Deck 45: Mobility and Immobility

Question 1

Which of the following is an abnormal anteroposterior and lateral curvature of the spine?

A) Lordosis
B) Kyphosis
C) Scoliosis
D) Kyphoscoliosis

Answer 1

D

Question 2

Which of the following would the nurse expect to use to maintain the patient's legs in abduction after total hip replacement surgery?

A) Foot boot
B) Wedge pillow
C) Trochanter roll
D) Sandbags

Answer 2

B

Question 3

A patient is admitted to the medical unit following a CVA.There is evidence of left-sided hemiparesis,and the nurse will be following up on range-of-motion (ROM)and other exercises performed in physiotherapy.Which of the following principles of ROM exercises does the nurse correctly teach the patient and family members?

A) Flex the joint to the point of discomfort.
B) Work from proximal to distal joints.
C) Move the joints quickly.
D) Provide support to the extremity.

Answer 3

D

Question 4

Which one of the following should the nurse implement to reduce the chance of plantar flexion (footdrop)in a patient on prolonged bed rest?

A) Trapeze bar
B) Foot boot
C) Trochanter roll
D) 30-degree lateral positioning

Question 5

When a patient with impaired physical mobility is in the recumbent position,what angle of lateral position is recommended?

A) 15 degrees
B) 30 degrees
C) 45 degrees
D) 90 degrees

Question 6

Antiembolism stockings,also known as thromboembolic device (TED)hose,are ordered for the patient on bed rest after surgery.Which of the following does the nurse explain to the patient is the primary purpose for these stockings?

A) To keep the skin warm and dry
B) To prevent abnormal joint flexion
C) To apply external pressure
D) To prevent bleeding

Question 7

The nurse assesses that the patient has torticollis and that this may adversely influence the patient's mobility.Which of the following signs does this individual exhibit?

A) Exaggeration of the lumbar spine curvature
B) Increased convexity of the thoracic spine
C) Abnormal anteroposterior and lateral curvature of the spine
D) Contracture of the sternocleidomastoid muscle with a head incline

Question 8

Two nurses are standing on opposite sides of the bed to move the patient up in bed with a drawsheet.Which of the following describes the correct position for the nurses to take to safely position the patient?

A) The nurses should face the patient.
B) The nurses should face the direction of movement.
C) The nurses should face each other.
D) The nurses should face opposite the direction of movement.

Question 9

For which of the following mobility-impaired patients is prevention of plantar flexion (footdrop)through the use of pillows to support the lower legs and elevate the toes a primary intervention?

A) A 54-year-old diagnosed with osteoarthritis in all lower extremity joints
B) A 25-year-old with a fractured pelvis as a result of a motorcycle accident
C) A 78-year-old who has experienced left-sided paralysis resulting from a CVA
D) A 15-year-old who has been comatose for two years as a result of a head injury sustained from a fall off a roof

Question 10

To reduce the chance of external hip rotation in a patient on prolonged bed rest,the nurse should implement the use of which following device?

A) Footboard
B) Trochanter roll
C) Trapeze bar
D) Bed board

Question 11

Which of the following is the best approach for the nurse to use to assess the presence of thrombosis in an immobilized patient?

A) Measure the calf and thigh diameters.
B) Attempt to elicit Homans' sign.
C) Palpate the temperature of the feet.
D) Observe for a loss of hair and skin turgor in the lower legs.

Question 12

The patient has sequential compression stockings in place.The nurse evaluates that the stockings have been implemented appropriately by the new staff nurse when which of the following statements is true?

A) Intermittent pressure is set at 40 mm Hg.
B) Initial measurement is made around the patient's calves.
C) Stockings are wrapped directly over the leg from ankle to knee.
D) Stockings are removed every hour during application.

Question 13

A patient has been on prolonged bed rest,and the nurse is observing for signs associated with immobility.While assessing the patient,the nurse is alert to which of the following signs?

A) Increased blood pressure
B) Decreased heart rate
C) Increased urinary output
D) Decreased peristalsis

Question 14

The nurse,who is caring for a 73-year-old female patient who has been hospitalized with a stroke,instructs the patient's daughter to continue to do passive ROM exercises with her mother on her affected side to prevent contractures.The nurse explains to the daughter that this is very important in an immobile older adult patient because contractures can form how quickly?

