Immobility

Question 1

. A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse’s action?

a. Prevention of atelectasis
b. Prevention of renal calculi
c. Prevention of pressure ulcers
d. Prevention of joint contractures

Answer 1

ANS: D

Goal achievement for passive ROM is prevention of joint contractures. Contractures develop in joints not moved periodically through their full ROM. ROM exercises reduce the risk of contractures. Researchers noted that prompt use of splinting with prescribed ROM exercises reduced contractures and improved active range of joint motion in affected lower extremities. Deep breathing and coughing and using an incentive spirometer will help prevent atelectasis. Adequate hydration helps prevent renal calculi and urinary tract infections. Interventions aimed at prevention of pressure ulcers include positioning, skin care, and the use of therapeutic devices to relieve pressure.

Question 2

. A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?

a. Thermometer
b. Elastic stockings
c. Blood pressure cuff
d. Sequential compression devices

Answer 2

ANS: C

A blood pressure cuff is needed. Orthostatic hypotension is a drop of blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure and symptoms of dizziness, light-headedness, nausea, tachycardia, pallor, or fainting when the patient changes from the supine to standing position. A thermometer is used to assess for fever. Elastic stockings and sequential compression devices are used to prevent thrombus.

Question 3

The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?

a. Maintain a narrow base of support.
b. Dangle the patient at the bedside.
c. Encourage isometric exercises.
d. Suggest a high-calcium diet.

Answer 3

ANS: B

To prevent injury, nurses implement interventions that reduce or eliminate the effects of orthostatic hypotension. Mobilize the patient as soon as the physical condition allows, even if this only involves dangling at the bedside or moving to a chair. A wide base of support increases balance. Isometric exercises (i.e., activities that involve muscle tension without muscle shortening) have no beneficial effect on preventing orthostatic hypotension, but they improve activity tolerance. A high-calcium diet can help with osteoporosis but can be detrimental in an immobile patient.

Question 4

A nurse reviews an immobilized patient’s laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?

a. Hypostatic pneumonia
b. Renal calculi
c. Pressure ulcers
d. Thrombus formation

Answer 4

ANS: B

Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi because they frequently have hypercalcemia. Hypercalcemia does not lead to hypostatic pneumonia, pressure ulcers, or thrombus formation. Immobility is one cause of hypostatic pneumonia, which is inflammation of the lung from stasis or pooling of secretions. A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) within tissues. A thrombus is an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel.

Question 5

A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient?

a. Increased appetite
b. Increased diarrhea
c. Increased metabolic rate
d. Altered nutrient metabolism

Answer 5

ANS: D

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, leading to constipation.

Question 6

The nurse is preparing to lift a patient. Which action will the nurse take first?

a. Position a drawsheet under the patient.
b. Assess weight and determine assistance needs.
c. Delegate the task to a nursing assistive personnel.
d. Attempt to manually lift the patient alone before asking for assistance.

Answer 6

ANS: B

When lifting, assess the weight you will lift, and determine the assistance you will need. The nurse has to assess before positioning a drawsheet or delegating the task. Manual lifting is the last resort, and it is used when the task at hand does not involve lifting most or all of the patient’s weight; most facilities have a no-lift policy.

Question 7

. The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?

a. Encourage the patient to perform as many self-care activities as possible.
b. Provide a complete bed bath to promote patient comfort.
c. Coordinate with occupational therapy for gait training.
d. Place the patient on bed rest to prevent fatigue.

Answer 7

ANS: A

Nurses should encourage the older-adult patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient’s immobility by providing unnecessary help with activities such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. After a stroke or brain attack, a patient likely receives gait training from a physical therapist; speech rehabilitation from a speech therapist; and help from an occupational therapist for ADLs such as dressing, bathing and toileting, or household chores.

Question 8

A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal?

a. When observed laterally, the spinal curves align in a reversed “S” pattern.
b. When observed posteriorly, the hips and shoulders form an “S” pattern.
c. The arms should be crossed over the chest or in the lap.
d. The feet should be close together with toes pointed out.

Answer 8

ANS: A

When the patient is observed laterally, the head is erect and the spinal curves are aligned in a reversed “S” pattern. When observed posteriorly, the shoulders and hips are straight and parallel. The arms hang comfortably at the sides. The feet are slightly apart to achieve a base of support, and the toes are pointed forward

Question 9

The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding?

a. The edge of the seat is in contact with the popliteal space.
b. Both feet are supported on the floor with ankles flexed.
c. The body weight is directly on the buttocks only.
d. The arms hang comfortably at the sides.

