RN- MOBILITY NCLEX QUESTIONS
To assess the joints, a nurse asks a client to perform various movements. As the client moves his arm
away from the midline, the nurse evaluates his ability to perform: *** abduction.
Explanation:
A client performs abduction when moving a body part away from the midline. Protraction refers to
drawing out or lengthening of a body part. Retraction, the opposite of protraction, refers to drawing
back or shortening of a body part. Adduction, the opposite of abduction, is movement of a body part
toward the midline
Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part
of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate
a successful outcome of this treatment? *** free, easy movement of the joints
Explanation:
ROM exercises help preserve joint motion and stimulate circulation. Contractures develop rapidly in
clients with spinal cord injuries, and the absence of this complication indicates treatment success.
Range of motion will keep the ankle joints freely mobile. Footdrop, however, is prevented by proper
positioning of the ankle and foot, which is usually accomplished with high-top sneakers or splints.
External rotation of the hips is prevented by using trochanter rolls.
Local ischemia over bony prominences is prevented by following a regular turning schedule.
Which is not a typical clinical manifestation of multiple sclerosis (MS)? *** sudden bursts of energy
,Explanation:
With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of
energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and
tremors are common symptoms of MS.
A nurse notes that a client has kyphosis and generalized muscle atrophy. Which problem is a priority
when the nurse develops a nursing plan of care? *** ineffective coughing and deep breathing
Explanation:
In kyphosis, the thoracic spine bends forward with convexity of the curve in a posterior direction,
making effective coughing and deep breathing difficult. Although the client may develop other problems
because respiratory status deteriorates when pulmonary secretions are not adequately cleared from
airways, ineffective coughing and deep breathing should receive priority attention.
After surgery and insertion of a total hip prosthesis, a client develops severe sudden pain and an inability
to move the extremity. The nurse interprets these findings as indicating: *** joint dislocation.
Explanation:
The joint has dislocated when the client with a total joint prosthesis develops severe sudden pain and an
inability to move the extremity. Clinical manifestations of an infection would include inflammation,
redness, erythema, and possibly drainage and separation of the wound. Bleeding could be external (e.g.,
blood visible from the wound or on the dressing) or internal and manifested by signs of shock (e.g.,
pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in
the operating room, when the glue is still in the liquid form. The glue dries into the hard, fixed form
before the wound is closed.
Four days after surgery for internal fixation of a C3-C4 fracture, a nurse is moving a client from the bed
to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which
features of the wheelchair are appropriate for the needs of this client? *** • back and head that are
high
• seat that is lower than normal
• chair controlled by the client's breath
,Explanation:
The client with a C3-C4 fracture has neck control but may tire easily using sore muscles around the
incision area to hold up the head. Therefore, the head and neck of the wheelchair should be high. The
seat of the wheelchair should be lower than normal to facilitate transfer from the bed to the wheelchair.
When a client can use the hands and arms to move the wheelchair, the placement of the back to the
client's scapula is necessary. This client cannot use the arms and will need an electric chair with breath,
chin, or voice control to manipulate movement of the chair. A firm or hard cushion adds pressure to
bony prominences; the cushion should instead be padded to reduce the risk of pressure ulcers.
After undergoing surgery the previous day for a total knee replacement, a client states that he doesn't
feel ready to ambulate yet. What should the nurse do?
You selected: Discuss the complications that the client's may experience if he doesn't cooperate with
the care plan. *** Discuss the complications that the client's may experience if he doesn't cooperate
with the care plan.
Explanation:
The nurse should discuss the care plan and its rationale with the client. Calling the physician to report
the client's noncompliance won't alter the client's degree of participation and shouldn't be used to force
the client to comply. Doing nothing isn't acceptable. Although the client does have the right to make
choices, it's the nurse's responsibility to provide education to help the client make informed decisions.
Although the nurse should ultimately document the client's refusal, she should first discuss the care plan
with the client.
When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the
client to prevent: *** contractures.
Explanation:
Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory
infections. Nursing care should be directed toward the goal of preventing these complications.
Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.
, The nurse should assess which clients for risk for falling? Select all that apply. *** • client who is 45
years of age, in hospice with terminal cancer, and receiving morphine every 2 hours
• client who is 62 years of age, recovering from breast biopsy in outpatient surgery, and has a fear of
falling
• client who is 80 years of age and in a locked facility for clients with cognitive impairment
• client who is 75 years of age and recovering at home from hip replacement surgery on the left hip
Explanation:
Clients who are at risk for falling include the client taking narcotics, the client with a known fear of
falling, the client with cognitive impairment, and the client with gait problems. Age and setting are not
necessarily risks for fallings.
Which indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has
been successful? *** maintenance of joint mobility
Explanation:
The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to
preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralization or
have a positive effect on the client's muscle tone.
A public health nurse is providing an information session focusing on injury prevention for young
children diagnosed with juvenile arthritis. Of the information offered below, what should be included in
this session? *** Daily range of motion exercises are required to support joint mobility.
Explanation:
Daily range of motion exercises are required to help children with juvenile arthritis strengthen their
muscles and use their joints to their full range of motion. Children should be encouraged to participate
in as much of their own care as possible to keep their joints fluid. Excessive exercise, as evidenced by
running, jumping, and so on, should be discouraged because it puts an excessive amount of pressure on
To assess the joints, a nurse asks a client to perform various movements. As the client moves his arm
away from the midline, the nurse evaluates his ability to perform: *** abduction.