A) Within 8 hours
B) Within 24 hours
C) Within 1 week
D) Within 1 month

Question 15

Which of the following body mass index (BMI)values would indicate that the patient is severely obese?

A) 21
B) 28
C) 36
D) 44

Question 16

A 61-year-old patient recently had left-sided paralysis from a cerebrovascular accident (CVA,stroke).In planning care for this patient,the nurse implements which one of the following as an appropriate intervention?

A) Encouraging an even gait when walking in place
B) Assessing the extremities for unilateral swelling and muscle atrophy
C) Encouraging holding the breath frequently to hyperinflate the lungs
D) Teaching the use of a two-point crutch technique for ambulation

Question 17

Which one of the following actions should the nurse take in order to promote respiratory function in the immobilized patient?

A) Change the patient's position every four to eight hours.
B) Encourage deep breathing and coughing every hour.
C) Use oxygen and nebulizer treatments regularly.
D) Suction the patient every hour.

Question 18

It has been determined that each one of the following patients is at risk for falling.Which one requires the nurse's priority for ambulation?

A) A 16-year-old with a sprained ankle being discharged from the emergency department
B) A 54-year-old who has taken the initial dose of an antihypertensive medication
C) A 45-year-old postoperative patient up for the first time since knee surgery
D) An 81-year-old who is asthmatic and had a hip replaced 18 months ago

Question 19

A patient with crutches places them in front and to the side of each foot.When achieving the basic crutch stance,how many centimetres in front and to the side of the foot should the crutches be?

A) 5 cm
B) 10 cm
C) 15 cm
D) 20 cm

Question 20

The patient is getting up for the first time after a period of bed rest.Which of the following actions should the nurse take first?

A) Assess respiratory function.
B) Obtain a baseline blood pressure.
C) Assist the patient to sit at the edge of the bed.
D) Ask the patient if he or she feels lightheaded.

Question 21

The nurse is emptying an ileostomy pouch for a patient.Which assessment finding would the nurse report immediately?

A) Liquid consistency of stool
B) Presence of blood in the stool
C) Noxious odor from the stool
D) Continuous output from the stoma

Question 22

Fecal impactions occur in which portion of the colon?

A) Ascending
B) Descending
C) Transverse
D) Rectum

Question 23

A patient expresses concerns over having black stool.The fecal occult test is negative.Which response by the nurse is most appropriate?

A) "This is probably a false negative; we should rerun the test."
B) "Do you take iron supplements?"
C) "You should schedule a colonoscopy as soon as possible."
D) "Sometimes severe stress can alter stool color."

Question 24

A patient informs the nurse that she was using laxatives three times daily to lose weight.After stopping use of the laxative,the patient had difficulty with constipation and wonders if she needs to take laxatives again.The nurse educates the patient that

A) Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur.
B) Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis.
C) Natural laxatives such as mineral oil are safer than chemical laxatives for relieving constipation.
D) Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced.

Question 25

The nurse provides knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient?

A) A 40-year-old patient with an ileostomy
B) A 25-year-old patient with Crohn's disease
C) A 30-year-old patient with C. difficile
D) A 70-year-old patient with stool incontinence

Question 26

The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success.What is the next priority nursing action?

A) Preparing the patient for a second tap water enema
B) Donning gloves for digital removal of the stool
C) Positioning the patient on the left side
D) Inserting a rectal tube

Question 27

Which physiological change can cause a paralytic ileus?

A) Chronic cathartic abuse
B) Surgery for Crohn's disease and anesthesia
C) Suppression of hydrochloric acid from medication
D) Fecal impaction

Question 28

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination.Which menu option should the nurse recommend?

A) Grape and walnut chicken salad sandwich on whole wheat bread
B) Broccoli and cheese soup with potato bread
C) Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing
D) Turkey and mashed potatoes with brown gravy

Question 29

The nurse would expect the least formed stool to be present in which portion of the digestive tract?

A) Ascending
B) Descending
C) Transverse
D) Sigmoid

Question 30

Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents ambulation?

A) Elevate the head of the bed 45 degrees 60 minutes after breakfast.
B) Use a mobility device to place the patient on a bedside commode.
C) Give the patient a pillow to brace against the abdomen while bearing down.
D) Administer a soap suds enema every 2 hours.

