NR 224 – v v
v Week 2 Edapts Mobility and Immobility
v v v v v
MobilityvandvImmobility
Adam,vav54-year-
v
oldvclientvonvbedvrest,vhasvavStagev1vpressurevinjuryvonvthevcoccyx.vWhichvinterventionsvshouldvth
evnursevimplement?v
Providevpropervskinvcare.
Repositionvthevclientveveryv1vtov2vhours.
Getvthevclientvavspecialtyvairvorvfoamvmattress.
Av77-year-
oldvisvrecoveringvfromvspinalvsurgeryvandvusingvavwalkervasvanvassistivevdevice.vThevclientvstates,v"
Ivdon'tvwantvanyvvisitorsvorvtovgovanywhere.vNovonevshouldvseevmevusingvavwalker.vIvwantvtovbevlef
tvalone."vWhatvisvthevmostvappropriatevnursingvdiagnosis?vSocialvisolation
Anv80-year-
oldvfellvatvhomevandvwasvnotvfoundvforvthreevdays.vThevclientvwasvadmittedvtovthevhospitalvwithvav
fracturedvhip.vWhichvcomplicationsvcanvoccurvduevtovimmobility?v
Embolus
Urinaryvretention
Musclevatrophy
Thevnursevisvassessingvavclientvwhovrecentlyvhadvsurgery.vLungvsoundsvonvthevrightvbasevarevdi
minishedvandvtherevarevnovbreathvsoundsvinvthevleftvbase.vWhatvcomplicationvdoesvthevnurse
vsuspect?vAtelectasis
KarivAnnv(preferredvpronouns:vshe,vher),vav32-year-
oldvfemale,visvhospitalizedvwithvmultiplevsclerosis.vHervconditionvhasvworsenedvandvshevwillvneedv
avwheelchairvfromvnowvon.vShevisvdivorcedvwithvfourvchildren.vWhichvstatementvindicatesvavneedv
forvimmediatevfollow-upvbyvthevnurse?
"Ivwon’tvneedvanyvhelpvatvhome."
Avclientvhasvbeenvonvprolongedvbedvrestvbutvnowvisvablevtovgetvup.vWhatvshouldvthevnursevassessvf
or?v
Activityvtolerance
Gait
Rangevofvmotionv(ROM)
Strength
Carolv(preferredvpronouns:vshe,vher)visvavnewvresidentvofvavlong-
termvcarevfacility.vShevhasvseverevarthritisvandvisvwheelchair-
, NR 224 – Week 2 Edapts
v v v v v
bound.vRecentvcomplicationsvledvCarolvtovbevhospitalizedvandvthenvtransferredvtovavcarevfacility.vS
hevappearsvveryvdepressedvandvwithdrawn.vWhatvisvthevnurse'svbestvaction?
BringvCarolvtovthevcommonvareavtovmeetvothervresidents.
Mobility and Immobility
v v
MaryvBrennervisvav60-year-oldvclientvwhovisvlessvthanv24vhoursvpost-
operativevfromvabdominalvsurgery.vTovpreventvimmobilityvcomplications,vwhatvpriorityvnursingvin
terventionvshouldvbevimplemented?
Ambulatevthevclientvinvthevhall.
Thevnursevnoticesvthatvavclientvwithvimpairedvmobilityvinvthevlowervextremitiesvhasvdecreasedvskin
vturgorvandvhypoactivevbowelvsounds.vWhichvfactorvmayvcontributevtovthesevsignsvinvthevimmobili
zedvclient?vInadequatevfluidvintake
Avnursevworksvonvanvorthopedicvsurgicalvfloorvinvavhospital.vThevnursevunderstandsvthatvclients
varevatvriskvofvwhichvphysiologicalvcomplicationvofvimmobility?vDecreasedvlungvexpansion
Anvunlicensedvassistivevpersonnelv(UAP)visvputtingvcompressionvstockingsvonvavclientvfollowingvm
ajorvsurgery.vThevclientvasksvwhyvtheyvhavevtovwearvthem.vWhatvisvthevUAP'svbestvanswer?
"Theyvpromotevcirculationvtovthevheart."
