Question 1

A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?

Accepted Answer

The nurse must develop an individualized plan of care for each nursing diagnosis and must set goals that are individualized, realistic, and measurable. The nurse should set realistic expectations for care and should include the patient and family when possible. The goals focus on preventing problems or risks to body alignment and mobility.

Question 2

The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to make this procedure safe?

Accepted Answer

This is not a one-person task. Helping a patient move up in bed without help from other co-workers or without the aid of an assistive device (e.g., friction-reducing pad) is not recommended and is not considered safe for the patient or the nurse. Remove the pillow from under head and shoulders and place it at the head of the bed to prevent striking the patient's head against the head of the bed. When pulling a patient up in bed, the bed should be flat to gain gravity assistance, and the side rails should be down.

Question 3

The patient is being admitted to the neurological unit with a diagnosis of stroke. When will the nurse begin discharge planning?

Accepted Answer

Discharge planning begins when a patient enters the health care system. In anticipation of the patient's discharge from an institution, the nurse makes appropriate referrals or consults a case manager or a discharge planner to ensure that the patient's needs are met at home. Referrals to home care or outpatient therapy are often needed. Planning the day before discharge, when outpatient therapy is no longer needed, and as soon as the discharge destination is known is too late.

Question 4

Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?

Accepted Answer

The nurse should collaborate with other health care team members such as physical or occupational therapists when considering mobility needs. For example, physical therapists are a resource for planning ROM or strengthening exercises. Nurses often delegate some interventions to nursing assistive personnel, but assessment of lung sounds is the nurse's responsibility. Nursing assistive personnel may turn and position patients, apply elastic stockings, help patients use the incentive spirometer, etc. Occupational therapists are a resource for planning activities of daily living that patients need to modify or relearn. A mental health advanced practice nurse or psychologist should be used for severe anxiety.

Question 5

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which $\bold{priority}$ action will the nurse take?

Accepted Answer

The diagnosis related to pain requires the nurse to assist the patient with comfort measures so that the patient is then willing and more able to move. Pain must be controlled so the patient will not be reluctant to initiate movement. The diagnosis related to reluctance to initiate movement requires interventions aimed at keeping the patient as mobile as possible and encouraging the patient to perform self-care and ROM.

Question 6

A nurse is caring for a patient with osteoporosis and lactose intolerance. What will the nurse do?

Accepted Answer

Encourage patients at risk to be screened for osteoporosis and assess their diets for calcium and vitamin D intake. Patients who have lactose intolerance need dietary teaching about alternative sources of calcium. Caffeine should be decreased. The goal of the patient with osteoporosis is to maintain independence with ADLs. Assistive ambulatory devices, adaptive clothing, and safety bars help the patient maintain independence.

Question 7

The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend?

Accepted Answer

Because the body needs protein to repair injured tissue and rebuild depleted protein stores, give the immobilized patient a high-protein, high-calorie diet. A high-carbohydrate, low-fat diet is not beneficial for an immobilized patient. Vitamins B and C are needed rather than A and E. Fluid restriction can be detrimental to the immobilized patient; this can lead to dehydration. A bland diet is not necessary for immobilized patients.

Question 8

Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan?

Accepted Answer

The diagnosis of Impaired physical mobility applies to the patient who has some limitation but is not completely immobile. The diagnosis of Risk for disuse syndrome applies to the patient who is immobile and at risk for multisystem problems because of inactivity. Beyond these diagnoses, the list of potential diagnoses is extensive because immobility affects multiple body systems.

Question 9

The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?

Accepted Answer

Placing a pillow under the patient's abdomen after turning decreases hyperextension of lumbar vertebrae and strain on lower back; breathing may also be enhanced. Head is turned toward one side with a small pillow to reduce flexion or hyperextension of cervical vertebrae. Legs should be supported with pillows to elevate toes and prevent footdrop. Forty-five degrees is the position for Fowler's position; prone is on the stomach.

Question 10

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse $\bold{most}$ likely try to prevent?

Accepted Answer

Back injuries are often the direct result of improper lifting and bending. The most common back injury is strain on the lumbar muscle group. While arm, hip, and ankle can occur, they are not as common as back.

Question 11

A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care?

Accepted Answer

A nurse supervises and aids personnel when there is a health care provider's order to logroll a patient. Patients who have suffered from spinal cord injury or are recovering from neck, back, or spinal surgery often need to keep the spinal column in straight alignment to prevent further injury. Hypostatic pneumonia, total knee replacement, and Stage IV ulcers do not have to be logrolled.

Question 12

Which goal is $\bold{most}$ appropriate for a patient who has had a total hip replacement?

Accepted Answer

"The patient will walk 100 feet using a walker by the time of discharge" is individualized, realistic, and measurable. "Ambulating briskly on a treadmill" is not realistic for this patient. The option that focuses on the nurse, not the patient, is not a measurable goal; this is an intervention. "The patient will ambulate by the time of discharge" is not measurable because it does not specify the distance. Even though we can see that the patient will ambulate, this does not quantify how far.

Question 13

The nurse is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the nurse use to help prevent injury secondary to this rotation?

Accepted Answer

A trochanter roll prevents external rotation of the hips when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. Hand-wrist splints are individually molded for the patient to maintain proper alignment of the thumb and the wrist. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bedframe. It allows the patient to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises.