Answer 9

ANS: B

Both feet are supported on the floor, and the ankles are comfortably flexed. Body weight is evenly distributed on the buttocks and thighs. A 1- to 2-inch space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee to ensure that no pressure is placed on the popliteal artery or nerve. The patient’s forearms are supported on the armrest, in the lap, or on a table in front of the chair.

Question 10

The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use?

a. Supine position
b. Lateral position
c. Lateral position with positioning supports
d. Supine position with no pillow under the patient’s head

Answer 10

ANS: B

Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position, not supine. Remove all positioning supports from the bed except for the pillow under the head, and support the body with an adequate mattress.

Question 11

The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take when assessing the respiratory system?

a. Inspect chest wall movements primarily during the expiratory cycle.
b. Auscultate the entire lung region to assess lung sounds.
c. Focus auscultation on the upper lung fields.
d. Assess the patient at least every 4 hours.

Answer 11

ANS: B

Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes. Perform a respiratory assessment at least every 2 hours for patients with restricted activity. Inspect chest wall movements during the full inspiratory-expiratory cycle. Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions.

Question 12

ANS: B
Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes. Perform a respiratory assessment at least every 2 hours for patients with restricted activity. Inspect chest wall movements during the full inspiratory-expiratory cycle. Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions.

Answer 12

ANS: B

Measure bilateral calf circumference and record it daily as an assessment for DVT. Unilateral increases in calf circumference are an early indication of thrombosis. Homan’s sign, or calf pain on dorsiflexion of the foot, is no longer a reliable indicator in assessing for DVT, and it is present in other conditions. Remove the patient’s elastic stockings and/or sequential compression devices (SCDs) every 8 hours, and observe the calves for redness, warmth, and tenderness. Instruct the family, patient, and all health care personnel not to massage the area because of the danger of dislodging the thrombus.

Question 13

A nurse is assessing the skin of an immobilized patient. What will the nurse do?

a. Assess the skin every 4 hours.
b. Limit the amount of fluid intake.
c. Use a standardized tool such as the Braden Scale.
d. Have special times for inspection so as to not interrupt routine care.

Answer 13

ANS: C

Consistently use a standardized tool, such as the Braden Scale. This identifies patients with a high risk for impaired skin integrity. Skin assessment can be as often as every hour. Limiting fluids can lead to dehydration, increasing skin breakdown. Observe the skin often during routine care.

Question 14

A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess?

a. Imbalance
b. Hemiplegia
c. Muscle sprain
d. Lower extremity paralysis

Answer 14

ANS: A

Damage to the cerebellum causes problems with balance, and motor impairment is directly related to the amount of destruction of the motor strip. A stroke can lead to hemiplegia. Direct trauma to the musculoskeletal system results in bruises, contusions, sprains, and fractures. A complete transection of the spinal cord can lead to lower extremity paralysis.

Question 15

Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobilityfor a care plan?

a. A patient who is completely immobile
b. A patient who is not completely immobile
c. A patient at risk for single-system involvement
d. A patient who is at risk for multisystem problems

Answer 15

ANS: B

The diagnosis of Impaired physical mobility applies to the patient who has some limitation but is not completely immobile. The diagnosis of Risk for disuse syndrome applies to the patient who is immobile and at risk for multisystem problems because of inactivity. Beyond these diagnoses, the list of potential diagnoses is extensive because immobility affects multiple body systems.

Question 16

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?

a. Encourage the patient to do self-care.
b. Keep the patient as mobile as possible.
c. Encourage the patient to perform ROM.
d. Assist the patient with comfort measures.

Answer 16

ANS: D

The diagnosis related to pain requires the nurse to assist the patient with comfort measures so that the patient is then willing and more able to move. Pain must be controlled so the patient will not be reluctant to initiate movement. The diagnosis related to reluctance to initiate movement requires interventions aimed at keeping the patient as mobile as possible and encouraging the patient to perform self-care and ROM.

Question 17

The patient is being admitted to the neurological unit with a diagnosis of stroke. When will the nurse begin discharge planning?

a. At the time of admission
b. The day before the patient is to be discharged
c. When outpatient therapy will no longer be needed
d. As soon as the patient’s discharge destination is known

Answer 17

ANS: A

Discharge planning begins when a patient enters the health care system. In anticipation of the patient’s discharge from an institution, the nurse makes appropriate referrals or consults a case manager or a discharge planner to ensure that the patient’s needs are met at home. Referrals to home care or outpatient therapy are often needed. Planning the day before discharge, when outpatient therapy is no longer needed, and as soon as the discharge destination is known is too late.