Anv18-year-
oldvvictimvofvavmotorvvehiclevcrashvwithvavfracturedvfemurvhasvbeenvimmobilizedvforvsixvdays.vTh
evnursevisvgettingvthevclientvoutvofvbedvforvthevfirstvtime.vWhichvnursingvdiagnosisvisvapplicablevtov
thisvaction?vRiskvforvactivityvintolerance
Marissavisvav4-year-
oldvwithvcerebralvpalsy.vInvthevnurse'svassessment,vwhichvfindingvwouldvindicatevavdevelopmental
vcomplication?
Marissavcannotvsayvtheirvfirstvandvlastvnamesvandvspeaksvunclearlyvsometimes.
Thevnursevhasvfourvclientsvonvthevunitvwithvimpairedvmobility.vWhichvclientvisvatvgreatestvriskvofvde
velopingvcomplicationsvfromvimmobility?
82-year-oldvwomanvwhovhasvsufferedvavcerebrovascularvaccidentv(CVA)
RangevofvMotion
, NR 224 –
v v
v Week 2 Edapts Mobility and Immobility
v v v v v
Avclientvarrivesvforvphysicalvtherapyvwithvlimitedvmotionvofvthevrightvknee.vHowvdoesvthevtherapist
vknowvthevextentvofvthevlimitation?
Measurevusingvavgoniometer.
Thevclientvisvexperiencingvpainvduringvrangevofvmotionvexercises.vWhatvisvthevnurse'svbestvaction?
Stopvthevrangevofvmotionvexercisevandvassessvthevpain.
Thevnursevisvusingvavgoniometervtovmeasurevavclient’svrangevofvmotion.vWhichvfindingvwillvthev
nursevdocument?vDegreesvofvavcirclevab-vmeansvawayvfromvandvad-vmeansvtoward.
Thevtermvflexionvbendsvavlimbvandvextensionvstraightensvavlimb.
Followingvhipvreplacementvsurgery,vCarlvisvreceivingvpassivevrangevofvmotionvonvthevlegvfromvavhe
althcarevprovider.vThevhealthcarevprovidervmovesvthevjointsvtovthevpointvofvresistance,vbutvCarlvco
mplainsvofvseverevpain.vWhatvisvthevprovider'svnextvstep?
Stopvthevcurrentvmotionvandvreverse.
Avclientvisvcomplainingvthatvtheyvarevstiffvlyingvinvthevhospital.vTheyvstatevtheyvusuallyvtwistvbackva
ndvforthvasvtheyvdovyoga.vTheyvdemonstratevthatvmotionvtovthevnurse.vThevnursevdecidesvtovdocu
mentvthisvinformationvinvthevclient'svchart.vWhichvstatementvshouldvthevchartingvinclude?
Thevclientvactivelyvrotatesvthevtrunkvforvreliefvfromvstiffnessvinvthevback.
Thevnursevisvassistingvavclientvwithvrangevofvmotionvexercisesvonvthevleftvarm.vWhichvisvconsideredv
bestvpractice?
Onlyvexposevthevleftvarm.
Thevnursevhasvthevclientvplacevthevrightvhand,vpalmvdown,vonvavtablevandvthenvasksvthevclientvtovtu
rnvthevhandvpalmvup.vThevclientvcompletesvthevmovement.vHowvwouldvthevnursevdocumentvthis?
Clientvablevtovcompletevsupinationvandvpronationvofvrightvhand.
Avnursevisvtakingvcarevofvavclientvwhovisvavballerinavandvhasvinjuredvthevleftvfoot.vWhichvrangevofv
motionvexercisevwouldvbevthevmostvimportantvforvthevleftvfoot?vPlantarvflexionv
Aftervfindingvoutvthatvrangevofvmotionvwasvordered,vavclientvstates,v"Isvitvreallyvnecessary?vItvhas
vonlyvbeenvavcouplevofvdaysvsincevmyvsurgery."vWhatvisvthevnurse'svbestvresponse?v"Rangevofvm
otionvcanvdecreasevpainvbyvincreasingvcirculationvandvdecreasingvstiffness."
