Question 1

The patient who is experiencing an alteration in mobility often has one or more nursing diagnoses.The nurse would use the diagnosis of Impaired physical mobility for a patient who is

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 2

When preparing a plan of care for an immobilized patient,the nurse should

Accepted Answer

The nurse should use established expected outcomes to evaluate the patient's response to care.The nurse should use creativity when designing new interventions to improve the patient's mobility status and should display humility when identifying those interventions that were not successful.Ask if the patient's expectations of care are being met and use objective data to determine the success of interventions.

Question 3

In developing an individualized plan of care for a patient,it is important for the nurse to

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 4

The patient is immobilized after undergoing hip replacement surgery.Which of the following would place the patient at risk for hemorrhage?

Accepted Answer

Heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of DVT.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,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 5

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder.This diagnosis means that the nurse should

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 better able to move.Pain must be controlled before so that the patient will not be reluctant to initiate movement.The diagnosis of Reluctance to initiate movement requires interventions aimed at keeping the patient as mobile as possible and encouraging the patient to do self-care and ROM.This cannot be accomplished until comfort is achieved.

Question 6

The patient is being admitted to the neurological unit with the diagnosis of stroke.The nurse should 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 will be met at home.Referrals to home care or outpatient therapy are often needed.

Question 7

The director of a nursing home has decided to institute ergonomic programs in the facility because these programs increase employee satisfaction and have been shown to

Accepted Answer

Research has demonstrated that ergonomic programs in health care facilities reduce costs,injuries to employees,and missed workdays.These programs also enhance recruitment,retention,and satisfaction of employees.

Question 8

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.One strategy that the nurse could use is

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 bed frame.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 9

In preparing to create a nursing diagnosis for a patient who is immobile,it is important for the nurse to understand that

Accepted Answer

Often the physiological dimension is the major focus of nursing care for patients with impaired mobility.Thus the psychosocial and developmental dimensions are neglected.Yet all dimensions are important to health.

Question 10

The patient is unable to move himself and needs to be pulled up in bed.For this repositioning to be done safely,the nurse must understand that

Accepted Answer

This is not a one-person task.Helping a patient move up in bed without help from other coworkers 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.When pulling a patient up in bed,the bed should be flat or in a Trendelenburg position (when tolerated)to gain gravity assistance,and the side rails should be down.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.

Question 11

The nurse needs to transfer the patient from the bed to the chair.The nurse should

Accepted Answer

Careful assessment of your patient's ability to assist in the positioning technique to be used is extremely important.Consider the use of a mechanical lift.Your role in assisting your patient to a sitting position is to guide and instruct.If the patient can bear weight and move to a sitting position independently,allow him or her to do so and offer assistance.A transfer belt maintains stability of the patient during transfer and reduces risk for falls.Ensure that the patient has stable nonskid shoes on his feet.

Question 12

Of the following nursing goals,which is the most appropriate for a patient who has had a total hip replacement?

Accepted Answer

"The patient will walk 1000 feet using her walker by the time of discharge" is individualized,realistic,and measurable."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."Ambulating briskly on a treadmill" is not realistic for this patient.The last option focuses on the nurse,not the patient,and is not measurable.

Question 13

In caring for immobile patients,the nurse understands that back injuries occur

Accepted Answer

Musculoskeletal injuries among health care workers are related not only to lifting and transferring patients.Nurses spend time in many activities involving bending and twisting,which also cause injury.Examples of such activities include lifting objects,pushing beds,and providing direct patient care such as bathing,feeding,dressing,and undressing patients.

Question 14

When creating a plan of care for a patient who is experiencing alterations in mobility,the nurse

Accepted Answer

The nurse should collaborate with other health care team members such as physical or occupational therapists when considering mobility needs.Nurses often delegate some interventions to nursing assistive personnel.Nursing assistive personnel may turn and position patients,apply elastic stockings,help patient use the incentive spirometer,etc.Occupational therapists are a resource for planning ADLs that patients need to modify or relearn.It is especially important in priority setting to make sure not to overlook potential complications.Many times,actual problems such as pressure ulcers are addressed only after they develop.They should be addressed before they develop.

Question 15

The nurse needs to reposition a 300-lb patient.Which of the following strategies is most likely to prevent back injury?

Accepted Answer

Assess and determine the number of people needed; to prevent injury,do not start until the task can be completed safely.Assess the situation and do not turn the patient alone if this cannot be done safely.The trunk should be erect and the knees bent,so that multiple muscle groups (not just the arms)work together in a coordinated manner.This is not a one-person task: DO NOT PULL FROM THE HEAD OF THE BED.

Question 16

To prevent injury,the nurse should not begin a task (e.g.,moving a bed from one room to another,lifting heavy objects)until the task can be completed safely.To prevent injury

Accepted Answer

Follow these steps to prevent injury: (1)tighten abdominal muscles and tuck the pelvis to provide balance and help protect the back; (2)keep the weight to be lifted as close to the body as possible; (3)bend at the knees to maintain the center of gravity,and use the stronger leg muscles; and (4)maintain the trunk erect and the knees bent so that multiple muscle groups work together in a coordinated manner.

Question 17

The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair.The nurse opts to use a mechanical lift (Hoyer lift).The nurse understands that when this lift is used,the

Accepted Answer

The nurse should attach the hooks on the strap to the holes in the sling.Short straps hook to top holes of the sling; longer straps hook to the bottom of the sling.This prevents the sling from flipping upside down.The horseshoe-shaped base goes under the side of the bed on the side with the chair.Position the patient and lower slowly into the chair in accordance with manufacturer guidelines to safely guide the patient into the back of the chair as the seat descends; then remove the straps and the mechanical/hydraulic lift.

Question 18

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.To help prevent injury secondary to this rotation,the nurse can use

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 bed frame.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 19

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients.The nurse is aware that the rate of occupational injury and illness in the hospital setting

Accepted Answer

The rate of work-related injury in health care settings has increased in recent years.In 2006,4.4 cases per 100 full-time workers who experienced occupational injury and illness were reported compared with 5 cases per 100 for private industry overall.The rate for nursing homes was 10.1 per 100 workers.

Question 20

In applying for a job on a nursing unit that requires frequent patient positioning,the nurse should be aware that nurses

Accepted Answer

Nurses and other health care staff are especially at risk for injury to lumbar muscles when lifting,transferring,or positioning immobilized patients.Therefore,the nurse should be aware of agency policies and protocols that protect staff and patients from injury.Current evidence supports that using mechanical or other ergonomic assistive devices is the safest way to reposition and lift patients who are unable to do these activities themselves.

Quiz 47: Mobility and Immobility