C HAPTER 39: I MMOBILITY
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. Which of the following statements regarding physical activit y and its
effect on activit y tolerance made by a client shows the most informed
knowledge regarding the connection between the two?
A. I know I need to walk more if I want to get st ronger.
B. I don’t like walking, but I do it because I know it will make me
stronger.
C. I try to walk a little farther each afternoon so I can dance at my
grandsons wedding.
D. I walk with m y son three evenings a week because its good for his
weight and for m y bon es.
ANS: C
Muscle tone helps maintain functional positions such as sitting or
standing without excess muscle fatigue and is maintained through
continual use of muscles. The better the muscle tone, the more stamina
the client will experience. The remainin g options do not state the
connection between activit y and stamina as well as the answer.
PTS: 1 DIF: C REF: 1244 OBJ: Anal ysis TOP: Nursing
Process: Evaluation MSC: NC LEX test plan designation:
Physiological Integrity/Basic Care and Comfort/Mobilit y/
Immobilit y
,2. A client recovering from hip surgery tells the nurse that she wants to get
better so she can walk down the aisle to her seat at her granddaughters
wedding. Which of the following nursing interventions will have the
greatest impact on achieving t hat goal?
A. Informing physical therapists that the client has expressed that goal
B. Reminding the ancillary staff to offer to walk with the client after
her bath
C. Regularl y praising the client for the efforts she is making to reach
her goal
D. Walking with the client to and from the dining room where she eats
her meals
ANS: D
Muscle tone helps maintain functional positions such as sitting or
standing without excess muscle fatigue and is maintained through
continual use of muscles. ADLs require muscle action and h elp
maintain muscle tone. When a client is immobile or on prolonged bed
rest, activit y level, activit y tolerance, and muscle tone decrease. The
better the muscle tone, the more stamina the client will experience.
Although all the interventions are appropri ate, actuall y walking with
the client will have the greatest impact on her abilit y to achieve the
goal.
PTS: 1 DIF: B REF: 1241 OBJ: Application TOP: Nursing
Process: Implementation MSC: NC LEX test plan
designation: Physiological Integrit y/Basic Care an d
Comfort/Mobilit y/ Immobilit y
,3. An infant born via cesarean section because of a breech presentation is
diagnosed with bilateral congenital hip dysplasia. The primary nursing
intervention directed toward this diagnosis is:
A. Assessing the infant frequentl y t o determine abduction of the thighs
B. Maintaining the infant in the position of continuous abduction of
both hips
C. Educating the parents about the importance of positioning the infant
so that the head of the femurs are in alignment with the hip sockets
D. Providing pain management so that the infant is comfortable in the
therapeutic position required
ANS: B
Maintenance of continuous abduction of the thigh so that the head of
the femur presses into the center of the acetabulum is critical in the
care and treatment of this infant. Although the other options are
appropriate, they are not primary interventions in this scenario.
PTS: 1 DIF: C REF: 1224 OBJ: Anal ysis TOP: Nursing
Process: Implementation MSC: NC LEX test plan
designation: Physiological Integrit y/Basi c Care and
Comfort/Mobilit y/ Immobilit y
4. A 16-year-old had a full leg cast for 4 months, and it is being removed
today. Which of the following statements made by the client shows the
most informed understanding of the effects of immobilization of a muscle
on its strength and stamina?
A. I’m hoping to be back at soccer practice in 3 weeks.
B. Walking and riding my bike will help regain the muscle.
C. Ill practice the strengthening routine the physical therapist taught
me, so I can play baseball in the spring.
, D. There was a good bit of muscle and strength loss, but Ill work at
getting it back like it was before the break.
ANS: C
Even this temporary immobilization results in some muscle atrophy,
loss of muscle tone, and joint stiffness. When a client is immobile or
on prolonged bed rest, activit y level, activit y tolerance, and muscle
tone decrease. Appropriate general exercise and specific exercise of the
atrophied muscle will increase both muscle tone and overall stamina.
Although the remaining options are not incorrect , the answer shows the
greatest insight because it provides both a plan and a time line for
recovery.
PTS: 1 DIF: C REF: 1223 OBJ: Anal ysis TOP: Nursing
Process: Evaluation MSC: NC LEX test plan designation:
Physiological Integrity/Basic Care and Comfort /Mobilit y/
Immobilit y
5. A staff member experienced a shoulder injury while assisting with a client
transfer. The nurse managers most therapeutic response to this situation is
to:
A. Thoroughl y review the accident report filed by the injured personnel
to determine the factors that contributed to the injury
B. Have a nonpunitive meeting with all the involved staff to discuss
correcting the factors that resulted in the injury
C. Require that mechanical lifts be used in the transfer of all clients
incapable of assisting with the transfer
D. Implement new policies and procedures to correct the factors that
resulted in the injury
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. Which of the following statements regarding physical activit y and its
effect on activit y tolerance made by a client shows the most informed
knowledge regarding the connection between the two?
