IMMOBILITY / EXAM 2 / NUR 112
QUESTIONS WITH ACCURATE ANSWERS
*Acute care - dressings*: correct answer Influence wound healing
Provide a moist environment to promote normal epidermal cell
migration
Absorb drainage to prevent pooling exudate
Surgical wounds: dressing removed when drainage stops
*Acute care - pressure ulcers*: correct answer Wound
management principles (wound healing)
Manage etiology
Systemic support (oxygen)
Nutrition
Wound cleansing/infection control
Patient education
*Age*: correct answer - Older adults: Loss of dermal thickness
increases risk for skin tears, more vulnerable to other factors.
- Neonates: fragile skin
*Assessment of mobility*: correct answer - Daily activity level
- Endurance
- Exercise/fitness goals
- Mobility problems
- Physical or mental health alterations
- External factors *One in ten premature deaths worldwide are
caused by inactivity.*
*Assistive devices*: correct answer - Drawsheets
- Use assistive devices when lifting more than 35 pounds.
- Reduce friction
- Motorized lift
- Explain assistive device & procedure to pt before the transfer.
- Practice proper body mechanics
- Sliding board (stretcher to bed)
- Ask another caregiver for assistance
- Use draw sheet to assist with turning
- Roll pt to side to position the sliding board
- Use draw sheet to slide pt to desired area
,*Blanchable hyperemia*: correct answer - Area's that appears red
& warm
- Blanches following finger-tip palpation
*Body mechanics*: correct answer The use of *proper body
positions* that provides protection from *stress of movements
and activity*, specifically in regards to *structure, function, and
position of the body*
- Coordinated efforts of the *musculoskeletal and nervous
system* to maintain *balance, posture, & body alignment*
- Used during lifting, bending, moving, & performing ADL's.
- Decreases risk of musculoskeletal injury & prevents muscle
strain & excessive use of muscle energy.
*Braden scale*: correct answer - *6 sub scales to identify patients
at risk*
- *Sensory perception, moisture, activity, mobility, nutrition,
friction, shear (23 points possible)*
- *Hospitalized adult with 16 or less & older adults with 18 or less
are at risk for pressure ulcer development*.
*Changing of dressings*: correct answer - Know the type of
dressing, placement of drains, & supplies needed.
- Check order
- Skills book
*Chemical restraints*: correct answer Meds, such as anxiolytics
and sedatives, used to control hyperactive behavior in agitated
pts
- Not a standard treatment for patients condition
*Cold*: correct answer - Cold moist compress
- Cold soak
- Ice bag or collar
- Commercial cold pack
, *Comfort measures for dressings*: correct answer - *Carefully
remove tape*
- Gently cleanse wound
- *Administer analgesics before dressing change*
- "Time-outs" during painful procedures
- Position & support for comfort
*Complication of restraints*: correct answer - Pressure ulcers
- Pneumonia
- Constipation
- Incontinence
- Strangulation (vest)
*Devices used for proper positioning*: correct answer - Pillows
- Foot boards
- Trochanter rolls
- Hand rolls
- Hand-wrist splints
- Trapeze bar
- Side rails
- Wedge pillow
*Diagnosing*: correct answer - Disturbed body image
- Deficient knowledge related to wound care
- Impaired tissue integrity (risk for)
- Impaired Skin Integrity (risk for)
- Risk for Infection
- Acute/Chronic Pain
- Impaired Physical Mobility
- Ineffective Peripheral Tissue Perfusion
- Imbalanced Nutrition: Less Than Body Requirements
*Dry or moist gauze*: correct answer Best for *moderate
drainage, deep wounds, undermining, & tunnels*.
*Effects of cold*: correct answer - Vasoconstriction
- Local anesthesia
- Reduced cell metabolism
QUESTIONS WITH ACCURATE ANSWERS
*Acute care - dressings*: correct answer Influence wound healing
Provide a moist environment to promote normal epidermal cell
migration
Absorb drainage to prevent pooling exudate
Surgical wounds: dressing removed when drainage stops
*Acute care - pressure ulcers*: correct answer Wound
management principles (wound healing)
Manage etiology
Systemic support (oxygen)
Nutrition
Wound cleansing/infection control
Patient education
*Age*: correct answer - Older adults: Loss of dermal thickness
increases risk for skin tears, more vulnerable to other factors.
- Neonates: fragile skin
*Assessment of mobility*: correct answer - Daily activity level
- Endurance
- Exercise/fitness goals
- Mobility problems
- Physical or mental health alterations
- External factors *One in ten premature deaths worldwide are
caused by inactivity.*
*Assistive devices*: correct answer - Drawsheets
- Use assistive devices when lifting more than 35 pounds.
- Reduce friction
- Motorized lift
- Explain assistive device & procedure to pt before the transfer.
- Practice proper body mechanics
- Sliding board (stretcher to bed)
- Ask another caregiver for assistance
- Use draw sheet to assist with turning
- Roll pt to side to position the sliding board
- Use draw sheet to slide pt to desired area
,*Blanchable hyperemia*: correct answer - Area's that appears red
& warm
- Blanches following finger-tip palpation
*Body mechanics*: correct answer The use of *proper body
positions* that provides protection from *stress of movements
and activity*, specifically in regards to *structure, function, and
position of the body*
- Coordinated efforts of the *musculoskeletal and nervous
system* to maintain *balance, posture, & body alignment*
- Used during lifting, bending, moving, & performing ADL's.
- Decreases risk of musculoskeletal injury & prevents muscle
strain & excessive use of muscle energy.
*Braden scale*: correct answer - *6 sub scales to identify patients
at risk*
- *Sensory perception, moisture, activity, mobility, nutrition,
friction, shear (23 points possible)*
- *Hospitalized adult with 16 or less & older adults with 18 or less
are at risk for pressure ulcer development*.
*Changing of dressings*: correct answer - Know the type of
dressing, placement of drains, & supplies needed.
- Check order
- Skills book
*Chemical restraints*: correct answer Meds, such as anxiolytics
and sedatives, used to control hyperactive behavior in agitated
pts
- Not a standard treatment for patients condition
*Cold*: correct answer - Cold moist compress
- Cold soak
- Ice bag or collar
- Commercial cold pack
, *Comfort measures for dressings*: correct answer - *Carefully
remove tape*
- Gently cleanse wound
- *Administer analgesics before dressing change*
- "Time-outs" during painful procedures
- Position & support for comfort
*Complication of restraints*: correct answer - Pressure ulcers
- Pneumonia
- Constipation
- Incontinence
- Strangulation (vest)
*Devices used for proper positioning*: correct answer - Pillows
- Foot boards
- Trochanter rolls
- Hand rolls
- Hand-wrist splints
- Trapeze bar
- Side rails
- Wedge pillow
*Diagnosing*: correct answer - Disturbed body image
- Deficient knowledge related to wound care
- Impaired tissue integrity (risk for)
- Impaired Skin Integrity (risk for)
- Risk for Infection
- Acute/Chronic Pain
- Impaired Physical Mobility
- Ineffective Peripheral Tissue Perfusion
- Imbalanced Nutrition: Less Than Body Requirements
*Dry or moist gauze*: correct answer Best for *moderate
drainage, deep wounds, undermining, & tunnels*.
*Effects of cold*: correct answer - Vasoconstriction
- Local anesthesia
- Reduced cell metabolism
