NMNC 1135-Principles of Nursing
Exam Questions All Solved Correctly.
A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which
technique will the nurse use for each movement?
a. Each movement is completed quickly and smoothly by the nurse.
b. Each movement is moved just to the point of resistance by the nurse
c. Each movement is repeated 5 times by the patient.
d. Each movement is performed until the patient reports pain. - Answer b. Each movement is
moved just to the point of resistance by the nurse
Rationale: Movements should be done slowly and smoothly. ROM should not cause pain.
A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing
assistive personnel?
a. Changing the patient's position
b. Identifying immobility hazards
c. Determining the level of comfort
d. Assessing circulation - Answer a. Changing the patient's position
Rationale: The skill of moving and positioning patients in bed can be delegated to nursing
assistive personnel (NAP). The nurse is responsible for assessing the patient's level of comfort
and for any hazards of immobility and assessing circulation.
The patient has been in bed for several days and needs to be ambulated. Which action will the
nurse take first?
a. Suggest a high-calcium diet.
b. Maintain a narrow base of support.
c. Encourage isometric exercises.
d. Dangle the patient at the bedside. - Answer d. Dangle the patient at the bedside.
Rationale: To prevent injury, nurses implement interventions that reduce or eliminate the
effects of orthostatic hypotension. Mobilize the patient as soon as the physical condition allows,
even if this only involves dangling at the bedside or moving to a chair. A wide base of support
increases balance. Isometric exercises (i.e., activities that involve muscle tension without muscle
shortening) have no beneficial effect on preventing orthostatic hypotension, but they improve
activity tolerance. A high-calcium diet can help with osteoporosis but can be detrimental in an
immobile patient.
, A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will
the nurse assess for?
a. Loss of weight
b. Loss of strength
c. Loss of hope
d. Loss of bone mass - Answer c. Loss of hope
Rationale: Loss of hope is a psychosocial aspect. Patients with restricted mobility may have
some depression. Depression is an affective disorder characterized by exaggerated feelings of
sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion
to reality. All the rest are physiological aspects: bone mass, strength, and weight.
The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which
intervention will the nurse add to the care plan?
a. Provide a complete bed bath to promote patient comfort.
b. Encourage the patient to perform as many self-care activities as possible.
c. Place the patient on bed rest to prevent fatigue.
d. Coordinate with occupational therapy for gait training. - Answer b. Encourage the patient
to perform as many self-care activities as possible.
Rationale: Nurses should encourage the older-adult patient to perform as many self-care
activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses
inadvertently contribute to a patient's immobility by providing unnecessary help with activities
such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation
leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased
risk for falls. After a stroke or brain attack, a patient likely receives gait training from a physical
therapist; speech rehabilitation from a speech therapist; and help from an occupational
therapist for ADLs such as dressing, bathing and toileting, or household chores.
Which goal is most appropriate for a patient who has had a total hip replacement?
a. The patient will walk 100 feet using a walker by the time of discharge.
b. The nurse will assist the patient to ambulate in the hall 2 times a day.
c. The patient will ambulate briskly on the treadmill by the time of discharge.
d. The patient will ambulate by the time of discharge. - Answer a. The patient will walk 100
feet using a walker by the time of discharge.
Rationale: "The patient will walk 100 feet using a walker by the time of discharge" is
individualized, realistic, and measurable. "Ambulating briskly on a treadmill" is not realistic for
this patient. The option that focuses on the nurse, not the patient, is not a measurable goal; this
Exam Questions All Solved Correctly.
A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which
technique will the nurse use for each movement?
a. Each movement is completed quickly and smoothly by the nurse.
b. Each movement is moved just to the point of resistance by the nurse
c. Each movement is repeated 5 times by the patient.
d. Each movement is performed until the patient reports pain. - Answer b. Each movement is
moved just to the point of resistance by the nurse
Rationale: Movements should be done slowly and smoothly. ROM should not cause pain.
A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing
assistive personnel?
a. Changing the patient's position
b. Identifying immobility hazards
c. Determining the level of comfort
d. Assessing circulation - Answer a. Changing the patient's position
Rationale: The skill of moving and positioning patients in bed can be delegated to nursing
assistive personnel (NAP). The nurse is responsible for assessing the patient's level of comfort
and for any hazards of immobility and assessing circulation.
The patient has been in bed for several days and needs to be ambulated. Which action will the
nurse take first?
a. Suggest a high-calcium diet.
b. Maintain a narrow base of support.
c. Encourage isometric exercises.
d. Dangle the patient at the bedside. - Answer d. Dangle the patient at the bedside.
Rationale: To prevent injury, nurses implement interventions that reduce or eliminate the
effects of orthostatic hypotension. Mobilize the patient as soon as the physical condition allows,
even if this only involves dangling at the bedside or moving to a chair. A wide base of support
increases balance. Isometric exercises (i.e., activities that involve muscle tension without muscle
shortening) have no beneficial effect on preventing orthostatic hypotension, but they improve
activity tolerance. A high-calcium diet can help with osteoporosis but can be detrimental in an
immobile patient.
, A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will
the nurse assess for?
a. Loss of weight
b. Loss of strength
c. Loss of hope
d. Loss of bone mass - Answer c. Loss of hope
Rationale: Loss of hope is a psychosocial aspect. Patients with restricted mobility may have
some depression. Depression is an affective disorder characterized by exaggerated feelings of
sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion
to reality. All the rest are physiological aspects: bone mass, strength, and weight.
The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which
intervention will the nurse add to the care plan?
a. Provide a complete bed bath to promote patient comfort.
b. Encourage the patient to perform as many self-care activities as possible.
c. Place the patient on bed rest to prevent fatigue.
d. Coordinate with occupational therapy for gait training. - Answer b. Encourage the patient
to perform as many self-care activities as possible.
Rationale: Nurses should encourage the older-adult patient to perform as many self-care
activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses
inadvertently contribute to a patient's immobility by providing unnecessary help with activities
such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation
leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased
risk for falls. After a stroke or brain attack, a patient likely receives gait training from a physical
therapist; speech rehabilitation from a speech therapist; and help from an occupational
therapist for ADLs such as dressing, bathing and toileting, or household chores.
Which goal is most appropriate for a patient who has had a total hip replacement?
a. The patient will walk 100 feet using a walker by the time of discharge.
b. The nurse will assist the patient to ambulate in the hall 2 times a day.
c. The patient will ambulate briskly on the treadmill by the time of discharge.
d. The patient will ambulate by the time of discharge. - Answer a. The patient will walk 100
feet using a walker by the time of discharge.
Rationale: "The patient will walk 100 feet using a walker by the time of discharge" is
individualized, realistic, and measurable. "Ambulating briskly on a treadmill" is not realistic for
this patient. The option that focuses on the nurse, not the patient, is not a measurable goal; this
