Mobility & Immobility Flashcards
A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client?
A. Decreased subcutaneous fat
B. Muscle atrophy
C. Pressure injury
D. Fecal impaction
C. CORRECT: The greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift his weight every 15 min and reposition the client after 1 hr.
A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.)
A. Instruct the client not to perform the Valsalva maneuver.
B. Apply elastic stockings.
C. Review laboratory values for total protein level.
D. Place pillows under the client’s knees and lower extremities.
E. Assist the client to change positions often.
B. CORRECT: Elastic stockings promote venous return and prevent thrombus formation.
E. CORRECT: Frequent position changes
prevents venous stasis.
A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?
A. Encourage the client to perform antiembolic exercises every 2 hr.
B. Instruct the client to cough and deep breathe every 4 hr.
C. Restrict the client’s fluid intake.
D. Reposition the client every 4 hr.
A. CORRECT: Encourage the client to perform antiembolic exercises every 1 to 2 hr to promote venous return and reduce the risk of thrombus formation
A nurse is evaluating a client’s understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding?
A. “This device will keep me from getting sores on my skin.”
B. “This device will keep the blood pumping through my leg.”
C. “With this device on, my leg muscles won’t get weak.”
D. “This device is going to keep my joints in good shape.”
B. CORRECT: Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation.
A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.)
A. Hold the cane on the right side.
B. Keep two points of support on the floor.
C. Place the cane 38 cm (15 in) in front of the feet before advancing.
D. After advancing the cane, move the weaker leg forward.
E. Advance the stronger leg so that it aligns evenly with the cane.
A. CORRECT: The client should hold the cane on the uninjured side to provide support for the injured left leg.
B. CORRECT: The client should keep two points of support on the ground at all times for stability.
D. CORRECT: The client should advance the weaker leg first, followed by the stronger leg.
A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure?
A. Age 78 years
B. History of cancer
C. Previous joint replacement
D. Bronchitis 2 weeks ago
D. CORRECT: The client who recently had bronchitis or a recent infection can experience failure of the prosthesis if micro-organisms are still present in the body and migrate to the surgical site
A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? (Select all that apply.)
A. Check continuous passive motion device settings.
B. Palpate dorsal pedal pulses.
C. Place a pillow behind the knee.
D. Elevate heels off bed.
E. Apply heat therapy to incision.
A. CORRECT: Check the continuous passive motion device settings to determine if the settings are as prescribed.
B. CORRECT: Assess the strength of the pulses of both lower extremities to help determine adequate circulation.
D. CORRECT: Prevent pressure injuries on the client’s heels by elevating the heels off the bed with a pillow
A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (Select all that apply.)
A. Clean the incision daily with soap and water.
B. Turn the toes inward when sitting or lying.
C. Sit in a straight‑backed armchair.
D. Bend at the waist when putting on socks.
E. Use a raised toilet seat.
A. CORRECT: The client should wash the surgical incision daily with soap and water to decrease the risk of infection.
C. CORRECT: Using a straight‑backed armchair decreases the chance of bending at a greater than 90° angle, which can cause dislocation of the hip prosthesis.
E. CORRECT: Using a toilet riser decreases the chance of bending greater than 90°, which can cause dislocation of the hip prosthesis.
A nurse is assessing a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings? (Select all that apply.)
A. Skin reddened over the joint
B. Pain when bearing weight
C. Joint crepitus
D. Swelling of the affected joint
E. Limited joint motion
B. CORRECT: Pain when bearing weight is an expected finding due to degeneration of the joint.
C. CORRECT: Joint crepitus due to degeneration of the joint tissue is an expected finding.
D. CORRECT: Swelling of the affected joint due to degeneration of the joint tissue is an expected finding.
E. CORRECT: Limited joint motion is due to degeneration of the joint tissue and is an expected finding
A nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? (Select all that apply.)
A. Encourage complete autologous blood donation.
B. Sit in a low reclining chair.
C. Instruct the client to roll onto the operative hip.
D. Use an abductor pillow when turning the client.
E. Perform isometric exercises.
A. CORRECT: Encourage the client to donate blood that can be used postoperatively.
D. CORRECT: Place an abductor device or pillow between the client’s legs when turning to prevent dislocation of the affected hip.
E. CORRECT: Instruct the client to perform isometric exercises to prevent blood clots and maintain muscle tone.
A nurse is admitting an adult client who has suspected osteoporosis. Which of following findings are risk factors for osteoporosis? (Select all that apply.)
A. History of consuming one glass of wine daily
B. Loss in height of 2 in (5.1 cm)
C. Body mass index (BMI) of 18
D. Kyphotic curve at upper thoracic spine
E. History of lactose intolerance
B. CORRECT: The loss of 2 inches of height is suggestive of osteoporosis due to fractures of the vertebral column.
C. CORRECT: A client who has a BMI of 18 is at risk of developing osteoporosis due to low body weight and thin body build, suggesting decreased bone mass.
D. CORRECT: Kyphosis curve is highly suggestive of osteoporosis due to fractures of the vertebrae causing the curve.
E. CORRECT: Lactose intolerance is highly suggestive of osteoporosis due to possible lack of calcium intake
A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following actions should the nurse take?
A. Apply heat to the puncture site.
B. Place the client in a supine position.
C. Turn the client every 1 hr.
D. Ambulate the client within the first hour postprocedure.
B. CORRECT: The client should remain in a supine position with the bed flat for the first 1 to 2 hr following the procedure to allow for hardening of the cement
A nurse is providing dietary teaching about calcium‑rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions?
A. White bread
B. Kale
C. Apples
D. Brown rice
B. CORRECT: Green leafy vegetables (broccoli, kale, mustard greens) are good sources of calcium
A nurse is performing health screenings at a health fair. Which of the following clients have a risk factor for osteoporosis? (Select all that apply.)
A. A 40‑year‑old client who has been taking prednisone for 4 months
B. A 30‑year‑old client who jogs 3 miles daily
C. A 45‑year‑old client who takes phenytoin for seizures
D. A 65‑year‑old client who has a sedentary lifestyle
E. A 70‑year‑old client who has smoked for 50 years
A. CORRECT: Prednisone affects the absorption and metabolism of calcium and places the client at risk for osteoporosis
when taken for an extended time (at least 3 months).
C. CORRECT: Phenytoin affects the absorption and metabolism of calcium and places the client at risk for osteoporosis.
D. CORRECT: A sedentary lifestyle places the client at risk for osteoporosis because bones need the stress of weight bearing activity for bone rebuilding and maintenance.
E. CORRECT: Smoking increases the risk for osteoporosis because it decreases osteogenesis.
A nurse is planning discharge teaching on home safety for an adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? (Select all that apply.)
A. Remove throw rugs in walkways.
B. Use prescribed assistive devices.
C. Remove clutter from the environment.
D. Wear soft-bottomed shoes.
E. Maintain lighting of doorway areas
A. CORRECT: Removing throw rugs in walkways can help to prevent a fall and bone fracture.
B. CORRECT: Using prescribed assistive devices can help to prevent a fall and bone fracture.
C. CORRECT: Removing clutter from the environment can help to prevent tripping, falling, and a bone fracture.
D. The client should wear rubber-bottomed
shoes to prevent slipping.
E. CORRECT: Good lighting in doorway areas can prevent a fall and bone fracture