Question 31

The nurse knows that most nutrients are absorbed in which portion of the digestive tract?

A) Stomach
B) Duodenum
C) Ileum
D) Cecum

Question 32

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use.Which of the following outcomes would the nurse evaluate as successful for the patient to establish normal defecation?

A) The patient reports eliminating a soft, formed stool.
B) The patient has quit taking opioid pain medication.
C) The patient's lower left quadrant is tender to the touch.
D) The nurse hears bowel sounds present in all four quadrants.

Question 33

A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed.Which action by the nurse would assist the patient in having a successful bowel movement?

A) Administering laxatives to the patient
B) Raising the head of the bed
C) Preparing to administer a barium enema
D) Withholding narcotic pain medication

Question 34

The nurse would anticipate which diagnostic examination for a patient with black tarry stools?

A) Ultrasound
B) Barium enema
C) Upper endoscopy
D) Flexible sigmoidoscopy

Question 35

Which of the following is not a function of the large intestine?

A) Absorbing nutrients
B) Absorbing water
C) Secreting bicarbonate
D) Eliminating waste

Question 36

Which patient is most at risk for increased peristalsis?

A) A 5-year-old child who ignores the urge to defecate owing to embarrassment
B) A 21-year-old patient with three final examinations on the same day
C) A 40-year-old woman with major depressive disorder
D) An 80-year-old man in an assisted-living environment

Question 37

The nurse is caring for a patient who is confined to the bed.The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because

A) The digested food needs to make room for recently ingested food.
B) Mastication triggers the digestive system to begin peristalsis.
C) The smell of bowel elimination in the room would deter the patient from eating.
D) More ancillary staff members are available after meal times.

Question 38

The nurse is preparing to perform a fecal occult blood test.The nurse plans to properly perform the examination by

A) Applying liberal amounts of stool to the guaiac paper.
B) Testing the quality control section before collecting the specimen section.
C) Reporting any abnormal findings to the provider.
D) Applying sterile disposable gloves.

Question 39

The nurse should question which order?

A) A normal saline enema to be repeated every 4 hours until stool is produced
B) A hypertonic solution enema with a patient with fluid volume excess
C) A Kayexalate enema for a patient with hypokalemia
D) An oil retention enema for a patient using mineral oil laxatives

Question 40

The nurse administers a cathartic to a patient.The nurse determines that the cathartic has had a therapeutic effect when the patient

A) Has a decreased level of anxiety.
B) Experiences pain relief.
C) Has a bowel movement.
D) Passes flatulence.

Question 41

The nurse is caring for a patient with Clostridium difficile.Which of the following nursing actions will have the greatest impact in preventing the spread of bacteria?

A) Monthly in-services about contact precautions
B) Placing all contaminated items in biohazard bags
C) Mandatory cultures on all patients
D) Proper hand hygiene techniques

Question 42

An older adult's perineal skin appears to be dry and thin with mild excoriation.When providing hygiene after a bowel movement,the nurse should

A) Thoroughly scrub the skin with a wash cloth and hypoallergenic soap.
B) Apply a skin protective lotion after perineal care.
C) Tape an occlusive moisture barrier pad to the patient's skin.
D) Massage the skin with deep kneading pressure.

Question 43

While a cleansing enema is administered to an 80-year-old patient,the patient expresses the urge to defecate.What is the next priority nursing action?

A) Positioning the patient in the dorsal recumbent position with a bed pan
B) Assisting the patient to the bedside commode
C) Stopping the enema cleansing and rolling the patient into right-lying Sims' position
D) Inserting a rectal plug to contain the enema solution

Question 44

A nurse is preparing a patient for a magnetic resonance imaging scan.Which nursing action is most important?

A) Ensuring that the patient does not eat or drink 2 hours before the examination
B) Removing all of the patient's metallic jewelry
C) Administering a colon cleansing product 12 hours before the examination
D) Obtaining an order for a pain medication before the test is performed

Question 45

The nurse knows that the ideal time to change an ostomy pouch is

A) Before eating a meal, when the patient is comfortable.
B) When the patient feels that he needs to have a bowel movement.
C) When ordered in the patient's chart.
D) After the patient has ambulated the length of the hallway.

