Immobility Flashcards
What are 3 Benefits of Bed rest
Good question =]
Conditions that may require bed rest
Acute pain in pain or joints, maternal or fetal complications during pregnancy, heart diseases, chorea, gout
What are metabolic changes due to immobility
changes in metabolism alter endocrine metabolism, calcium reabsortion, and the gastrointestinal system
What happens when you decrease the metabolic rate
It alters the the metabolism of carbs, fats and proteins, causing fluid and electrolyte imbalances and causes gastrointestinal disturbances like decreased metabolism and slows peristalisis
A nurse is repositioning a patient to his left lateral side. What Action should the nurse implement when positioning the patient?
A) Rest the right leg on top of the left leg
B) Maintain knee flexion at 90 degrees
C) Place the ankles in plantar flexion
D) left shoulder protracted
D
A nurse turns a patients ankle so that the sole of the foot moves medially toward the the midline. What word should the nurse use when documenting exactly what she did when preforming ROM? 1 inversion 2 Adduction 3 Plantar flexion 4 Internal rotation
1
A nurse is transferring a patient from the bed to a wheelchair. What should the nurse do to quickly assess this patients tolerance to the change in position?
1 obtain a BP
2 Monitor for braydcardia
3 Determine if the patient feels dizzy
4 Allow the patient time to adjust to the position change
3
A nurse is transferring a patient from the bed to the wheelchair using a mechanical lift. What is a basic nursing intervention associated with this procedure?
1 Lock the base lever in the open position when moving the lift
2 raise the mechanical lift so that the patient is six inches off the mattress
3 keep the wheels of the lift locked through out the procedure
4 ensure the patients feet are protected when in the mechanical lift
4
protects the dangling legs from injury during transfer
A patient has hemiplegia as a result of a brain attack (cerbrovascular accident). Which complication of immobility is of most concern to the nurse. 1 dehydration 2 contractures 3 incontinence 4 hypertension
2
contractors are a result of the permanent shortening of the muscles
Which stage pressure ulcer requires the nurse to measure the extent of undermining? 1 stage 0 2 stage I 3 stage II 4 stage III
4
stage III pressure ulcers there is a full thickness skin loss involving damage to subcutaneous tissue that may extend to the fascia and there may or may not be undermining, which is tissue destruction underneath intact skin along the wound margins
A patient has a cast from the hand to above the elbow because of a fractured ulna and radius. After the cast is removed, the nurse teaches the patient AROM exercises. Which patients action indicates you need to teach further?
1 moves elbow to point of resistance
2 keeps elbow flexed after procedure
3 assesses the elbows response after the procedure
4 puts the elbow through its full ROM x3
2
this is undesirable because it contributes to a flexion contractor. Functional alignment is preferred because it minimizes stress and strain on muscle tendons ligaments and joints
Which word is most clearly associated with nursing care associated with nursing care strategies to maintain functional alignment when patients are bed bound. 1 endurance 2 strength 3 support 4 balance
3
A nurse places a patient with a sacral pressure ulcer in the left sims position . How should the nurse position the right arm 1 on a pillow 2 behind the back 3 with the palm up 4 in internal rotation
1
the left sims position supports the pt right arm and leg on pillows to prevent internal rotation of the shoulder and hip
A patient with impaired mobility is to be discharged within a week from the hospital. Which is the best example of a discharge goal for this patient 1 understand ROM exercises 2 be taught ROM exercises 3 transfer independently to a chair 4 be kept clean and dry
3
this is a patient centered goal and is measureable
A nurse concludes that a patient has the potential for impaired mobility. Which assessment reflects a risk factor that may have precipitated this conclusion? 1 exertional fatigue 2 sedentary life 3 limited ROM 4 Increased respiratory rate
3
limited ROM is associated with contracture formation and impaired mobility
