NUR 155 EXAM 3 | ACTUAL QUESTIONS AND
ANSWERS 100% ACCURATE.
Framework for movement - Musculoskeletal system
Controls movement, posture, balance, and gait - Nervous system
Circulates oxygen and nutrients - Cardiopulmonary system
Altered musculoskeletal system - - Bone fragility
- Flaccidity or hypotonicity
Altered nervous system - - Hemiparesis
- Hemiplegia
- Paraplegia
- Quadriplegia
Altered cardiopulmonary system - - Compromised cardiac function
- Decreased tissue perfusion
- Diminished respiratory capacity
Effects of immobility on musculoskeletal system - - Weakness
- Decreased muscle tone
- Decreased bone and muscle mass
- Muscle atrophy wasting
- Contracture
Effects of immobility on nervous system - Proprioception and equilibrium can be altered
Effects of immobility on cardiopulmonary system - - Cardiac workload is increased
- Lung expansion is decreased
- Circulatory stasis occurs
- Pooled blood combined with weakened calf muscles can lead to deep vein thrombosis
(DVT)
- Activity intolerance may develop
Effects of immobility on nutrition - - Basal metabolic rate (BMR) is reduced
- Catabolism of protein leads to a negative nitrogen balance if dietary protein is
insufficient
- Continued immobility may lead to anorexia and nausea
,Effects of immobility on elimination - - Urinary stasis may develop, and may result in
UTIs and renal calculus
- Hypomotility of the GI tract may result
Effects of immobility on skin - - Pressure on bony prominences can cause tissue
ischemia
- Prolonged tissue ischemia may lead to necrosis
- Pressure injuries may develop
Effects of immobility on psychosocial impact - - Isolation and sensory deprivation may
result
- Self-concept may be altered
- Sleep and rest patterns may be disturbed
Musculoskeletal and nervous system interventions - - Early ambulating
- Isotonic exercise
- Isometric exercise
- Aerobic exercise
- Anaerobic exercise
- Active or passive range of motion exercises
- Pain assessment and treatment
Isotonic exercise - Active movement with constant muscle contraction (walking)
Isometric exercise - Tensing a muscle and holding it for a short time, followed by
complete relaxation of the muscle (kegel exercises)
Aerobic exercise - Have oxygen metabolism to give us energy, constant moving
Anaerobic exercise - Intense physical activity that requires little oxygen but uses short
bursts of energy (lifting weights)
Positioning devices - - Pillow
- Splints and braces
- Handrolls
Trochanter rolls - Rolled towel support placed against the hips and upper leg to prevent
external rotation of the legs while laying supine
Log roll - Method used to turn a patient with a spinal injury, in which the patient is
moved to the side in one motion
Mechanical lift - - Preferred transfer method
- Some can be used for ambulating
Steps to use mechanical lift - - Place pt in harness
, - Lift pt until feet are just touching the ground
- Pt walks holding onto lift device
- Lift supports pt weight
Lift equipment - - Maximizes patient assistance
- Drastically reduces injuries to nurses
Cardiopulmonary interventions - - Promote lung expansion
- nPrevent nDVT
Promoting nlung nexpansion n- n n- nRaise nhead nof nbed
- nTeach nroutine ncoughing nand ndeep-breathing
- nIncentive nspirometer nuse
- nTurn nand nreposition
Preventing nDVT n- n n- nTeach npatient nto nperform nleg, nankle, nand nfoot nexercises nor nperform
npassive nrange nof nmotion
- nApply nantiembolism nhose nor nsequential ncompression ndevices
- nAvoid nplacing npressure non nlower nextremities
Nutrition ninterventions n- n n- nOffer npatients nmeals nthat ninclude nlean nprotein
- nOffer nsmaller, nmore nfrequent nmeals
- nInvolve npatients nin ndietary nchoices
- nIncrease npatient nactivity nas ntolerated
- nEncourage nadequate nfluid nintake
Elimination ninterventions n- n n- nAdequate nfluid nintake
- nPosition nchanges
- nToileting nprogram
- nBedside ncommode
- nBedpan
- nIncreased nfiber
- nEarly nambulation
- nTreat nconstipation
Skin ninterventions n- n n- nTurn nimmobile npatients nQ2 nhrs
- nUse npressure nrelieving nand npressure nreducing nmattresses
- nUse nappropriate npositioning nand npillow nplacement
- nUse nheel nand nelbow nprotectors
Psychosocial ninterventions n- n n- nEncourage ncontact nwith nfamily nand nfriends
- nProvide nspiritual nsupport nas nneeded
- nMinimize ndisruption nof nsleep nand nrest
- nExplain nall nprocedures
- nOrient npatient nto nreality
ANSWERS 100% ACCURATE.
