Funds Ch. 39 Immobility test bank and
rationales
ssing body alignment. what is the nurse monitoring?
A. The relationship of one body part to another while in different positions.
B. The coordinated efforts to the musculoskeletal and nervous systems
C. The force that occurs in a direction to oppose movement
D. The inability to move about freely
ANS: A
Rationale: The terms body alignment and posture are similar and refer to the positioning of
the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Body
alignment means that the individuals center of gravity is stable. Body mechanics is a term
used to describe the coordinated efforts of the musculoskeletal and nervous systems.
Friction is a force that occurs in a direction to oppose movement. Immobility is the inability to
move about freely
A nurse is providing range of motion to the shoulder and must perform external rotation.
Which action will the nurse take?
A. moves patients arm in a full circle
B. moves patients arm cross the body as far as possible
C. moves patients arm behind the body, keeping elbow straight
D. moves patients arm until thumb is upward and lateral to head with elbow flexed
ANS: D
Rationale: External rotation: with elbow flexed, move arm until thumb is upward and lateral
to head. Circumduction: Move arm in full circle (circumduction is combination of all
movements of ball-and-sack joint). Adduction: lower arm sideways and across body as far
as possible. Hyperextension: move arm behind body, keeping elbow straight
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 repeated 5 times by the patient
B. each movement is performed until the patient experiences pain
C. each movement is completed quickly and smoothly by the nurse
, D. each movement is moved just to the point of resistance by the nurse
ANS: D
Rationale: Passive ROM exercises are performed by the nurse. Carry out movements
slowly and smoothly, just to the point of resistance; ROM should not cause pain. Never force
a joint beyond its capacity. Each movement needs to be repeated 5 times during the
session. The patient moves all joints through ROM unassisted in active ROM.
A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient.
Which finding will indicate goal achievement for the nurse's action?
A. prevention of atelectasis
B. prevention of renal calculi
C. prevention of pressure ulcers
D. prevention of joint contractures
ANS: D
Rationale: Goal achievement for passive ROM is prevention of joint contractures.
Contractures develop in joints not moved periodically through their full ROM. ROM exercises
reduce the risk of contractures. Researchers noted that prompt use of splinting with
prescribed ROM exercises reduced contractures and improved active range of joint motion
in affected lower extremities. Deep breathing and coughing and using an incentive
spirometer will help prevent atelectasis. Adequate hydration helps prevent renal calculi and
urinary tract infections. Interventions aimed at prevention of pressure ulcers include
positioning, skin care, and the use of therapeutic devices to relieve pressure.
A nurse is preparing to reposition a patient. Which task can the nurse delegate to the
nursing assistive personnel?
A. determining the level of comfort
B. changing the patients position
C. identifying immobility hazards
D. assessing circulation
ANS: B
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 patients level of
comfort and for any hazards of immobility and assessing circulation.
A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of
equipment will the nurse obtain to assess for this condition?
A. thermometer
rationales
ssing body alignment. what is the nurse monitoring?
A. The relationship of one body part to another while in different positions.
B. The coordinated efforts to the musculoskeletal and nervous systems
C. The force that occurs in a direction to oppose movement
D. The inability to move about freely
ANS: A
Rationale: The terms body alignment and posture are similar and refer to the positioning of
the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Body
alignment means that the individuals center of gravity is stable. Body mechanics is a term
used to describe the coordinated efforts of the musculoskeletal and nervous systems.
Friction is a force that occurs in a direction to oppose movement. Immobility is the inability to
move about freely
A nurse is providing range of motion to the shoulder and must perform external rotation.
Which action will the nurse take?
A. moves patients arm in a full circle
B. moves patients arm cross the body as far as possible
C. moves patients arm behind the body, keeping elbow straight
D. moves patients arm until thumb is upward and lateral to head with elbow flexed
ANS: D
Rationale: External rotation: with elbow flexed, move arm until thumb is upward and lateral
to head. Circumduction: Move arm in full circle (circumduction is combination of all
movements of ball-and-sack joint). Adduction: lower arm sideways and across body as far
as possible. Hyperextension: move arm behind body, keeping elbow straight
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 repeated 5 times by the patient
B. each movement is performed until the patient experiences pain
C. each movement is completed quickly and smoothly by the nurse
, D. each movement is moved just to the point of resistance by the nurse
ANS: D
Rationale: Passive ROM exercises are performed by the nurse. Carry out movements
slowly and smoothly, just to the point of resistance; ROM should not cause pain. Never force
a joint beyond its capacity. Each movement needs to be repeated 5 times during the
session. The patient moves all joints through ROM unassisted in active ROM.
A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient.
Which finding will indicate goal achievement for the nurse's action?
A. prevention of atelectasis
B. prevention of renal calculi
C. prevention of pressure ulcers
D. prevention of joint contractures
ANS: D
Rationale: Goal achievement for passive ROM is prevention of joint contractures.
Contractures develop in joints not moved periodically through their full ROM. ROM exercises
reduce the risk of contractures. Researchers noted that prompt use of splinting with
prescribed ROM exercises reduced contractures and improved active range of joint motion
in affected lower extremities. Deep breathing and coughing and using an incentive
spirometer will help prevent atelectasis. Adequate hydration helps prevent renal calculi and
urinary tract infections. Interventions aimed at prevention of pressure ulcers include
positioning, skin care, and the use of therapeutic devices to relieve pressure.
A nurse is preparing to reposition a patient. Which task can the nurse delegate to the
nursing assistive personnel?
A. determining the level of comfort
B. changing the patients position
C. identifying immobility hazards
D. assessing circulation
ANS: B
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 patients level of
comfort and for any hazards of immobility and assessing circulation.
A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of
equipment will the nurse obtain to assess for this condition?
A. thermometer