A. I know I need to walk more if I want to get st ronger.
B. I don’t like walking, but I do it because I know it will make me
stronger.
C. I try to walk a little farther each afternoon so I can dance at my
grandsons wedding.
D. I walk with m y son three evenings a week because its good for his
weight and for m y bon es.
ANS: C
Muscle tone helps maintain functional positions such as sitting or
standing without excess muscle fatigue and is maintained through
continual use of muscles. The better the muscle tone, the more stamina
the client will experience. The remainin g options do not state the
connection between activit y and stamina as well as the answer.
PTS: 1 DIF: C REF: 1244 OBJ: Anal ysis TOP: Nursing
Process: Evaluation MSC: NC LEX test plan designation:
Physiological Integrity/Basic Care and Comfort/Mobilit y/
Immobilit y
,2. A client recovering from hip surgery tells the nurse that she wants to get
better so she can walk down the aisle to her seat at her granddaughters
wedding. Which of the following nursing interventions will have the
greatest impact on achieving t hat goal?
A. Informing physical therapists that the client has expressed that goal
B. Reminding the ancillary staff to offer to walk with the client after
her bath
C. Regularl y praising the client for the efforts she is making to reach
her goal
D. Walking with the client to and from the dining room where she eats
her meals
ANS: D
Muscle tone helps maintain functional positions such as sitting or
standing without excess muscle fatigue and is maintained through
continual use of muscles. ADLs require muscle action and h elp
maintain muscle tone. When a client is immobile or on prolonged bed
rest, activit y level, activit y tolerance, and muscle tone decrease. The
better the muscle tone, the more stamina the client will experience.
Although all the interventions are appropri ate, actuall y walking with
the client will have the greatest impact on her abilit y to achieve the
goal.
PTS: 1 DIF: B REF: 1241 OBJ: Application TOP: Nursing
Process: Implementation MSC: NC LEX test plan
designation: Physiological Integrit y/Basic Care an d
Comfort/Mobilit y/ Immobilit y
,3. An infant born via cesarean section because of a breech presentation is
diagnosed with bilateral congenital hip dysplasia. The primary nursing
intervention directed toward this diagnosis is:
A. Assessing the infant frequentl y t o determine abduction of the thighs
B. Maintaining the infant in the position of continuous abduction of
both hips
C. Educating the parents about the importance of positioning the infant
so that the head of the femurs are in alignment with the hip sockets
D. Providing pain management so that the infant is comfortable in the
therapeutic position required
ANS: B
Maintenance of continuous abduction of the thigh so that the head of
the femur presses into the center of the acetabulum is critical in the
care and treatment of this infant. Although the other options are
appropriate, they are not primary interventions in this scenario.
PTS: 1 DIF: C REF: 1224 OBJ: Anal ysis TOP: Nursing
Process: Implementation MSC: NC LEX test plan
designation: Physiological Integrit y/Basi c Care and
Comfort/Mobilit y/ Immobilit y
4. A 16-year-old had a full leg cast for 4 months, and it is being removed
today. Which of the following statements made by the client shows the
most informed understanding of the effects of immobilization of a muscle
on its strength and stamina?
A. I’m hoping to be back at soccer practice in 3 weeks.
B. Walking and riding my bike will help regain the muscle.
C. Ill practice the strengthening routine the physical therapist taught
me, so I can play baseball in the spring.
, D. There was a good bit of muscle and strength loss, but Ill work at
getting it back like it was before the break.
ANS: C
Even this temporary immobilization results in some muscle atrophy,
loss of muscle tone, and joint stiffness. When a client is immobile or
on prolonged bed rest, activit y level, activit y tolerance, and muscle
tone decrease. Appropriate general exercise and specific exercise of the
atrophied muscle will increase both muscle tone and overall stamina.
Although the remaining options are not incorrect , the answer shows the
greatest insight because it provides both a plan and a time line for
recovery.
PTS: 1 DIF: C REF: 1223 OBJ: Anal ysis TOP: Nursing
Process: Evaluation MSC: NC LEX test plan designation:
Physiological Integrity/Basic Care and Comfort /Mobilit y/
Immobilit y
5. A staff member experienced a shoulder injury while assisting with a client
transfer. The nurse managers most therapeutic response to this situation is
to:
A. Thoroughl y review the accident report filed by the injured personnel
to determine the factors that contributed to the injury
B. Have a nonpunitive meeting with all the involved staff to discuss
correcting the factors that resulted in the injury
C. Require that mechanical lifts be used in the transfer of all clients
incapable of assisting with the transfer
D. Implement new policies and procedures to correct the factors that
resulted in the injury
