mod 6 ch 38 activity and movement: assess and rec cues

Question 1

musculoskeletal assessment

Answer 1

unexpected findings

Johns Hopkins Fall Risk Assessment Tool
Score 6–13 (moderate risk)
13 and above (high risk)

Morse Fall Scale
Score 25–44 (moderate risk)
45 and above (high risk)

Hendrich II Fall Risk Model
Score 5 and above

Question 2

best practice pearl

Answer 2

After any hip replacement surgery, patients should not flex hip past 90 degrees. This movement can cause the new hip to dislocate.

Question 3

dyssomnia

Answer 3

difficulty sleeping, does not feel rested upon awakening

Question 4

Which question would the nurse ask a patient to determine symptom-related issues with the musculoskeletal system?

Answer 4

“Have you noticed any differences in your gait?”

Asking about any difference in gait is a symptom-related question.

Question 5

Which patient finding is expected in a musculoskeletal assessment?

Answer 5

Morse Fall Scale score of 20

A Morse Fall Scale score of 20 is within the normal and expected range of 0 to 24, indicating the patient is not a fall risk.

Question 6

Which finding is unexpected when assessing effects of immobility?

Answer 6

Skin nonblanches

Skin nonblanching is unexpected because it indicates ischemia.

Question 7

factors in recognizing cues activity and movement

Answer 7

relevant
- Relevant cues relate to important information about joint movements, gait, coordination, and other musculoskeletal and multisystem information that the nurse obtains from patient interviews, mobility assessments, patient observation and medical record cues, and signs and symptoms.

irrelevant

most important

immediate concern

Question 8

musculoskeletal alterations with cues

Answer 8

Question 9

Which cue is relevant to alterations in the musculoskeletal system?

Answer 9

Has a shoulder joint that is edematous

A shoulder joint that is edematous is relevant to the musculoskeletal system because it is a component of the system.

Question 10

Match the musculoskeletal system alteration to its cause.

Answer 10

Porous, brittle bones

—Pathologic fracture

Deterioration of the muscle itself

—Muscle atrophy

Tissue that is usually easy to move tightens and pulls inward

—Contracture

Question 11

Which patient would likely be prone to reduced bone density?

Answer 11

One who cannot perform weight-bearing exercises

—-The patient who cannot perform weight-bearing exercises is prone to reduced bone density by allowing calcium to leak out of the bones.

Question 12

Which cues are relevant for weakness?

Answer 12

Flaccidity

—Flaccidity is a relevant cue for weakness.

Shuffling gait

—Shuffling gait is a relevant cue for weakness.

Feeble handgrip

—Feeble handgrip is a relevant cue for weakness.

Question 13

cardio and nervous system cues

Answer 13

Question 14

anorexia vs anorexia nervosa

Answer 14

Anorexia is not the same as anorexia nervosa. Anorexia is a physical disorder; anorexia nervosa is a mental health disorder.

Question 15

Which patient is prone to paralysis?

Answer 15

A patient with prolonged brain ischemia

—Prolonged ischemia in the brain can lead to paralysis.

Question 16

Which cues are relevant for activity intolerance?

Answer 16

Struggles to complete activities of daily living

—-Struggling to complete activities of daily living is a relevant cue for activity intolerance.

Exhibits dyspnea on exertion

—Dyspnea on exertion is a relevant cue for activity intolerance.

Has to sit down while doing the dishes

—Having to sit down while doing the dishes is a relevant cue for activity intolerance.

Question 17

Which graphic record cue indicates the patient has anorexia?

Answer 17

Eats less than 50% of meals

—Anorexia is a lack of appetite; thus a graphic record indicating the patient eats less than 50% of meals is a cue for anorexia.

Question 18

Which finding is a psychological consequence of bed rest and manifests in the patient becoming lonely or depressed?

Answer 18

Feelings of isolation

—Feelings of isolation are a consequence of bed rest and can manifest in the patient becoming lonely or depressed.

Question 19

pressure ulcer scale

Answer 19

Stage 1: intact skin with reddened area

Stage 2: break in epidermis or dermis with blistering (blisters ruptured or nonruptured) of skin

Stage 3: break extends into subcutaneous tissue with possible tunneling

Stage 4: break exposes muscle, bone, tendons, cartilage

Question 20

best pearl

Answer 20

Homans sign (when foot is dorsiflexed, pain occurs) is not a reliable assessment technique for DVT and is no longer performed by nurses.

Question 21

Pneumonia, Atelectasis, and Urinary Tract Infection

Answer 21

Pneumonia and urinary tract infection (UTI) both involve dependent areas (lungs, kidneys, and bladder are dependent when supine rather than upright, as when standing or sitting) that become excellent environments for growth of microorganisms. Pneumonia and atelectasis are presented together because they are pulmonary complications of immobility, while UTI is a urinary complication.

