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Exam (elaborations)

NCLEX Mobility questions with verified answers.

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NCLEX Mobility questions with verified answers.

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NCLEX Mobility questions with verified answers
A nurse concludes that a patient has the potential for impaired
mobility. Which assessments reflect risk factors that support this
conclusion? Select all that apply.
1. Joint pain
2. External fatigue
3. Sedentary lifestyle
4. Limited range of motion
5. Increased respiratory rate Ans✓✓✓ 1, 4


A nurse enters the room of the patient in the photograph. The patient
has right sided weakness and is attempting to transfer out of bed
without the nurses knowledge. What should the nurse do first?
1. Lower the height of the bed to its lowest position to the floor.
2. Reposition the patient back to the semi fowler position.
3. Move the wheelchair parallel to the foot of the bed.
4. Put on the patients slippers. Ans✓✓✓ 2. Reposition the patient back
to the semi-fowler position.


A nurse identifies that a patients pressure ulcer has just partial
thickness skin loss involving the epidermis and dermis. Which stage
pressure ulcer should the nurse document based on this assesment?
Ans✓✓✓ 2. Stage 2

,A nurse is assessing a patients risk for thrombus formation associated
with impaired mobility. Which factors constitute Virchows triad? Select
all that apply.
1. Compression of small vessels in the legs
2. Orthostatic hypotension
3. Coagulation activation
4. Hypostatic pneumonia.
5. Venous stasis Ans✓✓✓ 1, 3, 5


A nurse is caring for a male patient who is at risk fora pressure ulcer.
After reviewing the patient's clinical record, which area of the body
should the nurse identify is most at risk for pressure ulcers?
1. Greater trochanter
2. Ischial tuberosisties
3. Medial malleoulous
4. Spinal processes Ans✓✓✓ 2. Ischial tuberosisteis


A nurse is caring for a patient with impaired mobility. Which position
contributes most to the formation of a hip flexion contracture?
1. Low-fowler
2. Orthopenic
3. Supine
4. Sims Ans✓✓✓ 2. Orthopneic

, A nurse is caring for a variety of patients, each experiencing on of the
following problems. Which health problem places a patient at the
greatest risk for complications associated with immobility?
1. Incontinence
2. Quadriplegia
3. Hemiparesis
4. Confusion Ans✓✓✓ 2. Quadriplegia


A nurse is evaluating an ambulating patients balance. Which factor
about the patient is most important for the nurse to assess?
1. Posture
2. Strength
3. Energy level
4. Respitory rate Ans✓✓✓ 1. Posture


A nurse is in a community center conversing with a group of older
adults who voiced fears about falling. Which is the most common
consequence associated with older adults fear of falling that the nurse
should discuss with them?
1. Impaired skin integrity
2. Occurrence of panic attacks.
3. Self-imposed social isolation

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