Thevnursevisvreviewingvavclient'svchart.vWhichvdiagnosisvwouldvhavevbeenvassignedvduevtovlimitedv
rangevofvmotion?vRiskvforvfalls
v Week 2 Edapts Mobility and Immobility
v v v v v
MobilityvandvImmobility
Adam,vav54-year-
v
oldvclientvonvbedvrest,vhasvavStagev1vpressurevinjuryvonvthevcoccyx.vWhichvinterventionsvshouldvth
evnursevimplement?v
Providevpropervskinvcare.
Repositionvthevclientveveryv1vtov2vhours.
Getvthevclientvavspecialtyvairvorvfoamvmattress.
Av77-year-
oldvisvrecoveringvfromvspinalvsurgeryvandvusingvavwalkervasvanvassistivevdevice.vThevclientvstates,v"
Ivdon'tvwantvanyvvisitorsvorvtovgovanywhere.vNovonevshouldvseevmevusingvavwalker.vIvwantvtovbevlef
tvalone."vWhatvisvthevmostvappropriatevnursingvdiagnosis?vSocialvisolation
Anv80-year-
oldvfellvatvhomevandvwasvnotvfoundvforvthreevdays.vThevclientvwasvadmittedvtovthevhospitalvwithvav
fracturedvhip.vWhichvcomplicationsvcanvoccurvduevtovimmobility?v
Embolus
Urinaryvretention
Musclevatrophy
Thevnursevisvassessingvavclientvwhovrecentlyvhadvsurgery.vLungvsoundsvonvthevrightvbasevarevdi
minishedvandvtherevarevnovbreathvsoundsvinvthevleftvbase.vWhatvcomplicationvdoesvthevnurse
vsuspect?vAtelectasis
KarivAnnv(preferredvpronouns:vshe,vher),vav32-year-
oldvfemale,visvhospitalizedvwithvmultiplevsclerosis.vHervconditionvhasvworsenedvandvshevwillvneedv
avwheelchairvfromvnowvon.vShevisvdivorcedvwithvfourvchildren.vWhichvstatementvindicatesvavneedv
forvimmediatevfollow-upvbyvthevnurse?
"Ivwon’tvneedvanyvhelpvatvhome."
Avclientvhasvbeenvonvprolongedvbedvrestvbutvnowvisvablevtovgetvup.vWhatvshouldvthevnursevassessvf
or?v
Activityvtolerance
Gait
Rangevofvmotionv(ROM)
Strength
Carolv(preferredvpronouns:vshe,vher)visvavnewvresidentvofvavlong-
termvcarevfacility.vShevhasvseverevarthritisvandvisvwheelchair-
, NR 224 – Week 2 Edapts
v v v v v
bound.vRecentvcomplicationsvledvCarolvtovbevhospitalizedvandvthenvtransferredvtovavcarevfacility.vS
hevappearsvveryvdepressedvandvwithdrawn.vWhatvisvthevnurse'svbestvaction?
BringvCarolvtovthevcommonvareavtovmeetvothervresidents.
Mobility and Immobility
v v
MaryvBrennervisvav60-year-oldvclientvwhovisvlessvthanv24vhoursvpost-
operativevfromvabdominalvsurgery.vTovpreventvimmobilityvcomplications,vwhatvpriorityvnursingvin
terventionvshouldvbevimplemented?
Ambulatevthevclientvinvthevhall.
Thevnursevnoticesvthatvavclientvwithvimpairedvmobilityvinvthevlowervextremitiesvhasvdecreasedvskin
vturgorvandvhypoactivevbowelvsounds.vWhichvfactorvmayvcontributevtovthesevsignsvinvthevimmobili
zedvclient?vInadequatevfluidvintake
Avnursevworksvonvanvorthopedicvsurgicalvfloorvinvavhospital.vThevnursevunderstandsvthatvclients
varevatvriskvofvwhichvphysiologicalvcomplicationvofvimmobility?vDecreasedvlungvexpansion
Anvunlicensedvassistivevpersonnelv(UAP)visvputtingvcompressionvstockingsvonvavclientvfollowingvm
ajorvsurgery.vThevclientvasksvwhyvtheyvhavevtovwearvthem.vWhatvisvthevUAP'svbestvanswer?
"Theyvpromotevcirculationvtovthevheart."
