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NURS 1255 > Immobility: PowerPoint > Flashcards

Immobility: PowerPoint Flashcards

1
Q

(Abduction / Adduction) refers to moving a limb away from the midline of your body.
(Abduction/ Adduction) refers to moving a limb toward the midline of your body.

A

Abduction refers to moving a limb away from the midline of your body.

Adduction refers to moving a limb toward the midline of your body.

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2
Q

_____ is the movement of the limb, hand, or fingers in a circular pattern, using the sequential combination of flexion, adduction, extension, and abduction motions

A

Circumduction

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3
Q

(Extension / Flexion) is a movement that decreases the angle between two bones of a joint.

(Extension / Flexion) is a movement that increases the angle between two bones of a joint.

A

Flexion is a movement that decreases the angle between two bones of a joint.

Extension is a movement that increases the angle between two bones of a joint.



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4
Q

( Dorsiflexion / Plantarflexion)occurs when the ankle bends raising the toes upward, and this decreases the angle between the dorsal side of the foot and the tibia.

(Dorsiflexion/ Plantar) flexion occurs when the ankle bends in the direction that points the toes and plantar side of the foot downward.

A

Dorsiflexion occurs when the ankle bends raising the toes upward, and this decreases the angle between the dorsal side of the foot and the tibia.

Plantar flexion occurs when the ankle bends in the direction that points the toes and plantar side of the foot downward.

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5
Q

______ of the foot simply means to turn the sole of your foot outwards while the opposite is ____, which is when you stand on the outside edge of your foot.

A

Eversion / inversion

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6
Q

Explain difference between pronation and supination

A

Pronation is going downwards

Supination is going upwards

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7
Q

Kyphosis

Scoliosis

Lordosis

A

A forward rounding of the back.

sideways curvature of the spine

curving inward of the lower back.
Some lordosis is normal.

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8
Q

Neurovascular Assessment

Look at which side first

Injured or non injured

A

Injured

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9
Q

ROM can be graded 0 - 5

Describe quickly

A

0 No evidence of muscle contraction

  1. Trace.
  2. Poor complete ROM gravity is eliminated
  3. Fair complete ROM against gravity
  4. Good complete ROM against gravity some resistance
  5. Normal complete ROM against gravity full resistance
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10
Q

Systemic Effects if Immobility

Metabolism (slow/ increases)

A

Slows

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11
Q

Systemic Effects if Immobility

Respiratory changes

How does depth and rate change?

Pooling of secretions leading to …

A

Decreases

Pneumonia

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12
Q

Systemic Effects if Immobility

Blood pressure: What type of problem

Increase risk for DVT

(Decreased/Increased) Cardiac output and (Decreased/Increased) Cardiac workload

A

Orthostatic hypotension

Decreased cardiac output and increased cardiac workload

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13
Q

Systemic Effects if Immobility

Decreased circulation to tissue causing ____

A

Ischemia

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14
Q

Systemic Effects of Immobility

Impaired balance

Atrophy

At risk for Contractures

(What are contractures)

A

A contracture is a fixed tightening of muscles, tendons, ligaments, or skin. This can cause a deformity
, pain, and loss of movement in the joint. Contractures usually develop when normally elastic tissues like muscles or tendons are replaced by inelastic tissues (fibrosis)

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15
Q

What happens the Elimination GU / GI with Immobility

A

Both slowdown

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16
Q

During positioning which side rail do you raise

A

The one opposite of where your standing

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17
Q

Metabolic interventions for Immobility

A

High calorie / High Protein diet with Vitamin B & C Supplements

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18
Q

Respiratory interventions for Immobility

A

Cough and deep breath every 1 or 2 hours

Provide chest physiotherapy

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19
Q

Cardiovascular Interventions to prevent DVT

A

SCD
Sequential Compression Devices

Graduated Compression Stockings

Anticoagulant

ROM exercises

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20
Q

Walker sizing

What degree should the elbow be bent when using

A

15- 30

Wrsit crease should line up with hand grips

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21
Q

Cane usage

Size: line up with the anatomical feature

Cane on which side of the body

Move the cane and (strong/ weak) side together then move the (strong / weak) side forward

A

Greater trochanter

Stronger side

Move the cane and weak side together then the strong side

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22
Q

Canes

Stairs

Upstairs = (good / weak) first

Down = (good / weak) first

A

Up = Good
Down = Bad

“Up with the Good, Down with the bad”

23
Q

Crutches:

Sizing

____ gap between axillea and rest pad on crutches

Hand grip: even with this anatomical feature

Elbow needs to be bent at this angle

A

1 - 1.5 ‘

Hand grip even with hip line

Elbow bent 20 - 30 degrees

24
Q

Rest weight on arm pits when using crutches

True or False

A

False

Weight on the hand grips

25
Q

Describe stance for using crutches

A

Tripod 6” Diagonally from feet

In a upside down triangle shape

26
Q

Crutches

Rise from chair

  1. Slide to edge of chair
  2. Extend (Good / Injured) leg, to prevent weight bearing
  3. Place crutches on (good / injures) side, lean forward, push off using the crutches
A
  1. Extend Injured leg, to prevent weight bearing
  2. Place crutches on good side, lean forward, push off using the crutches
27
Q

Describe going Up & Down stairs using crutches

A

Up.
Good leg, Crutches, Bad Leg

Down
Crutches, bad, good

Good up, Bad Down

28
Q

Who teaches ADL & IADL to patients

A

OT & PT

Nurse reinforces the learning

29
Q

Which test measures ability to take physical care of one’s self

A

FIM score

30
Q

Meniere Disease to treat give these 2 medicines

A

Diuretics & Steroids

31
Q

Bon3 marrow produces (3)

A

Rbc, Wbc, Platelets

32
Q

Smooth muscle another term is Viseral.

