Chapter 39 Immobility Fundamentals of Nursing 11th Edition (Potter & Perry) 50 NCLEX-Style Exam Questions with Detailed Rationale

1. A nurse is caring for a patient who has been on bed rest for several days. Which finding indicates a complication of immobility? A. Decreased heart rate and increased respiratory rate B. Increased appetite and thirst C. Red, warm area on the calf D. Slight muscle soreness after turning Correct Answer: C Rationale: Redness and warmth in the calf may indicate deep vein thrombosis (DVT), a serious complication of immobility. ________________________________________ 2. Which intervention is most effective in preventing pulmonary complications of immobility? A. Administering antihistamines B. Encouraging incentive spirometry and deep breathing C. Increasing oral fluid intake to 4 L/day D. Keeping the patient in a high-Fowler’s position continuously Correct Answer: B Rationale: Incentive spirometry and deep breathing promote lung expansion and help prevent atelectasis and hypostatic pneumonia. ________________________________________ 3. What metabolic effect does immobility have on the body? A. Decreased calcium reabsorption B. Positive nitrogen balance C. Increased glucose utilization D. Increased risk for electrolyte loss Correct Answer: A Rationale: Immobility leads to bone demineralization and decreased calcium reabsorption, resulting in hypercalcemia and bone weakening. ________________________________________ 4. Which intervention should the nurse prioritize to prevent musculoskeletal complications in an immobile patient? A. Placing the patient in a semi-Fowler’s position B. Providing a high-protein diet C. Assisting with range-of-motion exercises D. Monitoring intake and output Correct Answer: C Rationale: ROM exercises help maintain joint mobility, prevent contractures, and reduce muscle atrophy during immobility. ________________________________________ 5. A patient on prolonged bed rest becomes confused and disoriented. Which condition is most likely contributing? A. Metabolic acidosis B. Fluid overload C. Sensory deprivation D. Stroke Correct Answer: C Rationale: Decreased environmental stimulation during immobility can lead to confusion and altered mental status. ________________________________________ 6. A nurse notices pressure injury development on a patient’s sacrum. What is the most appropriate action? A. Apply heat to the area B. Increase the patient’s fluid intake C. Reposition the patient every 2 hours D. Massage the reddened area Correct Answer: C Rationale: Repositioning helps relieve pressure, promoting circulation and preventing further tissue damage. Massaging is contraindicated. ________________________________________ 7. What cardiovascular adaptation occurs with immobility? A. Decreased cardiac workload B. Orthostatic hypotension C. Increased preload D. Reduced capillary permeability Correct Answer: B Rationale: Immobility causes deconditioning of the cardiovascular system, leading to blood pooling and orthostatic hypotension. ________________________________________ 8. What intervention prevents joint contractures in an immobile patient? A. Use of high-protein diet B. Application of antiembolism stockings C. Regular performance of passive ROM D. Administration of analgesics Correct Answer: C Rationale: ROM maintains flexibility and prevents shortening of muscles and tendons that lead to contractures. ________________________________________ 9. The nurse observes foot drop in a bedridden patient. Which device should be used to correct or prevent this? A. Trapeze bar B. Abduction pillow C. Trochanter roll D. Footboard or high-top sneakers Correct Answer: D Rationale: Footboards or sneakers maintain foot in dorsiflexion, preventing plantar flexion contractures known as foot drop.