Question 22

Tissue ischemia related to immobility can directly lead to the development of which complication?

Answer 22

Pressure injuries

Tissue ischemia related to immobility can directly lead to the development of pressure injuries.

Question 23

Which patient situation is a medical emergency?

Answer 23

Pulmonary embolus

A patient with a pulmonary embolus is having a medical emergency because the condition is life-threatening.

Question 24

Which cues are relevant for a deep vein thrombosis (DVT)?

Answer 24

Redness

–Redness occurs with a DVT.

Edema

–Edema occurs with a DVT.

Cramping

–Cramping occurs with a DVT.

Question 25

Which complication from immobility causes the alveoli to collapse?

Answer 25

Atelectasis

—Atelectasis causes the alveoli in the lungs to collapse.

Question 26

In which areas would the patient experience pain if a urinary tract infection is present?

Answer 26

Back

—The patient may experience pain in the back because of the location of the kidneys.

Bladder

—The patient may experience pain in the bladder with a urinary tract infection.

Lower abdomen

—The patient may experience pain in the lower abdomen because of the location of the bladder.

Question 27

Which response would the nurse make to an immobile patient who says, “I am just not hungry. I don’t understand it. I am always hungry”?

Answer 27

“You have been immobile for several days, which can decrease your metabolism and appetite.”

—-Decreased activity decreases the body’s basal metabolic rate and appetite.

Question 28

Which fall risk score would the nurse anticipate in a patient who is weak?

Answer 28

Hendrich II Fall Risk Model score of 8

A patient with weakness is at risk for falls. A score of 8, which is in the 5 or above range, indicates the patient is at high risk for falls.

Question 29

Patients on bed rest are likely at risk for which physiologic effects and conditions?

Answer 29

Increased venous return

—Patients on bed rest are at risk for increased venous return due to supine positioning.

Decreased lung expansion

—Patients on bed rest are at risk for decreased lung expansion due to pressure on the rib cage.

Atelectasis

—Patients on bed rest are at risk for atelectasis due to dependent positioning and limited lung expansion.

Pneumonia

—Patients on bed rest are at risk for pneumonia due to pooling of secretions in the lungs.

Question 30

Which changes in vital signs are indicative of postural hypotension when a patient stands up?

Answer 30

Systolic blood pressure drops from 120 to 100 mm Hg

—A drop in systolic blood pressure of 20 mm Hg when a patient stands is classified as postural hypotension.

—Heart rate increases from 65 to 85 beats/min

An increase in heart rate of 20 beats/min when a patient stands is classified as postural hypotension.

—Diastolic blood pressure drops from 70 to 60 mm Hg

A drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as postural hypotension.

Question 31

Which parameters would the nurse assess to determine if a urinary tract infection (UTI) has developed?

Answer 31

Chills

—Chills are a cue for a urinary tract infection.

Urinary frequency

—Assessment of urinary elimination would include the frequency of urination to determine a UTI.

Presence of dysuria

—Pain upon urination (dysuria) is a cue for a UTI.

Question 32

Match the pressure injury stage to its cues.

Answer 32

Blistering of epidermis or dermis

Stage 2

Intact skin with reddened area

Stage 1

Exposure of muscle and bone

Stage 4

Subcutaneous injury with possible tunneling

Stage 3

Question 33

Which action by the nurse initiates the physical assessment of a patient’s mobility?

Answer 33

Observing the patient

–Observing the patient initiates the physical assessment of the patient’s mobility; inspection is the first step in a physical assessment.

Question 34

Which patient finding would alert the nurse to stop passive range-of-motion exercises?

Answer 34

Resistance to movement is felt.

Range-of-motion exercises are stopped when resistance to movement is experienced.

Question 35

Which finding would be unexpected when the nurse is assessing for mobility issues?

Answer 35

Joint crepitus

Joint crepitus (air trapped under the skin that makes a crackling sound when palpated) is an unexpected finding.

Question 36

Patient reports of shortness of breath and fatigue while performing activities of daily living are indicative of which alteration?

Answer 36

Activity intolerance

Patient reports of shortness of breath and fatigue while performing activities of daily living are cues for activity intolerance.

Question 37

Which nutritional alteration is associated with immobility?

Answer 37

Decreased basal metabolic rate

Immobility is associated with a decreased metabolic rate due to a diminished activity level.

Question 38

Which interpretation would the nurse make when observing a darkened or reddened area of skin in an immobile patient?

Answer 38

Tissue ischemia has occurred.

Skin that appears darkened or reddened is indicative of tissue ischemia.