Anv18-year-
oldvvictimvofvavmotorvvehiclevcrashvwithvavfracturedvfemurvhasvbeenvimmobilizedvforvsixvdays.vTh
evnursevisvgettingvthevclientvoutvofvbedvforvthevfirstvtime.vWhichvnursingvdiagnosisvisvapplicablevtov
thisvaction?vRiskvforvactivityvintolerance
Marissavisvav4-year-
oldvwithvcerebralvpalsy.vInvthevnurse'svassessment,vwhichvfindingvwouldvindicatevavdevelopmental
vcomplication?
Marissavcannotvsayvtheirvfirstvandvlastvnamesvandvspeaksvunclearlyvsometimes.
Thevnursevhasvfourvclientsvonvthevunitvwithvimpairedvmobility.vWhichvclientvisvatvgreatestvriskvofvde
velopingvcomplicationsvfromvimmobility?
82-year-oldvwomanvwhovhasvsufferedvavcerebrovascularvaccidentv(CVA)
RangevofvMotion
, NR 224 –
v v
v Week 2 Edapts Mobility and Immobility
v v v v v
Avclientvarrivesvforvphysicalvtherapyvwithvlimitedvmotionvofvthevrightvknee.vHowvdoesvthevtherapist
vknowvthevextentvofvthevlimitation?
Measurevusingvavgoniometer.
Thevclientvisvexperiencingvpainvduringvrangevofvmotionvexercises.vWhatvisvthevnurse'svbestvaction?
Stopvthevrangevofvmotionvexercisevandvassessvthevpain.
Thevnursevisvusingvavgoniometervtovmeasurevavclient’svrangevofvmotion.vWhichvfindingvwillvthev
nursevdocument?vDegreesvofvavcirclevab-vmeansvawayvfromvandvad-vmeansvtoward.
Thevtermvflexionvbendsvavlimbvandvextensionvstraightensvavlimb.
Followingvhipvreplacementvsurgery,vCarlvisvreceivingvpassivevrangevofvmotionvonvthevlegvfromvavhe
althcarevprovider.vThevhealthcarevprovidervmovesvthevjointsvtovthevpointvofvresistance,vbutvCarlvco
mplainsvofvseverevpain.vWhatvisvthevprovider'svnextvstep?
Stopvthevcurrentvmotionvandvreverse.
Avclientvisvcomplainingvthatvtheyvarevstiffvlyingvinvthevhospital.vTheyvstatevtheyvusuallyvtwistvbackva
ndvforthvasvtheyvdovyoga.vTheyvdemonstratevthatvmotionvtovthevnurse.vThevnursevdecidesvtovdocu
mentvthisvinformationvinvthevclient'svchart.vWhichvstatementvshouldvthevchartingvinclude?
Thevclientvactivelyvrotatesvthevtrunkvforvreliefvfromvstiffnessvinvthevback.
Thevnursevisvassistingvavclientvwithvrangevofvmotionvexercisesvonvthevleftvarm.vWhichvisvconsideredv
bestvpractice?
Onlyvexposevthevleftvarm.
Thevnursevhasvthevclientvplacevthevrightvhand,vpalmvdown,vonvavtablevandvthenvasksvthevclientvtovtu
rnvthevhandvpalmvup.vThevclientvcompletesvthevmovement.vHowvwouldvthevnursevdocumentvthis?
Clientvablevtovcompletevsupinationvandvpronationvofvrightvhand.
Avnursevisvtakingvcarevofvavclientvwhovisvavballerinavandvhasvinjuredvthevleftvfoot.vWhichvrangevofv
motionvexercisevwouldvbevthevmostvimportantvforvthevleftvfoot?vPlantarvflexionv
Aftervfindingvoutvthatvrangevofvmotionvwasvordered,vavclientvstates,v"Isvitvreallyvnecessary?vItvhas
vonlyvbeenvavcouplevofvdaysvsincevmyvsurgery."vWhatvisvthevnurse'svbestvresponse?v"Rangevofvm
otionvcanvdecreasevpainvbyvincreasingvcirculationvandvdecreasingvstiffness."
Thevnursevisvreviewingvavclient'svchart.vWhichvdiagnosisvwouldvhavevbeenvassignedvduevtovlimitedv
rangevofvmotion?vRiskvforvfalls