Question 18

ANS: A
Discharge planning begins when a patient enters the health care system. In anticipation of the patient’s discharge from an institution, the nurse makes appropriate referrals or consults a case manager or a discharge planner to ensure that the patient’s needs are met at home. Referrals to home care or outpatient therapy are often needed. Planning the day before discharge, when outpatient therapy is no longer needed, and as soon as the discharge destination is known is too late.

Answer 18

ANS: B

“The patient will walk 100 feet using a walker by the time of discharge” is individualized, realistic, and measurable. “Ambulating briskly on a treadmill” is not realistic for this patient. The option that focuses on the nurse, not the patient, is not a measurable goal; this is an intervention. “The patient will ambulate by the time of discharge” is not measurable because it does not specify the distance. Even though we can see that the patient will ambulate, this does not quantify how far.

Question 19

. A nurse is caring for a patient with osteoporosis and lactose intolerance. What will the nurse do?

a. Encourage dairy products.
b. Monitor intake of vitamin D.
c. Increase intake of caffeinated drinks.
d. Try to do as much as possible for the patient.

Answer 19

ANS: B

Encourage patients at risk to be screened for osteoporosis and assess their diets for calcium and vitamin D intake. Patients who have lactose intolerance need dietary teaching about alternative sources of calcium. Caffeine should be decreased. The goal of the patient with osteoporosis is to maintain independence with ADLs. Assistive ambulatory devices, adaptive clothing, and safety bars help the patient maintain independence.

Question 20

A nurse is providing care to a group of patients. Which patient will the nurse see first?

a. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
b. A bedridden patient who has a reddened area on the buttocks who needs to be turned
c. A patient on bed rest who has renal calculi and needs to go to the bathroom
d. A patient after knee surgery who needs range of motion exercises

Answer 20

ANS: A

A patient on prolonged bed rest will be prone to deep vein thrombosis, which can lead to an embolus. An embolus can travel through the circulatory system to the lungs and impair circulation and oxygenation, resulting in tachycardia and shortness of breath. Venous emboli that travel to the lungs are sometimes life threatening. While the patient with a reddened area needs to be turned, a patient with renal calculi needing the restroom, and a patient needing range of motion, these are not as life threatening as the chest pain and dyspnea.

Question 21

The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient?

a. Thick, tenacious pulmonary secretions
b. Low-molecular-weight heparin doses
c. SCDs wrapped around the legs
d. Elastic stockings (TED hose)

Answer 21

ANS: B

Heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of deep vein thrombosis. Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding. Pulmonary secretions that become thick and tenacious are difficult to remove and are a sign of inadequate hydration or developing pneumonia but not of bleeding. SCDs consist of sleeves or stockings made of fabric or plastic that are wrapped around the leg and are secured with Velcro. They decrease venous stasis by increasing venous return through the deep veins of the legs. They do not usually cause bleeding. Elastic stockings also aid in maintaining external pressure on the muscles of the lower extremities and in promoting venous return. They do not usually cause bleeding.

Question 22

. The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one?

1. Grasp the drawsheet firmly near the patient.
2. Move the patient and drawsheet to the desired position.
3. Position one nurse at each side of the bed.
4. Place the drawsheet under the patient from shoulder to thigh.
5. Place your feet apart with a forward-backward stance.
6. Flex knees and hips and on count of three shift weight from the front to back leg.
   a. 1, 4, 5, 6, 3, 2
   b. 4, 1, 3, 5, 6, 2
   c. 3, 4, 1, 5, 6, 2
   d. 5, 6, 3, 1, 4, 2

Answer 22

ANS: C
Assisting a patient up in bed with a drawsheet (two or three nurses):
(1) Place the patient supine with the head of the bed flat. A nurse stands on each side of the bed.
(2) Remove the pillow from under the patient’s head and shoulders and place it at the head of the bed.
(3) Turn the patient side to side to place the drawsheet under the patient, extending it from shoulders to thighs.
(4) Return the patient to the supine position.
(5) Fanfold the drawsheet on both sides, with each nurse grasping firmly near the patient.
(6) Nurses place their feet apart with a forward-backward stance. Nurses should flex knees and hips. On the count of three, nurses should shift their weight from front to back leg and move the patient and drawsheet to the desired position in the bed.

Question 23

The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?

a. Place pillow under the patient’s abdomen after turning.
b. Turn head toward one side with large, soft pillow.
c. Position legs flat against bed.
d. Raise head of bed to 45 degrees.

