NURS 230 Test 4 questions with complete solutions
to pass
1. In an immobility assessment
-Apical, peripheral pulses and baseline vitals are
what are expected findings of
within normal range
vital signs?
-Blood pressure and pulse remain stable
when pa- tient changes positions (from lying
to sitting to standing)
-Orthostatic/postural hypotension occurs
2. In an immobility assessment
when pa- tient changes position (from
what are unexpected findings
pooling of blood in legs and ineflcient
of vital signs?
vasoconstriction to get blood back to the
heart) -Systolic pressure drops 20 mm Hg
-Diastolic pressure drops 10 mm Hg
-Heart rate increases 20 beats/min
-Nutritional intake adequate for height and weig
3. In an immobility assessment -Weight unchanged
what are expected findings of -Serum albumin levels within normal range
nutrition in- take? -High-fiber food intake occurs
-Nutritional intake inadequate
4. In an immobility assessment -Weight loss
what are unexpected findings -Serum albumin levels low
of nutrition intake? -Fiber-rich food intake is decreased
-Intake is close to output
5. In an immobility assessment -Concentration of urine is clear with no strong
what are expected findings of odor
the urinary system?
6. In an immobility assessment -Intake less than output
what are unexpected findings -Urine dark, cloudy, and odorous
of the uri- nary system?
,NURS 230 Test 4 questions with complete solutions
to pass
-Urine may have stones
7.
,NURS 230 Test 4 questions with complete solutions
to pass
In an immobility assessment what -Bowel sound active with soft abdomen
are expected findings of the gastroin- -Soft stools expelled
testinal system? what are unexpected
findings of psycho- logica
8. In an immobility assessment issues?
what are unexpected findings
of the gas- trointestinal
system?
9. In an immobility assessment
what are expected findings of
the integu- mentary system?
10. In an immobility assessment
what are unexpected
findings of the in-
tegumentary system?
11. In an immobility assessment
what are expected findings of
psychologi- cal issues?
12. In an immobility assessment
,NURS 230 Test 4 questions with complete solutions
to pass
-Fecal impaction not present
-Bowel sounds decreased on auscultation
-Constipation present
-Abdomen distended with discomfort
-Fecal impaction (buildup of hardened feces in the
lower intestine) present
-Pink in color
-Skin intact
-Skin blanches (when pressure is applied, the skin
turns white but returns to its normal color promptly,
which indicates adequate perfusion)
-Braden Scale score of 19 or above
-Color darkened in tone or reddened (indicates is-
chemia or necrosis)
-Skin nonblanches: skin stays red when pressed with
finger (indicates ischemia)
-Braden Scale score of 18 or lower
-Mood and behavior remain unchanged
-Patient statements or behaviors indicate strong
self-concept and coping mechanisms
-Sleep patterns unchanged and sleeping through
the night
-Mood or behavior has changed drastically or sub-
tly, indicating concern related to immobility or iso-
lation (talkative but now withdrawn)
-Patient statements or behaviors indicate alterations
to pass
1. In an immobility assessment
-Apical, peripheral pulses and baseline vitals are
what are expected findings of
within normal range
vital signs?
-Blood pressure and pulse remain stable
when pa- tient changes positions (from lying
to sitting to standing)
-Orthostatic/postural hypotension occurs
2. In an immobility assessment
when pa- tient changes position (from
what are unexpected findings
pooling of blood in legs and ineflcient
of vital signs?
vasoconstriction to get blood back to the
heart) -Systolic pressure drops 20 mm Hg
-Diastolic pressure drops 10 mm Hg
-Heart rate increases 20 beats/min
-Nutritional intake adequate for height and weig
3. In an immobility assessment -Weight unchanged
what are expected findings of -Serum albumin levels within normal range
nutrition in- take? -High-fiber food intake occurs
-Nutritional intake inadequate
4. In an immobility assessment -Weight loss
what are unexpected findings -Serum albumin levels low
of nutrition intake? -Fiber-rich food intake is decreased
-Intake is close to output
5. In an immobility assessment -Concentration of urine is clear with no strong
what are expected findings of odor
the urinary system?
6. In an immobility assessment -Intake less than output
what are unexpected findings -Urine dark, cloudy, and odorous
of the uri- nary system?
,NURS 230 Test 4 questions with complete solutions
to pass
-Urine may have stones
7.
,NURS 230 Test 4 questions with complete solutions
to pass
In an immobility assessment what -Bowel sound active with soft abdomen
are expected findings of the gastroin- -Soft stools expelled
testinal system? what are unexpected
findings of psycho- logica
8. In an immobility assessment issues?
what are unexpected findings
of the gas- trointestinal
system?
9. In an immobility assessment
what are expected findings of
the integu- mentary system?
10. In an immobility assessment
what are unexpected
findings of the in-
tegumentary system?
11. In an immobility assessment
what are expected findings of
psychologi- cal issues?
12. In an immobility assessment
,NURS 230 Test 4 questions with complete solutions
to pass
-Fecal impaction not present
-Bowel sounds decreased on auscultation
-Constipation present
-Abdomen distended with discomfort
-Fecal impaction (buildup of hardened feces in the
lower intestine) present
-Pink in color
-Skin intact
-Skin blanches (when pressure is applied, the skin
turns white but returns to its normal color promptly,
which indicates adequate perfusion)
-Braden Scale score of 19 or above
-Color darkened in tone or reddened (indicates is-
chemia or necrosis)
-Skin nonblanches: skin stays red when pressed with
finger (indicates ischemia)
-Braden Scale score of 18 or lower
-Mood and behavior remain unchanged
-Patient statements or behaviors indicate strong
self-concept and coping mechanisms
-Sleep patterns unchanged and sleeping through
the night
-Mood or behavior has changed drastically or sub-
tly, indicating concern related to immobility or iso-
lation (talkative but now withdrawn)
-Patient statements or behaviors indicate alterations
