Unit 7: Ch. 28 Activity, Immobility, and Safe Movement Flashcards
.An uncooperative 70-year-old male with right-sided paralysis from a recent cerebrovascular accident (CVA) has to be transferred from the bed to a wheelchair. Which action indicates the best method to transfer this patient?
a. A two-person lift is performed, with one person on each side of the patient.
b. The patient is steadied under the arms and pivoted on his left leg.
c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP).
d. A stand assist lift is used with the help of another nurse.
c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP).
According to safe patient handling algorithms, a full-body sling with more than one caregiver is indicated because the patient is uncooperative and able to bear only partial weight. Lifting a patient manually has the potential to injure the patient and the care providers. The stand-and-pivot technique is not indicated because the patient is uncooperative. The stand assist lift is not indicated because the patient is uncooperative.
After instruction, which action by a patient who can bear weight on both feet indicates an understanding of the proper use of crutches?
a. Adjusting the crutches so that they rest directly under the axilla
b. Moving the opposing crutch and leg together for a two-point crutch walk
c. Using a four-point crutch walk when not weight bearing on the left leg
d. Placing the crutches 12 inches forward and then swinging both legs forward
Answer: b
Moving the opposing crutch and leg together provides needed stability for patients who can bear partial weight on each foot. Crutches must rest at minimum of two to three finger widths below the axilla to prevent brachial nerve damage. The patient can bear weight on both legs. Crutches should be advanced no more than 6 to 8 inches, and the swing-to gait is not appropriate for this patient.
What bony prominences are at greatest risk for skin breakdown on a patient who is restricted to bed rest and placed in the side-lying position? (Select all that apply.)
a. Sternum
b. Ears
c. Elbows
d. Hips
e. Coccyx
Answer: b, c, d
The patient’s ears, elbows, and hips are in contact with the bed surface in the side-lying position. Breakdown on the sternum would be a potential risk if the patient were in prone position. The coccyx experiences the most pressure when a patient is sitting or in the supine position.
Which area of the central nervous system has most likely sustained damage if a patient exhibits a lack of coordination and an unsteady gait after a traumatic head injury?
a. Medulla oblongata
b. Articular disk
c. Brainstem
d. Cerebellum
Answer: d
Injury to the cerebellum directly affects a patient’s ability to ambulate and control movement. The medulla oblongata regulates heart rate, breathing, blood pressure, and reflexive actions (such as vomiting). The articular disk is fibrous connective tissue in the temporomandibular joint, which facilitates jaw movement. The brainstem connects the spinal cord to the hemispheres of the brain.
A nurse is providing patient education on the prevention of osteoporosis. Which important fact should the nurse include in the teaching care plan?
a. Calcium should be taken with vitamin D to increase calcium absorption.
b. African American women are more prone to developing osteoporosis than white women.
c. Increased phosphorus metabolism may lead to bone fragility.
d. Anaerobic exercise is more advantageous than weight-bearing exercise in preventing osteoporosis.
Answer: a
Vitamin D is required for calcium metabolism. White women are more prone to osteoporosis than African American women. Phosphorus deficiency may lead to malformation of bones. Weight-bearing exercise is more beneficial than an anaerobic exercise in the prevention of osteoporosis.
What nursing action would be most effective in preventing flaccidity in a hospitalized patient?
a. Early ambulation after surgery
b. Administering calcium with vitamin D
c. Coughing and deep breathing exercises
d. Referring the patient to occupational therapy
Answer: a
Ambulation is the most effective intervention to promote maintenance of muscle tone and prevent flaccidity. Calcium with vitamin D helps prevent osteoporosis. Coughing and deep breathing are important for the prevention of pneumonia associated with immobility, and occupational therapy is typically ordered to help patients regain their ability to complete activities of daily living (ADLs) independently.
Identify all nursing interventions that are necessary when caring for a quadriplegic patient injured 2 years earlier in a motor vehicle accident. (Select all that apply.)
a. Monitoring respiratory status and breathing difficulties
b. Assisting with feeding and activities of daily living (ADLs)
c. Developing a care plan with the patient’s power of attorney
d. Using mechanical lifts to assist with transferring the patient
e. Placing a gait belt around the patient’s waist before ambulation
Answer: a, b, d
Quadriplegia is the result of a high spinal cord injury that affects a patient’s ability to breathe without mechanical assistance and severely limits the patient’s ability to move all extremities. Most quadriplegics are confined to a wheelchair and unable to ambulate even with assistance. Mechanical lifts should be used to safely transfer this patient. Quadriplegic patients should be given the opportunity to direct their care and fully participate in setting care plan goals.
Which cue during an admission assessment of a patient transferred from a long-term care facility does the nurse recognize as the result of immobility?
a. Bilateral elbow contractures
b. Increased muscle tone
c. Decreased cardiac workload
d. Orthostatic hypertension
Answer: a
Joint contractures may begin within hours of immobility and cause irreparable damage to joint flexibility. Muscle tone decreases and cardiac workload increases with immobility. Pooling of blood in the lower extremities and quickly changing position may cause a rapid drop, rather than increase, in blood pressure, known as orthostatic hypotension.
Which set of cues is most concerning in a patient with deep vein thrombosis (DVT) in the left calf?
a. High blood pressure and low heart rate
b. Coughing up blood and chest pain
c. Low oral intake and urine output
d. Bruising on the upper arm and torso
Answer: b
The patient who is coughing up blood and has chest pain has the most concerning cues. A pulmonary embolism (PE) is suspected when a patient has sudden shortness of breath, chest pain, dizziness, irregular heartbeat or palpitations, low blood pressure or is coughing up blood. High blood pressure and low heart rate are the opposite of that seen in PE. Fluid intake is important in the prevention of venous thrombolytic events but is not the most concerning cue. Bruising might be related to anticoagulant therapy but is not the most concerning cue.
After application of sequential compression devices (SCDs) on a patient, what assessment finding is essential for the nurse to include in documentation?
a. Warmth of bilateral upper extremities
b. Lower extremity circulatory status
c. Circumoral cyanosis
d. Altered bowel sounds
Answer: b
The nurse must document the date and time of initiating SCD placement and the results of a skin, circulatory, and neurologic assessment of the lower extremities. SCDs do not affect the upper extremities or cardiac or respiratory status leading to circumoral cyanosis or altered bowel sounds.
Increased muscle tone
Spasticity
Inability to move all four extremities
Quadriplegia
Death of cells, tissues, or organs
Necrosis
Manner of walking
Gait
Reduced blood flow
Ischemia
Lack of muscle tone
Flaccidity
Wasting
Atrophy
Weakness on one side of the body
Hemiparesis
Awareness of posture and movement
Proprioception
Permanent fixation of a joint
Contracture
Which assessment questions will help the nurse determine if a patient is experiencing difficulty with mobility?
-Are you experiencing any stiffness, joint discomfort, or pain with movement?
-Have you noticed any difficulty with dizziness or balance?
-Do you become short of breath or easily fatigued when completing your activities of daily living?
-How is your appetite? What is your typical dietary intake in a day?
-What is the frequency of your BMs?
- Describe your normal sleep pattern.
-Do you exercise?
What are some alterations in the Musculoskeletal system that can lead to impaired mobility?
-Hypotonicity.
-Inadequate dietary intake of Ca.
-Stiffness.
What are some alterations in the Neurological system that can lead to impaired mobility?
-Paresthesia.
-Hemiplegia.
What are some alterations in the Cardiopulmonary system that can lead to impaired mobility?
-Productive cough.
-Orthostatic Hypotension.
-Dyspnea on exertion.