Question 46

A nurse is caring for a patient who has had diarrhea for the past week.Which additional assessment finding would the nurse expect?

A) Increased energy levels
B) Distended abdomen
C) Decreased serum bicarbonate
D) Increased blood pressure

Question 47

A nurse is caring for an older adult patient with fecal incontinence due to cathartic use.The nurse is most concerned about which complication that has the greatest risk for severe injury?

A) Rectal skin breakdown
B) Contamination of existing wounds
C) Falls from attempts to reach the bathroom
D) Cross-contamination into the upper GI tract

Question 48

Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube?

A) Lubricating the nares with water-soluble lubricant
B) Applying a small ice bag to the nose for 5 minutes every 4 hours
C) Instilling Xylocaine into the nares once a shift
D) Changing the tape holding the tube in place once a shift

Question 49

A nurse is educating a patient on how to irrigate an ostomy bag.Which statement by the patient indicates the need for further instruction?

A) "I can use a fleet enema to save money because it contains the same irrigation solution."
B) "Sitting on the toilet lets the irrigation sleeve eliminate into the bowl."
C) "I should never attempt to reach into my stoma to remove fecal material."
D) "Using warm tap water will reduce cramping and discomfort during the procedure."

Question 50

The nurse should place the patient in which position when preparing to administer an enema?

A) Left Sims' position
B) Fowler's
C) Supine
D) Semi-Fowler's

Question 51

A guaiac test has been ordered.The nurse knows that this is a test for

A) Bright red blood.
B) Dark black blood.
C) Blood that contains mucus.
D) Blood that cannot be seen.

Question 52

A patient has constipation and hypernatremia.The nurse prepares to administer which type of enema?

A) Oil retention
B) Carminative
C) Saline
D) Tap water

Question 53

A patient had an ileostomy surgically placed 2 days ago.Which diet would the nurse recommend to the patient to ease the transition of the new ostomy?

A) Eggs over easy, whole wheat toast, and orange juice with pulp
B) Chicken fried rice with stir fried vegetables and iced tea
C) Turkey meatloaf with white rice and apple juice
D) Fish sticks with macaroni and cheese and soda

Question 54

A nurse is providing discharge teaching for a patient who is going home with a guaiac test.Which statement by the patient indicates the need for further education?

A) "If I get a positive result, I have gastrointestinal bleeding."
B) "I should not eat red meat before my examination."
C) "I should schedule to perform the examination when I am not menstruating."
D) "I will need to perform this test three times if I have a positive result."

Question 55

A patient is diagnosed with a bowel obstruction.The nurse chooses which type of tube for gastric decompression?

A) Salem sump
B) Dobhoff
C) Sengstaken-Blakemore
D) Small bore

Question 56

The nurse is caring for a patient who had a colostomy placed yesterday.The nurse should report which assessment finding immediately?

A) Stoma is protruding from the abdomen.
B) Stoma is moist.
C) Stool is discharging from the stoma.
D) Stoma is purple.

Question 57

After a patient returns from a barium swallow,the nurse's priority is to

A) Encourage the patient to increase fluids to flush out the barium.
B) Monitor stools closely for bright red blood or mucus, which indicates trauma from the procedure.
C) Inform the patient that his bowel movements are radioactive, and that he should be sure to flush the toilet three times.
D) Thicken all patient drinks to prevent aspiration.

Question 58

A nurse is pouching an ostomy on a patient with an ileostomy.Which action by the nurse is most appropriate?

A) Changing the skin barrier portion of the ostomy pouch daily
B) Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying
C) Thoroughly scrubbing the skin around the stoma to remove excess stool and adhesive
D) Measuring the correct size for the barrier device while leaving a 1/8-inch space around the stoma

Question 59

A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days.The nurse would expect which other assessment finding?

A) Hypoactive bowel sounds
B) Jaundice in sclera
C) Decreased skin turgor
D) Soft tender abdomen

Question 60

The nurse is assessing a patient 2 hours after a colonoscopy.Based on the procedure done,what focused assessment will the nurse include?

A) Bowel sounds
B) Presence of flatulence
C) Bowel movements
D) Nausea