ATI Fundamentals Mobility and Immobility Chapter 40 Exam 2025

_____ is freedom and independence in purposeful movement and refers to adapting to and having self-awareness of the environment. - Correct Answer-Mobility _____ is the inability to move freely and independently at will. - Correct Answer-Immobility _____ _____ are designed to maintain mobility and prevent or minimize complications of immobility. - Correct Answer-Nursing interventions Cutaneous stimulation in the form of ______ and ______ applications helps relieve pain and promote healing. - Correct Answer-cold / heat Promoting _____ _____ is another key component of reducing the complications of immobility. - Correct Answer-venous return Immobility time frames/examples - Correct Answer-Temporary - knee arthroplasty Permanent - paraplegia Sudden onset - fractured arm Slow onset - multiple sclerosis Movement depends on: - Correct Answer-Intact skeletal system Skeletal muscles Nervous system Nursing Interventions Integumentary - Correct Answer-Maintain intact skin Nursing Interventions Respiratory - Correct Answer-Maintain airway patency, achieve optimal lung expansion and gas exchange, and mobilize airway secretions. Nursing Interventions Cardiovascular - Correct Answer-Maintain cardiovascular function, increase activity tolerance, and prevent thrombus formation. Nursing Interventions Metabolic - Correct Answer-Reduce skin injury and maintain metabolism. Nursing Interventions Elimination - Correct Answer-Maintain or achieve normal urinary and bowel elimination patterns. Nursing Interventions Musculoskeletal - Correct Answer-Maintain or regain body alignment and stability, decrease skin and musculoskeletal system changes, achieve full or optimal ROM, and prevent contractures. Nursing Interventions Psychosocial - Correct Answer-Maintain an acceptable sleep/wake pattern, achieve socialization, and complete self-care independently. Integumentary Assessment - Correct Answer-Use Norton or Braden scale Assess at least every 2 hrs Turn every 1 to 2 hours Limit sitting in a chair to 1 hr; Instruct pt to shift their weight every 15 min Respiratory Assessment - Correct Answer-Asses every 2 hrs Reposition every 1 to 2 hrs Remove abdominal binders every 2 hrs and replace Turn, cough, and breath deeply every 1 to 2 hr while awake Yawn every hour while awake Cardiovascular Assessment - Correct Answer-Instruct pt to avoid the Valsalva maneuver Use sequential compression devices or intermittent pneumatic compression Administer low dose heparin or enoxaparin Metabolic Assessment - Correct Answer-Provide a high calorie, high protein diet with vitamin B and C supplements Asses I&O Elimination Assessment - Correct Answer-Teach bladder and bowel training Consume a diet that includes fruits and vegetables and is high in fiber Cane Instructions - Correct Answer--Maintain two points of support on the ground at all times. -Keep the cane on the stronger side of the body. -Support body weight on both legs, move the cane forward 6 to 10 inches, then move the weaker leg forward toward the cane. -Next, advance the stronger leg past the cane Crutch Instructions - Correct Answer--Do not alter crutches after fitting. -Follow the prescribed crutch gait. -Support body weight at the hand grips with the elbows flexed at 20° to 30°. -Position the crutches on the unaffected side when sitting or rising from a chair. Four-point gait - Correct Answer-Bears weight on both legs Alternates each leg with the opposite crutch so three points of support are on the floor at all times Three point gait - Correct Answer-Bears all weight on one foot Affected leg never bears weight Two point gait - Correct Answer-partial weight bearing on both feet Moves crutch while moving the opposite leg at the same time Therapeutic effects of heat: - Correct Answer-Increases blood flow Increases tissue metabolism Relaxes muscles Eases joint stiffness and pain Therapeutic effects of cold: - Correct Answer-Decreases inflammation Prevents swelling Reduces bleeding Reduces fever Diminishes muscle spasms Decreases pain by decreasing the velocity of nerve conduction Clients at risk for injury from heat/cold applications: - Correct Answer-Very young, fair-skinned, and older clients have fragile skin. Immobile clients cannot move away from uncomfortable treatments. Clients with impaired sensory perception may not feel pain/burning. Do not over use treatments or response might be opposite. Heat treatment contraindications: - Correct Answer-Bony prominences are more sensitive to heat. Avoid heat applications over metal devices (ex. pacemakers). Do not apply to abdomen of pregnant women. Do not use under an immobile client due to burn risk. Cold applications are inappropriate for clients with: - Correct Answer-cold intolerance vascular insufficiency cold aggravated conditions like Raynaud's Make sure heat and cold application orders include: - Correct Answer-Location Duration and frequency Specific type (moist or dry) Temperature Types of MOIST HEAT applications: - Correct Answer-Hot compresses Hot soaks Sitz baths Types of DRY HEAT applications: - Correct Answer-Hot pack Warming blanket Types of MOIST COLD applications: - Correct Answer-Large basin of ice Cold water Cold pack to be used in place of ice Types of DRY COLD applications: - Correct Answer-Ice bag, Ice collar, ice glove, or a cold pack Cooling blanket Assess heat and cold treatment sites every _____ to _____ minutes - Correct Answer-5 to 10 Symptoms to check for with heat or cold treatments: - Correct Answer-Redness or pallor Pain or burning Numbness Shivering (with cold application) Blisters Decreased sensation Cyanosis (with cold application) Most heat or cold applications are used from _____ to _____ minutes. - Correct Answer-15 to 30 Documentation Heat & Cold Application - Correct Answer-Location, type, length of application Condition of skin before and after Client's ability to tolerate treatment Promoting Venous Return - Correct Answer-SCDs and IPC are plastic or fiber sleeves that inflate and deflate around the leg Machines are set to cycle 10 to 15 sec inflation and 45 to 60 sec deflation Antiembolic stockings - Correct Answer-Measure the calf and/or thigh circumference and the length of the leg to select the correct siz