Chapter 28- Activity, Immobility, Safe Movement
Question 1 of 25
What response would the nurse give the patient when questioned about the effect of rheumatoid arthritis on the musculoskeletal
system?
¥ Muscle wasting
¥ Joint spasticity
¥ Joint inflammation
¥ Muscle weakness
Rheumatoid arthritis and osteoarthritis cause inflammation of joints, resulting in pain and limited joint mobility, not muscle mobility.
Genetic disorders such as muscular dystrophy result in muscle weakness and gradual muscle wasting. Spasticity (increased muscle
tone) occurs in developmental disorders, such as cerebral palsy, and results in reduced range-of-motion (ROM) and abnormal
movement patterns.
Question 2 of 25
The nurse is implementing generalized falls precautions for patients who are at risk for falls. Which intervention indicates a lack of
understanding of these precautions?
¥ The patient is wearing socks.
¥ The patient’s call light is within reach.
¥ The bed is placed in the low position.
¥ The patient’s cell phone is by the bedside.
If the patient is ambulatory, require the use of nonskid footwear. Socks can be slippery unless they have a grip surface on them. Keep
patient belongings (e.g., tissues, water, urinals, personal items) within the patient’s reach. Keep the call light in reach and remind the
patient to use it and keep the bed in the low position.
Question 3 of 25
The nurse is educating the family of a patient on falls risk precautions. Which statement by the family indicates a need for further
education?
¥ “I should keep her cell phone close to her bed.”
¥ “I should leave her slippers by the wheelchair.”
¥ “I should leave the bathroom light on as she does at her home.”
¥ “I should keep the wheelchair locked unless using it to move Mom.”
The slippers should be close to wherever the patient is as it is important to keep patient belongings (e.g., tissues, water, urinals,
personal items) within the patient’s reach.
Leave lights on or off at night, depending on the patient’s cognitive status and personal preference. Keep the wheels of any wheeled
device (e.g., bed, wheelchair) in the locked position.
Question 4 of 25
The nurse is performing passive range-of-motion exercises on a patient when the patient begins to complain of pain. What is the
first thing the nurse should do?
¥ Notify the health care provider.
¥ Switch to active range of motion.CO
¥ Stop the range of motion.
¥ Hyperextend the joint.
Stop range-of-motion exercises if the patient begins to complain of pain or if resistance to movement is experienced. Never
hyperextend or flex a patient’s joints beyond the position of comfort. Active range of motion is when the patient moves the joint.
Notifying the health care provider would happen later.
, Question 5 of 25
The nurse recognizes which goal to be appropriate for the patient who is postoperative day one from a hip fracture with the nursing
diagnosis Impaired mobility?
¥ Patient will interact with others.
¥ Patient will ambulate to the bathroom with assistance.
¥ Patient will have no skin breakdown.
¥ Patient will have a physical therapy consult.
Patients with a diagnosis of impaired mobility should have a goal aimed at improving their mobility. Although immobility can impact
social isolation and skin breakdown, those goals are not appropriate for this diagnosis. Have a physical therapy consult is not a goal
but an intervention.
Question 6 of 25
The nurse identifies which goal to be appropriate for the patient who is postoperative day one from abdominal surgery and on bed
rest with the nursing diagnosis of Impaired skin integrity?
¥ Patient will eat 50% of meals.
¥ Patient will have no further skin breakdown.
¥ Patient will ambulate twice a day.
¥ Patient will interact with others.
The patient already has a wound, so the goal is focused on no further skin breakdown as a result of the bed rest and immobility.
Although nutrition is important to wound healing, it is not the focus of this nursing diagnosis. Ambulating and interacting with others
are not goals for this diagnosis.
Question 7 of 25
The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicates a good
understanding of these exercises?
¥ “An example of this type of exercise is Kegels.”
¥ “An example of this type of exercise is weightlifting.”
¥ “An example of this type of exercise is walking.”
¥ “An example of this type of exercise is running.”
Isometric exercise requires tension and relaxation of muscles without joint movement. An example is tension and relaxation of pelvic
floor muscles (i.e., Kegel exercise). Isotonic exercise involves active movement with constant muscle contraction, such as walking,
turning in bed, and self-feeding. Aerobic exercise requires oxygen metabolism to produce energy. Patients may engage in rigorous
walking or repeated stair climbing to achieve the positive effects of aerobic exercise. Anaerobic exercise builds power and body mass.
Without oxygen to produce energy for activity, anaerobic exercise takes place, such as heavy weightlifting.
Question 8 of 25
The nurse is preparing to assist the patient to walk to the bathroom after medicating the patient with a narcotic for pain
management. What possible adverse effect should the nurse be immediately aware?
¥ Depression
¥ Pain relief
¥ Constipation
¥ Dizziness
Potential adverse side effects of narcotics include respiratory depression, hypotension, confusion, sedation, constipation, and
dizziness. The nurse should be immediately aware of dizziness during ambulation because of the safety risks. Pain relief is expected.
Depression is not an immediate adverse side effect. Constipation will not impact the nurse’s ability to safely ambulate the patient.