Question 14

A nurse is evaluating care of an immobilized patient. Which action will the nurse take?

Accepted Answer

From your perspective as the nurse, you are to evaluate outcomes and response to nursing care and compare the patient's actual outcomes with the outcomes selected during planning. Ask if the patient's expectations (subjective data) of care are being met, and use objective data to determine the success of interventions. Just as it was important to include the patient during the assessment and planning phase of the care plan, it is essential to have the patient's evaluation of the plan of care, not just the patient's family and health care team.

Question 15

A nurse is providing care to a group of patients. Which patient will the nurse see $\bold{first}$?

Accepted Answer

A patient on prolonged bed rest will be prone to deep vein thrombosis, which can lead to an embolus. An embolus can travel through the circulatory system to the lungs and impair circulation and oxygenation, resulting in tachycardia and shortness of breath. Venous emboli that travel to the lungs are sometimes life threatening. While the patient with a reddened area needs to be turned, a patient with renal calculi needing the restroom, and a patient needing range of motion, these are not as life threatening as the chest pain and dyspnea.

Question 16

The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient?

Accepted Answer

Heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of deep vein thrombosis. Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding. Pulmonary secretions that become thick and tenacious are difficult to remove and are a sign of inadequate hydration or developing pneumonia but not of bleeding. SCDs consist of sleeves or stockings made of fabric or plastic that are wrapped around the leg and are secured with Velcro. They decrease venous stasis by increasing venous return through the deep veins of the legs. They do not usually cause bleeding. Elastic stockings also aid in maintaining external pressure on the muscles of the lower extremities and in promoting venous return. They do not usually cause bleeding.

Question 17

The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use?

Accepted Answer

A foot cradle may be used in patients with poor peripheral circulation as a means of reducing pressure on the tips of a patient's toes. A trochanter roll prevents external rotation of the hips when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bedframe. It allows the patient to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises.

Question 18

A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the NAP to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?

Accepted Answer

In the side-lying (or lateral) position the patient rests on the side with the major portion of body weight on the dependent hip and shoulder. Patients in the supine position rest on their backs. Sims' position is semiprone. The patient in the prone position lies face or chest down on the abdomen.

Question 19

A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess?

Accepted Answer

Damage to the cerebellum causes problems with balance, and motor impairment is directly related to the amount of destruction of the motor strip. A stroke can lead to hemiplegia. Direct trauma to the musculoskeletal system results in bruises, contusions, sprains, and fractures. A complete transection of the spinal cord can lead to lower extremity paralysis.

Question 20

The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one?
1) Grasp the drawsheet firmly near the patient.
2) Move the patient and drawsheet to the desired position.
3) Position one nurse at each side of the bed.
4) Place the drawsheet under the patient from shoulder to thigh.
5) Place your feet apart with a forward-backward stance.
6) Flex knees and hips and on count of three shift weight from the front to back leg.

Accepted Answer

Assisting a patient up in bed with a drawsheet (two or three nurses): (1) Place the patient supine with the head of the bed flat. A nurse stands on each side of the bed. (2) Remove the pillow from under the patient's head and shoulders and place it at the head of the bed. (3) Turn the patient side to side to place the drawsheet under the patient, extending it from shoulders to thighs. (4) Return the patient to the supine position. (5) Fanfold the drawsheet on both sides, with each nurse grasping firmly near the patient. (6) Nurses place their feet apart with a forward-backward stance. Nurses should flex knees and hips. On the count of three, nurses should shift their weight from front to back leg and move the patient and drawsheet to the desired position in the bed.

Quiz 28: Immobility

A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?

The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to make this procedure safe?

The patient is being admitted to the neurological unit with a diagnosis of stroke. When will the nurse begin discharge planning?

Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which $\bold{priority}$ action will the nurse take?

A nurse is caring for a patient with osteoporosis and lactose intolerance. What will the nurse do?

The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend?

Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan?

The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse $\bold{most}$ likely try to prevent?

A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care?

Which goal is $\bold{most}$ appropriate for a patient who has had a total hip replacement?

The nurse is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the nurse use to help prevent injury secondary to this rotation?

A nurse is evaluating care of an immobilized patient. Which action will the nurse take?

A nurse is providing care to a group of patients. Which patient will the nurse see $\bold{first}$ ?

The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient?

The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use?

A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the NAP to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?

A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess?

Quiz 28: Immobility

A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?

The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to make this procedure safe?

The patient is being admitted to the neurological unit with a diagnosis of stroke. When will the nurse begin discharge planning?

Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority\bold{priority}priority action will the nurse take?

A nurse is caring for a patient with osteoporosis and lactose intolerance. What will the nurse do?

The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend?

Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan?

The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most\bold{most}most likely try to prevent?

A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care?

Which goal is most\bold{most}most appropriate for a patient who has had a total hip replacement?

The nurse is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the nurse use to help prevent injury secondary to this rotation?

A nurse is evaluating care of an immobilized patient. Which action will the nurse take?

A nurse is providing care to a group of patients. Which patient will the nurse see first\bold{first}first ?

The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient?

The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use?

A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the NAP to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?

A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess?

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which $\bold{priority}$ action will the nurse take?

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse $\bold{most}$ likely try to prevent?

Which goal is $\bold{most}$ appropriate for a patient who has had a total hip replacement?

A nurse is providing care to a group of patients. Which patient will the nurse see $\bold{first}$ ?