Question 39

A patient with redness, warmth, and swelling in the right lower leg is at risk for which complication?

Answer 39

Pulmonary embolism

Redness, warmth, and swelling in an extremity is indicative of a deep vein thrombosis, which places the patient at risk for developing a pulmonary embolism.

Question 40

Which graphic record cue is associated with constipation?

Answer 40

Infrequent stools

Infrequent stools is a graphic record cue for constipation.

Question 41

Which musculoskeletal alterations does immobility predispose a patient to developing?

Answer 41

Weakness

—Immobility predisposes a patient to weakness due to inactivity.

Decreased muscle tone

–Immobility predisposes a patient to decreased muscle tone due to inactivity.

Decreased muscle mass

—Immobility predisposes a patient to decreased muscle mass due to inactivity.

Reduced bone density

Immobility predisposes a patient to reduced bone density due to lack of weight-bearing on bones.

Question 42

Which cues would likely occur with atelectasis?

Answer 42

Cyanosis

—Cyanosis occurs with atelectasis.

Dyspnea

—Dyspnea occurs with atelectasis.

Diminished breath sounds noted in nurse’s notes

—Diminished breath sounds occur with atelectasis.

Question 43

Match the alteration to its patient cues.

Answer 43

—Unable to move joints because of foot drop

Contracture

—Decreased muscle size with weak handgrip

Muscle atrophy

—Inability to move, with a loss of sensation

Paralysis

—Irregular patterns of behavior from inadequate coping

Altered self-concept

Question 44

1. A nurse is instructing a patient who has decreased leg strength on the left side on how to use a cane. Which actions indicate proper cane use by the patient? (Select all that apply.)

Answer 44

3. The patient keeps two points of support on the floor at all times.
4. The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step.

Question 45

2. A patient is experiencing some problems with joint stability in the right leg. The doctor has prescribed crutches for the patient to use while being allowed to bear weight only on the left leg. Which of the following gaits should the patient be taught to use?

Answer 45

2. Three-point

Question 46

3. Which of the following motivates a patient to participate in an exercise program? (Select all that apply.)

Answer 46

2. Providing information to the patient when he or she is ready to change behavior
3. Having a structured daily plan that incorporates physical activity
4. Having support from significant other to engage in exercise

Question 47

4. Which of the following is the proper sequence for a four-point crutch gait?

Answer 47

a, has darkened footprint every other box and darkened cane print every other box

Question 48

5. The nurse is caring for an older adult in a long-term care setting. The nurse reviews the medical record to find that the patient has progressive loss of total bone mass. The patient’s history and tendency to take smaller steps with feet kept closer together will most likely result in which of the following?

Answer 48

1. Increase the patient’s risk for falls and injuries

Question 49

6. Place in the correct order the steps needed (below) to transfer a patient with sufficient lower body strength to a chair.

Answer 49

5. Apply gait/transfer belt.
6. Help patient apply stable, nonskid shoes/socks.
7. Spread your feet apart. Flex hips and knees, aligning knees with patient’s knees.
8. Grasp transfer belt along patient’s sides.
9. On count of three, instruct patient to stand while straightening hips and legs and keeping knees slightly flexed.
10. Maintain patient’s balance as you pivot foot farthest from chair and then help patient ease into chair.
11. Assist patient to assume proper alignment in sitting position.

Question 50

7. Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.)

Answer 50

1. Patient’s weight
2. Patient’s activity tolerance
3. Patient’s level of mobility

Question 51

8. Which of the following indicates that additional assistance is needed to transfer a patient from the bed to the stretcher? (Select all that apply.)

Answer 51

3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation.
4. The patient received analgesia for pain 30 minutes ago.

Question 52

9. A 51-year-old adult comes to a medical clinic for an annual physical exam. The patient is found to be slightly overweight and reports being inactive, walking only 2 to 3 times a week with his wife after work. He has good muscle strength and coordination of lower extremities. Which of the following recommendations from the Physical Activity Guidelines for Americans should the nurse suggest? Choose all that apply

Answer 52

1. Move more and sit less throughout the day.
2. Perform muscle-strengthening activities using light weights on 2 or more days a week.
3. Walk at a vigorous pace with wife at least 150 minutes over five days a week.

Question 53

10. Family members have asked for a meeting with the nursing staff of an assisted-living residential center to discuss the feasibility of their mother using a walker. The family is worried that her health is declining; they wonder whether she can use the walker safely. Which of the following instructions should the nurse give the family after assessing that it is safe for the woman to use a walker? (Select all that apply.)

Answer 53

1. A walker is useful for patients who have impaired balance.
2. Walkers should not be used on stairs.
3. If the patient has difficulty advancing the walker, a walker with wheels is an option.