Chapter 45: Mobility and Immobility Potter et al: Canadian Fundamentals of Nursing, 6th Edition.

Chapter 45: Mobility and Immobility Potter et al: Canadian Fundamentals of Nursing, 6th Edition. 1. A patient has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. While assessing the patient, the nurse is alert to which of the following signs? Correct Answer: Decreased peristalsis. 2. A 61-year-old patient recently had left-sided paralysis from a cerebrovascular accident (CVA; also known as stroke). In planning care for this patient, the nurse would do which of the following? Correct Answer: Assess the extremities for unilateral swelling and muscle atrophy. 3. When a patient with impaired physical mobility is in the recumbent position, what angle of lateral position is recommended? Correct Answer: 30 degrees. 4. The patient has sequential compression stockings in place. The nurse evaluates that the stockings have been implemented appropriately by the new staff nurse when the nurse observes what? Correct Answer: Intermittent pressure is set at 40 mm Hg. 5. The patient with torticollis would exhibit which of the following? Correct Answer: Contracture of the sternocleidomastoid muscle with a head incline. 6. The nurse expects to maintain the patient's legs in abduction after total hip replacement surgery with the use of which of the following? Correct Answer: Wedge pillow. 7. The patient is about to get up for the first time after a period of bed rest. What is the initial nursing action? Correct Answer: Obtain a baseline blood pressure. 2 | P a g e 8. Immobilized patients frequently have hypercalcemia, which places them at risk for what? Correct Answer: Renal calculi. 9. Patients on bed rest or otherwise immobile are at risk for what condition? Correct Answer: Altered metabolic function. 10. In caring for a patient who is immobile, what is important for the nurse to understand? Correct Answer: Changes in role and self-concept may lead to depression. 11. Immobility is a major risk factor for pressure ulcers. In caring for the patient who is immobilized, the nurse needs to be aware of which of the following? Correct Answer: A 30-degree lateral position is recommended. 12. The nurse is caring for a patient who has suffered a stroke. As part of the patient's ongoing care, what should the nurse do? Correct Answer: Encourage the patient to perform as many self-care activities as possible. 13. The nurse is assessing the way the patient walks. The manner of walking is known as what? Correct Answer: Gait. 14. When assessing the body alignment of a patient while he or she is standing, the nurse is aware of which of the following? Correct Answer: When observed laterally, the spinal curves align in a reversed S pattern. 15. The nurse is evaluating the body alignment of a patient in the sitting position. In this position, how is the body aligned? Correct Answer: Both feet are supported on the floor with ankles flexed. 3 | P a g e 16. The nurse is assessing body alignment for a patient who is immobilized. What must the nurse do? Correct Answer: Place the patient in a lateral position. 17. The nurse must assess the patient for hazards of immobility by performing a head-to-toe physical assessment. When assessing the respiratory system, what should the nurse do? Correct Answer: Auscultate the entire lung region to assess lung sounds. 18. The nurse is aware that patients who are immobile are at increased risk of developing deep vein thromboses (DVTs). Because of this, what action does the nurse take? Correct Answer: Measure the calf circumference of both legs. 19. A patient is admitted to the medical unit after a CVA. There is evidence of leftsided hemiparesis, and the nurse will be following up on range-of-motion (ROM) and other exercises performed in physiotherapy. Which of the following principles of ROM exercises does the nurse correctly teach the patient and family members? Correct Answer: Provide support to the extremity. 20. The nurse is caring for an older patient with the diagnosis of urinary tract infection (UTI). The patient is confused and agitated. It is important for the nurse to realize that confusion in older people is which of the following? Correct Answer: Not a normal expectation.