Chapter 39 Immobility-Fundamentals of Nursing

Chapter 39: Immobility
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MULTIPLE CHOICE ra




1. A nursing attendant is assessing body alignment. What is the nursing attendant monitoring
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?
a. The relationship of one body part to another while in different positions
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b. The coordinated efforts of the musculoskeletal and nervous systems
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c. The force that occurs in a direction to oppose movement
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d. The inability to move about freely
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ACCURATE ANSWER:-A ra




The terms body alignment and posture are similar and refer to the positioning of the joints, tendo
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ns, ligaments, and muscles while standing, sitting, and lying. Body alignment means that the in
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dividual’s center of gravity is stable. Body mechanics is a term used to describe the coordinated
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efforts of the musculoskeletal and nervous systems. Friction is a force that occurs in a directio
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n to oppose movement. Immobility is the inability to move about freely.
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DIF:Understand (comprehension) ra



OBJ:Discuss physiological and pathological influences on mobility.
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TOP:Assessment MSC: Basic Care and Comfort ra ra ra ra




2. A nursing attendant is providing range of motion to the shoulder and must perform
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external rotation. Which action will the nursing attendant take?
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Moves hospital client ’s arm in a full circle.
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b. Moves hospital client ’s arm cross the body as far as possible.
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c. Moves hospital client ’s arm behind body, keeping elbow straight.
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d. Moves hospital client ’s arm until thumb is upward and lateral to head with elbow flexed.
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ACCURATE ANSWER:-D ra




External rotation: With elbow flexed, move arm until thumb is upward and lateral to head. C
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ircumduction: Move arm in full circle (Circumduction is combination of all movements of ballan
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d-
socket joint.) Adduction: Lower arm sideways and across body as far as possible. Hyperextensi
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on: Move arm behind body, keeping elbow straight.
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DIF:Apply (application) ra



OBJ:Select hospital client centered interventions for improving or maintaining hospital client s’ m
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obility. TOP:Imp lementation MSC: Basic Care and Comfort
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3. A nursing attendant is providing passive range of motion (ROM) for a hospital client
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with impaired mobility. Which technique will the nursing attendant use for each m
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ovement?
a. Each movement is repeated 5 times by the hospital client .
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b. Each movement is performed until the hospital client reports pain.
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c. Each movement is completed quickly and smoothly by the nursing attendant .
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d. Each movement is moved just to the point of resistance by the nursing attendant .
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, ACCURATE ANSWER:-D ra



Passive ROM exercises are performed by the nursing attendant . Carry out movements slowly
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and smoothly, just to the point of resistance; ROM should not cause pain. Never force a joint
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beyond its capacity. Each movement needs to be repeated 5 times during the session. The hos
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pital client moves all joints through ROM unassisted in active ROM.
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DIF:Apply (application) ra



OBJ:Select hospital client centered interventions for improving or maintaining hospital client s’ m
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obility. TOP:Imp lementation MSC: Basic Care and Comfort
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4. A nursing attendant is performing passive range of motion (ROM) and splinting on an atris
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k hospital client . The absence of which finding will indicate goal achievement for the nurs
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ing attendant ’s action? a. Atelectasis
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b. Renal calculi ra




c. Pressure ulcers ra




d. Joint contractures ra




ACCURATE ANSWER:-D ra



Goal achievement for passive ROM is prevention of joint contractures. Contractures develop
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in joints not moved periodically through their full ROM. ROM exercises reduce the risk of c
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ontractures. Researchers noted that prompt use of splinting with prescribed ROM exercises
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areduced contractures and improved active range of joint motion in affected lower extremities.
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Deep breathing and coughing and using an incentive spirometer will help prevent atelectasis
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. Adequate hydration helps prevent renal calculi and urinary tract infections. Interventions ai
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med at prevention of pressure ulcers include positioning, skin care, and the use of therapeuti
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c devices to relieve pressure.
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DIF:Understand (comprehension) ra