Framework for movement - Musculoskeletal system
Controls movement, posture, balance, and gait - Nervous system
Circulates oxygen and nutrients - Cardiopulmonary system
Altered musculoskeletal system - - Bone fragility
- Flaccidity or hypotonicity
Altered nervous system - - Hemiparesis
- Hemiplegia
- Paraplegia
- Quadriplegia
Altered cardiopulmonary system - - Compromised cardiac function
- Decreased tissue perfusion
- Diminished respiratory capacity
Effects of immobility on musculoskeletal system - - Weakness
- Decreased muscle tone
- Decreased bone and muscle mass
- Muscle atrophy wasting
- Contracture
Effects of immobility on nervous system - Proprioception and equilibrium can be altered
Effects of immobility on cardiopulmonary system - - Cardiac workload is increased
- Lung expansion is decreased
- Circulatory stasis occurs
- Pooled blood combined with weakened calf muscles can lead to deep vein thrombosis
(DVT)
- Activity intolerance may develop
Effects of immobility on nutrition - - Basal metabolic rate (BMR) is reduced
- Catabolism of protein leads to a negative nitrogen balance if dietary protein is
insufficient
- Continued immobility may lead to anorexia and nausea
,Effects of immobility on elimination - - Urinary stasis may develop, and may result in
UTIs and renal calculus
- Hypomotility of the GI tract may result
Effects of immobility on skin - - Pressure on bony prominences can cause tissue
ischemia
- Prolonged tissue ischemia may lead to necrosis
- Pressure injuries may develop
Effects of immobility on psychosocial impact - - Isolation and sensory deprivation may
result
- Self-concept may be altered
- Sleep and rest patterns may be disturbed
Musculoskeletal and nervous system interventions - - Early ambulating
- Isotonic exercise
- Isometric exercise
- Aerobic exercise
- Anaerobic exercise
- Active or passive range of motion exercises
- Pain assessment and treatment
Isotonic exercise - Active movement with constant muscle contraction (walking)
Isometric exercise - Tensing a muscle and holding it for a short time, followed by
complete relaxation of the muscle (kegel exercises)
Aerobic exercise - Have oxygen metabolism to give us energy, constant moving
Anaerobic exercise - Intense physical activity that requires little oxygen but uses short
bursts of energy (lifting weights)
Positioning devices - - Pillow
- Splints and braces
- Handrolls
Trochanter rolls - Rolled towel support placed against the hips and upper leg to prevent
external rotation of the legs while laying supine
Log roll - Method used to turn a patient with a spinal injury, in which the patient is
moved to the side in one motion
Mechanical lift - - Preferred transfer method
- Some can be used for ambulating
Steps to use mechanical lift - - Place pt in harness
, - Lift pt until feet are just touching the ground
- Pt walks holding onto lift device
- Lift supports pt weight
Lift equipment - - Maximizes patient assistance
- Drastically reduces injuries to nurses
Cardiopulmonary interventions - - Promote lung expansion
- nPrevent nDVT
Promoting nlung nexpansion n- n n- nRaise nhead nof nbed
- nTeach nroutine ncoughing nand ndeep-breathing
- nIncentive nspirometer nuse
- nTurn nand nreposition
Preventing nDVT n- n n- nTeach npatient nto nperform nleg, nankle, nand nfoot nexercises nor nperform
npassive nrange nof nmotion
- nApply nantiembolism nhose nor nsequential ncompression ndevices
- nAvoid nplacing npressure non nlower nextremities
Nutrition ninterventions n- n n- nOffer npatients nmeals nthat ninclude nlean nprotein
- nOffer nsmaller, nmore nfrequent nmeals
- nInvolve npatients nin ndietary nchoices
- nIncrease npatient nactivity nas ntolerated
- nEncourage nadequate nfluid nintake
Elimination ninterventions n- n n- nAdequate nfluid nintake
- nPosition nchanges
- nToileting nprogram
- nBedside ncommode
- nBedpan
- nIncreased nfiber
- nEarly nambulation
- nTreat nconstipation
Skin ninterventions n- n n- nTurn nimmobile npatients nQ2 nhrs
- nUse npressure nrelieving nand npressure nreducing nmattresses
- nUse nappropriate npositioning nand npillow nplacement
- nUse nheel nand nelbow nprotectors
Psychosocial ninterventions n- n n- nEncourage ncontact nwith nfamily nand nfriends
- nProvide nspiritual nsupport nas nneeded
- nMinimize ndisruption nof nsleep nand nrest
- nExplain nall nprocedures
- nOrient npatient nto nreality