Explanation:
A client performs abduction when moving a body part away from the midline. Protraction refers to
drawing out or lengthening of a body part. Retraction, the opposite of protraction, refers to drawing
back or shortening of a body part. Adduction, the opposite of abduction, is movement of a body part
toward the midline
Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part
of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate
a successful outcome of this treatment? *** free, easy movement of the joints
Explanation:
ROM exercises help preserve joint motion and stimulate circulation. Contractures develop rapidly in
clients with spinal cord injuries, and the absence of this complication indicates treatment success.
Range of motion will keep the ankle joints freely mobile. Footdrop, however, is prevented by proper
positioning of the ankle and foot, which is usually accomplished with high-top sneakers or splints.
External rotation of the hips is prevented by using trochanter rolls.
Local ischemia over bony prominences is prevented by following a regular turning schedule.
Which is not a typical clinical manifestation of multiple sclerosis (MS)? *** sudden bursts of energy
,Explanation:
With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of
energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and
tremors are common symptoms of MS.
A nurse notes that a client has kyphosis and generalized muscle atrophy. Which problem is a priority
when the nurse develops a nursing plan of care? *** ineffective coughing and deep breathing
Explanation:
In kyphosis, the thoracic spine bends forward with convexity of the curve in a posterior direction,
making effective coughing and deep breathing difficult. Although the client may develop other problems
because respiratory status deteriorates when pulmonary secretions are not adequately cleared from
airways, ineffective coughing and deep breathing should receive priority attention.
After surgery and insertion of a total hip prosthesis, a client develops severe sudden pain and an inability
to move the extremity. The nurse interprets these findings as indicating: *** joint dislocation.
Explanation:
The joint has dislocated when the client with a total joint prosthesis develops severe sudden pain and an
inability to move the extremity. Clinical manifestations of an infection would include inflammation,
redness, erythema, and possibly drainage and separation of the wound. Bleeding could be external (e.g.,
blood visible from the wound or on the dressing) or internal and manifested by signs of shock (e.g.,
pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in
the operating room, when the glue is still in the liquid form. The glue dries into the hard, fixed form
before the wound is closed.
Four days after surgery for internal fixation of a C3-C4 fracture, a nurse is moving a client from the bed
to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which
features of the wheelchair are appropriate for the needs of this client? *** • back and head that are
high
• seat that is lower than normal
• chair controlled by the client's breath
,Explanation:
The client with a C3-C4 fracture has neck control but may tire easily using sore muscles around the
incision area to hold up the head. Therefore, the head and neck of the wheelchair should be high. The
seat of the wheelchair should be lower than normal to facilitate transfer from the bed to the wheelchair.
When a client can use the hands and arms to move the wheelchair, the placement of the back to the
client's scapula is necessary. This client cannot use the arms and will need an electric chair with breath,
chin, or voice control to manipulate movement of the chair. A firm or hard cushion adds pressure to
bony prominences; the cushion should instead be padded to reduce the risk of pressure ulcers.
After undergoing surgery the previous day for a total knee replacement, a client states that he doesn't
feel ready to ambulate yet. What should the nurse do?
You selected: Discuss the complications that the client's may experience if he doesn't cooperate with
the care plan. *** Discuss the complications that the client's may experience if he doesn't cooperate
with the care plan.
Explanation:
The nurse should discuss the care plan and its rationale with the client. Calling the physician to report
the client's noncompliance won't alter the client's degree of participation and shouldn't be used to force
the client to comply. Doing nothing isn't acceptable. Although the client does have the right to make
choices, it's the nurse's responsibility to provide education to help the client make informed decisions.
Although the nurse should ultimately document the client's refusal, she should first discuss the care plan
with the client.
When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the
client to prevent: *** contractures.
Explanation:
Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory
infections. Nursing care should be directed toward the goal of preventing these complications.
Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.
, The nurse should assess which clients for risk for falling? Select all that apply. *** • client who is 45
years of age, in hospice with terminal cancer, and receiving morphine every 2 hours
• client who is 62 years of age, recovering from breast biopsy in outpatient surgery, and has a fear of
falling
• client who is 80 years of age and in a locked facility for clients with cognitive impairment
• client who is 75 years of age and recovering at home from hip replacement surgery on the left hip
Explanation:
Clients who are at risk for falling include the client taking narcotics, the client with a known fear of
falling, the client with cognitive impairment, and the client with gait problems. Age and setting are not
necessarily risks for fallings.
Which indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has
been successful? *** maintenance of joint mobility
Explanation:
The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to
preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralization or
have a positive effect on the client's muscle tone.
A public health nurse is providing an information session focusing on injury prevention for young
children diagnosed with juvenile arthritis. Of the information offered below, what should be included in
this session? *** Daily range of motion exercises are required to support joint mobility.
Explanation:
Daily range of motion exercises are required to help children with juvenile arthritis strengthen their
muscles and use their joints to their full range of motion. Children should be encouraged to participate
in as much of their own care as possible to keep their joints fluid. Excessive exercise, as evidenced by
running, jumping, and so on, should be discouraged because it puts an excessive amount of pressure on