Where is it found

A

Lining organs. Inside mouth?

33
Q

Move walker how

A

Walker, Weak side, strong

34
Q

How should walker be positioned in relationship to their feet

A

Back pegs halfway through feet

35
Q

Walker ambulation

Start: back tips of walker even with middle of foot

  1. Lift walker forward (all four feet on ground)
  2. Move (strong / weak) side forward
  3. Put weight on hand via walker hand grips
  4. Then move (strong/weak) side forward
A

1st Weak

2nd strong

36
Q

Is the following correct, in reference to using a walker

I should first take a step with my weak leg and then move with the walker.

A

Walker

Weak side

Strong side

37
Q

I should keep my eyes on the floor to avoid tripping over objects

Walker use

True or False

A

False

Keep eyes straightforward

38
Q

Client stated:

I won’t be able to do any activities that I used to enjoy

What is the first correct response

A. Encourage to explore activities that they can enjoy
B. Teach client about which activities they can do
C. Allow client time to discuss feelings of loss related to the injury
D. Consult pastrol care to provide encouragement to the client.

A

C. Give people who are grieving time to do so.

39
Q

Which of the following is true

A. Delirium is usually easily distinguished from irreversible dementia
B. Therapeutic drug intoxication is a common cause of dementia
C. Reversible systemic disorders are often implications as a cause of delirium
D. Cognitive deterioration is an inevitable outcome for human aging process

A

Reversible system disorders are often implications as a cause of delirium

Causes: Electrolytes, cerebral anoxia, hypoglycemia, “medications”, Tumors, cerebrovascular infections, hemorrhage

40
Q

Which reflects best understanding of self administration of medicine

A. I don’t seem to have side effects, but I will let my Dr. Know if something happens

B. Im lucky since my daughter is really good about keeping up with my medicine

C. I’ll be sure to read the insert and ask my pharmacist if I don’t understand

D. It should not be too hard to keep it straight because I don’t have serious health issues

A

C. I’ll be sure to read the insert and ask my pharmacist if I don’t understand

41
Q

Older client expresses fear of not being able to return home after getting transferred to a nursing home. Which is the most therapeutic response

A. What makes you think your transfer will be permanent?
B. The reason for the transfer is to support you when you heal
C. It is your decision how long you stay in the nursing home
D. The nursing home is lovely. Give it a chance

A

A. What makes you think your transfer will be permanent?

Making the client talk is our goal

Not reassuring them

42
Q

A nurse caring for older adults in an assisted living facility recognizes that a client’s quality of life needs new best determined by

A. Excelente physical, social, and emotional nursing assessments
B. A working knowledge of this age group’s developmental needs
C. Therapeutic nurse-client relationship that facilitates communication
D. The clients need for complete physical, emotional, and cognitive care

A

C. Therapeutic nurse-client relationship that facilitates communication

43
Q

When a fall results in an injury and disuse. The disuse is most likely the result of .

A. Decreasing muscle strength
B. Decreased joint mobility
C. Fear of repeated falls
D. Changes in sensory perception

A

C. Fear of repeated falls

44
Q

Related to changes in respitory system

Select All that Apply

A. Decrease in residual lung volume
B. Decrease gas exchange
C. Decrease cough efficiency
D. Increased gas exchange

A

B. Decrease gas exchange
C. Decrease cough efficiency

45
Q

Donepezil (Aricept) does what…

A

Treats confusion (dementia) related to AD. May increase memory, awareness, ability to function

46
Q

What does Immobility do to the workload on the heart (increase/decrease)

A

Increase work load

47
Q

Which assisting device would be used in a patient who is unable to assist in moving up in a bed

A. Arm splints
B. Trapeze bar
C. Full-body sling
D. Trochanter roll

A

Full body sling on a hoyer lift

48
Q

Trochanter roll is…

A

safety device that helps to support hips and legs so that the femur does not rotate outward.

49
Q

Immobility has these impacts on urine

A. Increased fluid intake
B. Increased urinary output
C. Increased Risk of renal calculi
D. Increased urinary concentration
E. Increased Risk for UTI

A

C. Increased Risk of renal calculi
D. Increased urinary concentration
E. Increased Risk for UTI

50
Q

Which data support a possible pulmonary problem relates to Immobility

A. BP 128/84
B. Resp. 26 per minute
C. HR 114
D. Crackles heard on Ausculation
E. Pain reported 3 on a 0 - 10 scale

A

B. Resp. 26 per minute
C. HR 114
D. Crackles heard on Ausculation

51
Q

A contracture of a joint develops when

A

Muscle fibers become shorter due to disuse

52
Q

Do patients need to be repositioned while sleeping

A

Yes

53
Q

Which side do you walk on when assisting someone with an injury

A

The weak side

NURS 1255 (13 decks)

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