Answer 23

ANS: A

Placing a pillow under the patient’s abdomen after turning decreases hyperextension of lumbar vertebrae and strain on lower back; breathing may also be enhanced. Head is turned toward one side with a small pillow to reduce flexion or hyperextension of cervical vertebrae. Legs should be supported with pillows to elevate toes and prevent footdrop. Forty-five degrees is the position for Fowler’s position; prone is on the stomach.

Question 24

. The nurse is caring for a patient with a spinal cord injury and notices that the patient’s hips have a tendency to rotate externally when the patient is supine. Which device will the nurse use to help prevent injury secondary to this rotation?

a. Hand rolls
b. A trapeze bar
c. A trochanter roll
d. Hand-wrist splints

Answer 24

ANS: C

A trochanter roll prevents external rotation of the hips when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. Hand-wrist splints are individually molded for the patient to maintain proper alignment of the thumb and the wrist. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bedframe. It allows the patient 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.

Question 25

. The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to make this procedure safe?

a. Place the pillow under the patient’s head and shoulders.
b. Do by self if the bed is in the flat position.
c. Place the side rails in the up position.
d. Use a friction-reducing device.

Answer 25

ANS: D

This is not a one-person task. Helping a patient move up in bed without help from other co-workers or without the aid of an assistive device (e.g., friction-reducing pad) is not recommended and is not considered safe for the patient or the nurse. Remove the pillow from under head and shoulders and place it at the head of the bed to prevent striking the patient’s head against the head of the bed. When pulling a patient up in bed, the bed should be flat to gain gravity assistance, and the side rails should be down.

Question 26

The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient’s toes. Which device will the nurse use?

a. Hand rolls
b. A foot cradle
c. A trapeze bar
d. A trochanter roll

Answer 26

ANS: B

A foot cradle may be used in patients with poor peripheral circulation as a means of reducing pressure on the tips of a patient’s toes. A trochanter roll prevents external rotation of the hips when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bedframe. It allows the patient 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.

Question 27

The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend?

a. High protein, high calorie
b. High carbohydrate, low fat
c. High vitamin A, high vitamin E
d. Fluid restricted, bland

Answer 27

ANS: A

Because the body needs protein to repair injured tissue and rebuild depleted protein stores, give the immobilized patient a high-protein, high-calorie diet. A high-carbohydrate, low-fat diet is not beneficial for an immobilized patient. Vitamins B and C are needed rather than A and E. Fluid restriction can be detrimental to the immobilized patient; this can lead to dehydration. A bland diet is not necessary for immobilized patients.

Question 28

. The nurse is caring for a patient who has had a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive ROM will be initiated. When should the nurse begin this therapy?

a. After the acute phase of the disease has passed
b. As soon as the ability to move is lost
c. Once the patient enters the rehab unit
d. When the patient requests it

Answer 28

ANS: B

Passive ROM exercises should begin as soon as the patient’s ability to move the extremity or joint is lost. The nurse should not wait for the acute phase to end. It may be some time before the patient enters the rehab unit or the patient requests it, and contractures could form by then.

Question 29

44. The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient’s nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient?
    a. Obtain assistance and physically transfer the patient to the chair.
    b. Assist with ambulation and measure how far the patient walks.
    c. Give pain medication after ambulation so the patient will have a clear mind.
    d. Bring the patient to the cafeteria for group instruction on ambulation.

Answer 29

ANS: B

Assist with walking and measure how far the patient walks to quantify progress. The nurse should allow the patient to do as much for self as possible. Therefore, the nurse should observe the patient transferring from the bed to the chair using the walker and should provide assistance as needed. The patient should be encouraged to use adequate pain medication to decrease the effects of pain and to increase mobility. The patient should be instructed on safe transfer and ambulation techniques in an environment with few distractions, not in the cafeteria.

Question 30

The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the nurse use for logrolling?

a. Use at least three people.
b. Have the patient reach for the opposite side rail when turning.
c. Move the top part of the patient’s torso and then the bottom part.
d. Do not use pillows after turning.

Answer 30

ANS: A

At least three to four people are needed to perform this skill safely. Have the patient cross the arms on the chest to prevent injury to the arms. Move the patient as one unit in a smooth, continuous motion on the count of three. Gently lean the patient as a unit back toward pillows for support.

Question 31

The nurse is caring for a patient with impaired physical mobility. Which potential complications will the nurse monitor for in this patient? (Select all that apply.)

a. Footdrop
b. Somnolence
c. Hypostatic pneumonia
d. Impaired skin integrity
e. Increased socialization

Answer 31

ANS: A, C, D

Immobility leads to complications such as hypostatic pneumonia. Other possible complications include footdrop and impaired skin integrity. Interruptions in the sleep-wake cycle and social isolation are more common complications than somnolence or increased socialization.