Immobility

Question 1

Body aligment:

Answer 1

Individual’s center of gravity is stable

Relationship of one body part to another while in different positions

Question 2

Body mechanics:

Answer 2

Coordinated efforts of musculoskeletal and nervous system

Question 3

Passive ROM:

Answer 3

Exercises performed by the nurse, just to the point of resistance

Question 4

Prevention of atelectasis:

Answer 4

Deep breathing and coughing using an incentive spirometer

Question 5

Repositioning immobile patient

Nurse duty:
AP duty:

Answer 5

Level of comfort, hazards of immobility, assessing circulation

Positioning pt

Question 6

To prevent injury from orthostatic hypotension…

Answer 6

Dangle pt at bedside or move to a chair

Question 7

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

Answer 7

Altered nutrient metabolism

Question 8

Body alignment in standing position:

Answer 8

• Laterally, spinal curves align in a reversed “S” pattern
• Posteriorly, shoulder and hips are straight and parallel
• Arms hang comfortably at side
• Feet slightly apart to achieve base of support
• Toes pointed forward

Question 9

Body alignment in sitting position:

Answer 9

-Feet on the floor with ankles flexed
-Weight evenly distributed on butt and thighs
1-2 in space between edge of seat and popliteal artery or nerve
-Forearms supported by armrest

Question 10

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

Answer 10

Lateral position

Question 11

Actions by the nurse when assessing respiratory system on an immobile pt:

Answer 11

• Auscultate entire lung region
• Assess respiratory every 2 hrs for restricted pts
• Focus assessment on dependent lung fields

Question 12

SCD to be removed:

Answer 12

Every 8 hrs

Question 13

Precaution when assessing for DVT:

Answer 13

Do not massage area due to danger of moving thrombus

Question 14

Braden scale: (3)

Answer 14

• Tests skin integrity and pressure ulcers
• Lower number= higher risk
• Less than 17= risk for pressure ulcers

Question 15

Discharge planning begins:

Answer 15

When a pt enters the health care system upon admission

Question 16

The most widely used drugs in the prophylaxis of DVT:

Answer 16

Heparin and low-molecular-weight heparin

Question 17

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?

Answer 17

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

Question 18

Trochanter roll:

Answer 18

Prevents external rotation of hips when pt is in supine position

Question 19

Hand rolls:

Answer 19

Maintain the thumb in slight adduction and opposition to the fingers

Question 20

Foot cradle:

Answer 20

Used for pt’s with poor peripheral circulation to reduce pressure on the tips of pt’s toes

Question 21

Logrolling provides care to what kind of pt?

Answer 21

Pt who has suffered a spinal cord injury or are recovering from neck, back, or spinal surgery

Question 22

Sims position pressure pts:

Answer 22

Ileum, humerus, clavicle, knees, ankle

Question 23

Lateral position pressure pts:

Answer 23

Ear, shoulder, anterior iliac spine, ankles

Question 24

Prone position pressure pts:

Answer 24

Chin, elbows, female breasts, hips, knees, toes

Question 25

Supine position pressure pts:

Answer 25

Occipital, vertebrae, coccyx, elbow, heels

Question 26

Logrolling technique requires:

Answer 26

3-4 people

Question 27

Lordosis:

Answer 27

Exaggeration of anterior convex curve of lumbar spine

Question 28

Kyphosis:

Answer 28

Increased convexity in curvature of thoracic spine

Question 29

Scoliosis:

Answer 29

Lateral-S- or C-shaped spinal column with vertebral rotation

Question 30

Genu valgum

Answer 30

Legs curved inward so knees come together as person walks

Question 31

Genu varum:

Answer 31

One or both legs bent outward at knee

Question 32

Torticollis:

Answer 32

Inclining of head to affected side

Question 33

Morse fall scale:

Answer 33

Six-item fall risk assessment tool

Question 34

nursing diagnosis for immobility:

Answer 34

impaired physical mobility
risk for disuse symdrome
ineffective airway clearance
ineffective coping
impaired urinary emliniation
impaired skin integrety
social isolation

Question 35

Positioning techniques:

Answer 35

• Trochanter roll
• Hand roll
• Trapeze bar
• Supported Fowler’s-head 45-60 degrees
• Supine
• Prone
• Side-lying
• Sims’