cordless phone next to the patient’s bed
2,3
The three-legged stool on wheels in the kitchen and the braided throw rug in the entry hallway and between the bedroom and bathroom
The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. The nurse would recommend which of the following menus?
1 Cream of broccoli soup with whole wheat crackers and tapioca for dessert
2 Hamburger on soft roll with a side salad and an apple for dessert
3 Low-fat turkey chili with sour cream and fresh pears for dessert
4 Chicken salad on toast with tomato and lettuce and honey bun for dessert
1 Cream of broccoli soup with whole wheat crackers and tapioca for dessert
Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.)
1 Patient’s weight
2 Patient’s level of cooperation
3 Patient’s ability to assist
4 Presence of medical equipment
5 24-hour calorie intake
- 1, 2, 3, 4;
24- hour calorie intake is not correct
A patient of any age can develop a contracture of a joint when:
1 The adductors muscles are weakened as a result of immobility.
2 The muscle fibers become shortened because of disuse.
3 The calcium-to-phosphorus ratio becomes disrupted.
4 There is a deficiency in vitamin D.
- 2
The muscle fibers become shortened because of disuse
Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would reduce this risk? (Select all that apply.)
1 Repositioning patient every 1 to 2 hours while awake
2 Using an objective, valid scale to assess patient’s risk for pressure ulcer development
3 Using a device to relieve pressure when patient is seated in chair
4 Teaching patient how to shift weight at regular intervals while sitting in a chair
5 A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes
- 2, 3, 4, 5
Repositioning patient every 1 to 2 hours while awake is incorrect
Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher?
1 The patient is 5 feet 6 inches and weighs 120 lbs.
2 The patient speaks and understands English.
3 The patient received an injection of morphine 30 minutes ago for pain.
4 You feel comfortable handling a patient of his size and with his level of cooperation.
- 3
The patient received an injection of morphine 30 minutes ago for pain.
A patient with left-sided weakness asks his nurse, “Why are you walking on my left side? I can hold on to you better with my right hand.” What would be your best therapeutic response?
1 “Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you.”
2 “Would you like me to walk on your right side so you feel more secure?”
3 “Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side.”
4 “By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint. (
- 4
“by walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.”
Which is an outcome for a patient diagnosed with osteoporosis?
1 Maintain serum level of calcium.
2 Maintain independence with activities of daily living (ADLs).
3 Reduce supplemental sources of vitamin D.
4 Reverse bone loss through dietary manipulation.
- 2
Maintain independence with activities of daily living (ADL)
Range of motion (ROM)
is the maximum amount of movement available at a joint in one of the three planes
Assessment of patient mobility focuses on ROM, gait, exercise and activity tolerance, and body alignment.
Mobility
Extension
Return head to erect position
anthropometric measurements
Body measures of height, weight, and skinfolds to evaluate muscle atrophy.
anaphylactic reactions
Hypersensitive condition induced by contact with certain antigens.
Adverse effect:
Harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention.
Adduction
Movement of a limb toward the body.
activity tolerance
Kind or amount of exercise or work that a person is able to perform
Position of maximal extension of a joint.
Hyperextension:
Movement of the limb away from the body
Abduction:
Absorption
Passage of drug molecules into the blood. Factors influencing drug absorption include route of administration, ability of the drug to dissolve, and conditions at the site of absorption.
buccal
Of or pertaining to the inside of the cheek or the gum next to the cheek.
Cheyne-Stokes respiration
Occurs when there is decreased blood flow or injury to the brainstem.
gait
Manner or style of walking, including rhythm, cadence, and speed.
friction
Effects of rubbing or the resistance that a moving body meets from the surface on which it moves; a force that occurs in a direction to oppose movement.
are white, glistening, fibrous bands of tissue that connect muscle to bone. They are strong, flexible, and inelastic; and they occur in various lengths and thicknesses.
Tendons
a nonvascular (without blood vessels) supporting connective tissue located chiefly in the joints and thorax, trachea, larynx, nose, and ear.
Cartilage
concentric tension
increased muscle contraction causes muscle shortening, resulting in movement such as when a patient uses an overhead trapeze to pull up in bed.
Eccentric tension
helps control the speed and direction of movement.
(static contraction) causes an increase in muscle tension or muscle work but no shortening or active movement of the muscle (e.g., instructing the patient to tighten and relax a muscle group, as in quadriceps set exercises or pelvic floor exercises).
Isometric contraction
Muscle tone, or tonus
is the normal state of balanced muscle tension.
The regulation of posture and movement is also regulate by which system?
Nervous system
is an accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel.
A thrombus
What three factors should a nurse assess, when dealing with Thrombus.
damage to the vessel wall (e.g., injury during surgical procedures)
alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest)
(3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity).
are the factors causing blood clot.
Virchow’s triad
To avoid Thrombus formation, the nurse should teach the client.
avoid crossing legs
sitting for prolonged periods of time wearing clothing that constricts the
legs or waist
putting pillows under the knees
massaging legs
Prevent pressure on posterior knee & deep veins in lower extremities
To avoid Thrombus formation, the nurse should do?
ROM Antiembolic exercises: Fluids Positioning Heparin and low-molecular weight heparin SCDS and IPCs stockings Thromboembolic Device (TED)Hose aka elastic stockings
What assistive devices do patients use?
Walkers
Canes
Crutches and Crutch Gaits
Gait Belt
Trochanter roll
prevents external rotation of the hips when the client is in supine position
Fowlers
HOB elevated 45-60 degrees and the knees are slightly elevated
Embolus
A foreign object, a quantity of air or gas, a bit of tissue or tumor, or a piece of thrombus that circulates in the bloodstream until it becomes lodged in a vessel.
Trapeze bar
allows the client to pull with the upper extremities to raise the trunk off the bed, assist in transfer, or to perform exercises
Identify the nursing interventions that will reduce the impact of immobility on Integumentary system
a. positioning and skin care
b. use of therapeutic devices to relieve pressure
Identify the nursing interventions that will reduce the impact of immobility on Respiratory system
a. deep breathe and cough every 1-2 hours
b. CPT c. ensure intake of 2000 mL of fluid per day
Identify the nursing interventions that will reduce the impact of immobility on Metabolic Systems
a. a high caloric diet
b. vitamin B and C supplements
Identify some examples of health promotion activities that address mobility and immobility
a. prevention of work-related injury
b. fall prevention measures
c. exercise
d. early detection of scoliosis
Identify the nursing interventions that will reduce the impact of immobility on Psychosocial
a. anticipate change in the client’s status and provide routine and informal socialization
b. stimuli to maintain client’s orientation
hemiparesis
Muscular weakness of one half of the body.
hemiplegia
Paralysis of one side of the body.
disuse osteoporosis
A decline is bone density that is associated with impaired mobility or immobilization of an extremity because of fracture, paralysis, or bone or joint inflammation.
