Question 1

The nurse is assessing body alignment for a patient who is immobilized.To do this,the nurse must

Accepted Answer

Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position,not supine.Remove all positioning support from the bed,except for the pillow under the head.

Question 2

When assessing the skin of an immobilized patient,the nurse should

Accepted Answer

Consistently use a standardized tool,such as the Braden Scale.This identifies patients with high risk of impaired skin integrity.Nursing instinct in this case is not enough.At a minimum,skin assessment occurs every 2 hours.Continually assess the patient's skin for breakdown and color changes such as pallor or redness.Continual assessment reduces the need for the creation of special times for inspection.

Question 3

The nurse is caring for a patient who has been diagnosed with a stroke.As part of her ongoing care,the nurse should

Accepted Answer

Nurses should encourage the patient to perform as many self-care activities as possible,thereby maintaining the highest level of mobility.Sometimes nurses inadvertently contribute to a patient's immobility by providing unnecessary help with activities such as bathing and transferring.Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline,resulting in weakness,fatigue,and increased risk for falls.Anorexia and insufficient assistance with eating lead to malnutrition.

Question 4

Patients on bed rest or otherwise immobile are at risk for

Accepted Answer

Immobility disrupts normal metabolic functioning: decreasing the metabolic rate,altering the metabolism of carbohydrates,fats,and proteins (nutritional function); causing fluid,electrolyte,and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.

Question 5

The nurse is caring for an elderly patient with the diagnosis of urinary tract infection (UTI).The patient is confused and agitated.It is important for the nurse to realize that confusion in the elderly is

Accepted Answer

Acute confusion in older adults is not normal; a thorough nursing assessment is the priority.
Abrupt changes in personality often have a physiological cause such as surgery,a medication reaction,a pulmonary embolus,or an acute infection.For example,the primary symptom of compromised older patients with an acute urinary tract infection or fever is confusion.Identifying confusion is an important component of the nurse's assessment.

Question 6

Joints are the connections between bones.The joint that is freely movable is known as the _____ joint.

Accepted Answer

The synovial joint,or true joint,is a freely movable joint in which contiguous bony surfaces are covered by articular cartilage and are connected by ligaments lined with a synovial membrane.The synostotic joint refers to bones jointed by bones.No movement is associated with this type of joint.In the cartilaginous joint,or synchondrosis joint,cartilage unites bony components.When bone growth is complete,the joints ossify.The fibrous joint,or syndesmosis joint,is a joint in which a ligament or membrane unites two bony surfaces,permitting a limited amount of movement only.

Question 7

The term body alignment refers to positioning of the joints,tendons,ligaments,and muscles while standing,sitting,and lying.A term that is similar to body alignment is

Accepted Answer

The terms body alignment and posture are similar and refer to positioning of the joints,tendons,ligaments,and muscles while standing,sitting,and lying.Weight is the force exerted on a body by gravity.Friction is a force that occurs in a direction to oppose movement.Body mechanics is a term used to describe the coordinated efforts of the musculoskeletal and nervous systems.

Question 8

The nurse is evaluating the body alignment of a patient in the sitting position.In this position

Accepted Answer

Both feet are supported on the floor,and the ankles are comfortably flexed.With patients of short stature,a footstool is used to ensure that the ankles are comfortably flexed.Body weight is evenly distributed on the buttocks and thighs.A 1- to 2-inch space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee to ensure that no pressure is placed on the popliteal artery or nerve.The patient's forearms are supported on the armrest,in the lap,or on a table in front of the chair.

Question 9

In caring for a patient who is immobile,it is important for the nurse to understand that

Accepted Answer

The immobilized patient often becomes depressed because of changes in role and self-concept.Every patient responds to immobility differently.Immobility or bed rest frequently affects coping and creates sleep-wake alterations because of changes in routine or in the environment.Because immobilization removes the patient from a daily routine,he or she has more time to worry about disability.Worrying quickly increases the patient's depression,causing withdrawal.Withdrawn patients often do not want to participate in their own care.

Question 10

Without balance control,the center of gravity is displaced,thus creating risk for falls and subsequent injuries.Balance is enhanced by

Accepted Answer

Without balance control,the center of gravity is displaced,thus creating risk for falls and subsequent injuries.Balance is enhanced by keeping the center of gravity of the body low with a wide base of support and by maintaining correct body posture.