Question 1 of 25
What response would the nurse give the patient when questioned about the effect of rheumatoid arthritis on the musculoskeletal
system?
¥ Muscle wasting
¥ Joint spasticity
¥ Joint inflammation
¥ Muscle weakness
Rheumatoid arthritis and osteoarthritis cause inflammation of joints, resulting in pain and limited joint mobility, not muscle mobility.
Genetic disorders such as muscular dystrophy result in muscle weakness and gradual muscle wasting. Spasticity (increased muscle
tone) occurs in developmental disorders, such as cerebral palsy, and results in reduced range-of-motion (ROM) and abnormal
movement patterns.
Question 2 of 25
The nurse is implementing generalized falls precautions for patients who are at risk for falls. Which intervention indicates a lack of
understanding of these precautions?
¥ The patient is wearing socks.
¥ The patient’s call light is within reach.
¥ The bed is placed in the low position.
¥ The patient’s cell phone is by the bedside.
If the patient is ambulatory, require the use of nonskid footwear. Socks can be slippery unless they have a grip surface on them. Keep
patient belongings (e.g., tissues, water, urinals, personal items) within the patient’s reach. Keep the call light in reach and remind the
patient to use it and keep the bed in the low position.
Question 3 of 25
The nurse is educating the family of a patient on falls risk precautions. Which statement by the family indicates a need for further
education?
¥ “I should keep her cell phone close to her bed.”
¥ “I should leave her slippers by the wheelchair.”
¥ “I should leave the bathroom light on as she does at her home.”
¥ “I should keep the wheelchair locked unless using it to move Mom.”
The slippers should be close to wherever the patient is as it is important to keep patient belongings (e.g., tissues, water, urinals,
personal items) within the patient’s reach.
Leave lights on or off at night, depending on the patient’s cognitive status and personal preference. Keep the wheels of any wheeled
device (e.g., bed, wheelchair) in the locked position.
Question 4 of 25
The nurse is performing passive range-of-motion exercises on a patient when the patient begins to complain of pain. What is the
first thing the nurse should do?
¥ Notify the health care provider.
¥ Switch to active range of motion.CO
¥ Stop the range of motion.
¥ Hyperextend the joint.
Stop range-of-motion exercises if the patient begins to complain of pain or if resistance to movement is experienced. Never
hyperextend or flex a patient’s joints beyond the position of comfort. Active range of motion is when the patient moves the joint.
Notifying the health care provider would happen later.
, Question 5 of 25
The nurse recognizes which goal to be appropriate for the patient who is postoperative day one from a hip fracture with the nursing
diagnosis Impaired mobility?
¥ Patient will interact with others.
¥ Patient will ambulate to the bathroom with assistance.
¥ Patient will have no skin breakdown.
¥ Patient will have a physical therapy consult.
Patients with a diagnosis of impaired mobility should have a goal aimed at improving their mobility. Although immobility can impact
social isolation and skin breakdown, those goals are not appropriate for this diagnosis. Have a physical therapy consult is not a goal
but an intervention.
Question 6 of 25
The nurse identifies which goal to be appropriate for the patient who is postoperative day one from abdominal surgery and on bed
rest with the nursing diagnosis of Impaired skin integrity?
¥ Patient will eat 50% of meals.
¥ Patient will have no further skin breakdown.
¥ Patient will ambulate twice a day.
¥ Patient will interact with others.
The patient already has a wound, so the goal is focused on no further skin breakdown as a result of the bed rest and immobility.
Although nutrition is important to wound healing, it is not the focus of this nursing diagnosis. Ambulating and interacting with others
are not goals for this diagnosis.
Question 7 of 25
The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicates a good
understanding of these exercises?
¥ “An example of this type of exercise is Kegels.”
¥ “An example of this type of exercise is weightlifting.”
¥ “An example of this type of exercise is walking.”
¥ “An example of this type of exercise is running.”
Isometric exercise requires tension and relaxation of muscles without joint movement. An example is tension and relaxation of pelvic
floor muscles (i.e., Kegel exercise). Isotonic exercise involves active movement with constant muscle contraction, such as walking,
turning in bed, and self-feeding. Aerobic exercise requires oxygen metabolism to produce energy. Patients may engage in rigorous
walking or repeated stair climbing to achieve the positive effects of aerobic exercise. Anaerobic exercise builds power and body mass.
Without oxygen to produce energy for activity, anaerobic exercise takes place, such as heavy weightlifting.
Question 8 of 25
The nurse is preparing to assist the patient to walk to the bathroom after medicating the patient with a narcotic for pain
management. What possible adverse effect should the nurse be immediately aware?
¥ Depression
¥ Pain relief
¥ Constipation
¥ Dizziness
Potential adverse side effects of narcotics include respiratory depression, hypotension, confusion, sedation, constipation, and
dizziness. The nurse should be immediately aware of dizziness during ambulation because of the safety risks. Pain relief is expected.
Depression is not an immediate adverse side effect. Constipation will not impact the nurse’s ability to safely ambulate the patient.