OBJ:Evaluate hospital client outcomes for improving or maintaining ra ra ra ra ra ra ra ar



mobility. TOP:Evaluation MSC: Management of Care ra ra ra ra




5. A hospital client requires repositioning every 2 hours. Which task can the nursing
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attendant delegate to the nursing assistive personnel? a. Determining the level of comfort
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b. Changing the hospital client ’s position ra ra ra ra ra




c. Identifying immobility hazards ra ra




d. Assessing circulation ra




ACCURATE ANSWER:-B ra



The skill of moving and positioning hospital client s in bed can be delegated to nursing assistive
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personnel (NAP). The nursing attendant is responsible for assessing the hospital client ’s level o
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f comfort and for any hazards of immobility and assessing circulation.
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DIF:Apply (application) ra



OBJ:Select hospital client - ra ra ra



centered interventions for improving or maintaining hospital client s’ mobility. TOP:Plan
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ning MSC: Management of Care ra ra ra




6. A nursing attendant is preparing to assess a hospital client
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for orthostatic hypotension. Whic
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h piece of equipment will the nursing attendant obtain to assess for this condition? a.
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Thermometer
b. Elastic stockings ra

, c. Blood pressure cuff ra ra




d. Sequential compression devices ra ra




ACCURATE ANSWER:-C ra



A blood pressure cuff is needed. Orthostatic hypotension is a drop of blood pressure greater
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than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure and symptoms of diz
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ziness, lightheadedness, nausea, tachycardia, pallor, or fainting when the hospital client changes
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from th e supine to standing position. A thermometer is used to assess for fever.
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Elastic stockings and sequential compression devices are used to prevent thrombus.
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DIF:Apply (application) ra



OBJ:Identify changes in physiological and psychosocial function associated with immobility.
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TOP:Assessment MSC: Reduction of Risk Potential ra ra ra ra




7. The hospital client has been in bed for several days and needs to be ambulated. Which action
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will the nursing attendant take first?
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a. Maintain a narrow base of support. ra ra ra ra ra




b. Dangle the hospital client at the bedside. ra ra ra ra ra ra




c. Encourage isometric exercises. ra ra




d. Suggest a high-calcium diet. ra ra ra




ACCURATE ANSWER:-B ra



To prevent injury, nursing attendant s implement interventions that reduce or eliminate the
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effects of orthostatic hypotension. Mobilize the hospital client as soon as the physical condit
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ion allows, even if this only involves dangling at the bedside or moving to a chair. A wide base
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of support increases balance. Isometric exercises (i.e., activities that involve muscle tension
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without muscle shortening) have no beneficial effect on preventing orthostatic hypotension, b
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ut they improve activity tolerance. A highcalcium diet can help with osteoporosis but can be d
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etrimental in an immobile hospital clien t . ra ra ra ra ra ra




DIF:Apply (application) ra



OBJ:Select hospital client centered interventions for improving or maintaining hospital client s’ m
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obility. TOP:Imp lementation MSC: Basic Care and Comfort
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8. A nursing attendant reviews an immobilized hospital client ’s laboratory results and d
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iscovers hypercalcemia. Which condition will the nursing attendant monitor for most
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closely in this hospital client ? ra ra ra ra ra




a. Hypostatic pneumonia ra




b. Renal stones ra




c. Pressure ulcers ra




d. Thrombus formation ra




ACCURATE ANSWER:-B ra



Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Im
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mobilized hospital client s are at risk for calculi because they frequently have hypercalcemia
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. Hypercalcemia does not lead to hypostatic pneumonia, pressure ulcers, or thrombus forma
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tion. Immobility is one cause of hypostatic pneumonia, which is inflammation of the lung fr
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om stasis or pooling of secretions. A pressure ulcer is an impairment of the skin that results f
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rom prolonged ischemia (decreased blood supply) within tissues. A thrombus is an accumula
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tion of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the in
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terior wall of a vein or artery, which sometimes occludes the lumen of the vessel.
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DIF:Apply (application) ra