Question 11

When assessing the body alignment of a patient while he or she is standing,the nurse is aware that

Accepted Answer

When the patient is observed laterally,the head is erect and the spinal curves are aligned in a reversed "S" pattern.When observed posteriorly,the shoulders and hips are straight and parallel.The arms hang comfortably at the sides.The feet are slightly apart to achieve a base of support,and the toes are pointed forward.

Question 12

During voluntary movement,impulses descend from the motor strip to the spinal cord.Impulses stimulate muscles by way of

Accepted Answer

Through a complex process,neurotransmitters,or chemicals such as acetylcholine transfer electrical impulses from the nerve across the neuromuscular junction to the muscle.The neurotransmitter reaches a muscle and stimulates it.Ligaments are white,shiny,flexible bands of fibrous tissue that bind joints together and connect bones and cartilages.Tendons connect muscle to bone.Cartilage is nonvascular,supporting connective tissue located chiefly in the joints and in the thorax,trachea,larynx,nose,and ear.

Question 13

Muscles that attach to bones to provide the needed strength to move an object use which of the following to obtain their objective?

Accepted Answer

Leverage is an inducing or compelling force that occurs when specific bones,such as the humerus,ulna,and radius,and associated joints,such as the elbows,act together as a lever.Posture is the position of the body in relation to the surrounding space.Isometric contraction causes an increase in muscle tension but no active movement.Muscle tone is the normal state of balanced muscle tension.

Question 14

Although isometric contractions do not result in muscle shortening,the nurse understands that isometric contractions

Accepted Answer

Although isometric contractions do not result in muscle shortening,energy expenditure increases.It is important to understand the energy expenditure associated with isometric exercises because they are sometimes contraindicated in certain illnesses.Isometric contractions increase muscle tension but not active movement of the muscle.

Question 15

Immobilized patients frequently have hypercalcemia,placing them at risk for

Accepted Answer

Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters.Immobilized patients are at risk for calculi because they frequently have hypercalcemia.Osteoporosis is caused by accelerated bone loss.A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply)within tissues.A thrombus is an accumulation of platelets,fibrin,clotting factors,and cellular elements of the blood attached to the interior wall of a vein or artery,which sometimes occludes the lumen of the vessel.

Question 16

Immobility is a major risk factor for pressure ulcers.In caring for the patient who is immobilized,the nurse needs to be aware that

Accepted Answer

Immobility is a major risk factor for pressure ulcers.Any break in the integrity of the skin is difficult to heal.Preventing a pressure ulcer is much less expensive than treating one; therefore,preventive nursing interventions are imperative.An older adult who is immobilized can develop skin breakdown within 3 hours.Tissue metabolism depends on the supply of oxygen and nutrients to and the elimination of metabolic wastes from the blood.Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation.

Question 17

What is meant by "concentric tension" of muscles?

Accepted Answer

In concentric tension,increased muscle contraction causes muscle shortening,resulting in movement.Eccentric tension helps control the speed and direction of movement.Concentric and eccentric muscle actions are necessary for active movement and are referred to as dynamic or isotonic contraction.Isometric contraction (static contraction)causes an increase in muscle tension or muscle work but no shortening or active movement of the muscle.

Question 18

The nurse is aware that patients who are immobile are at increased risk of developing deep vein thromboses (DVTs).Because of this,the nurse should

Accepted Answer

Measure bilateral calf circumference and record it daily as an assessment for DVT.Homans' sign,or calf pain on dorsiflexion of the foot,is contraindicated in patients when a DVT is suspected.It is no longer a reliable indicator in assessing for DVT,and it is present in other conditions.Remove the patient's elastic stockings and/or sequential compression devices (SCDs)every 8 hours,and observe the calves for redness,warmth,and tenderness.Bilateral calf circumferences (not ankle)should be measured daily to detect unilateral increases that may be an early indication of thrombosis.

Question 19

The nurse is assessing the way the patient walks.The manner of walking is known as the patient's

Accepted Answer

The term gait describes a particular manner or style of walking.Activity tolerance is the type and amount of exercise or work that a person is able to perform.Body alignment refers to the position of the joints,tendons,ligaments,and muscles while standing,sitting,and lying.Range of motion is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal,frontal,or transverse.

Question 20

The nurse must assess the patient for hazards of immobility by performing a head-to-toe physical assessment.When assessing the respiratory system,the nurse should

Accepted Answer

Auscultate the entire lung region to identify diminished breath sounds,crackles,or wheezes.Perform a respiratory assessment at least every 2 hours for patients with restricted activity.Inspect chest wall movements during the full inspiratory-expiratory cycle.Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions.

Quiz 92: Mobility and Immobility