Question 1

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,what can the nurse 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 moulded 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 2

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

Accepted Answer

A goal of walking 305 m (1000 feet)with the use of 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 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 3

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

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 a patient is pulled up in bed,the bed should be flat or in the Trendelenburg position (when tolerated)for gravity assistance,and the side rails should be down.The pillow should be removed from under the patient's head and shoulders and placed at the head of the bed to keep the patient's head from striking against the head of the bed.

Question 4

The patient is being admitted to the neurological unit with the diagnosis of stroke.When should 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 5

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

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.However,all dimensions are important in health.

Question 6

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,the nurse must assess the patient continually 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.Sequential compression devices 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,and they also do not usually cause bleeding.

Question 7

When the nurse creates a plan of care for a patient who is experiencing alterations in mobility,which of the following is true?

Accepted Answer

The nurse should collaborate with other health care team members such as physiotherapists or occupational therapists when considering mobility needs.Nurses often delegate some interventions to unregulated care providers.Unregulated care providers may perform such tasks as turning and positioning patients,applying elastic stockings,and helping patient use the incentive spirometer.Occupational therapists are a resource for planning ADLs that patients need to modify or relearn.It is especially important in priority setting to account for potential complications.Many times,actual problems such as pressure ulcers are addressed only after they develop.They should be addressed before they develop.

Question 8

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

Accepted Answer

Careful assessment of the patient's ability to assist in the positioning technique to be used is extremely important.The use of a mechanical lift should be considered.The nurse's role in assisting the patient to a sitting position is to guide and instruct.If the patient can bear weight and move to a sitting position independently,he or she should be allowed to do so,and the nurse may offer assistance.A transfer belt maintains stability of the patient during transfer and reduces risk for falls.The nurse must ensure that the patient has stable nonskid shoes on the feet.

Question 9

The nurse needs to reposition a 136.1 kg (300-pound)patient.Which of the following strategies is most likely to prevent back injury?

Accepted Answer

The nurse must assess and determine the number of people needed;to prevent injury,the task should not be started until it can be completed safely.The nurse should assess the situation and not turn the patient alone if this cannot be done safely.The nurse's 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: the nurse must not pull from the head of the bed.

Question 10

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.What is one strategy that the nurse could use?

Accepted Answer

A foot cradle may be used for 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 11

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

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 the patient will be willing to initiate movement.The diagnosis of Reluctance to initiate movement necessitates interventions aimed at keeping the patient as mobile as possible and encouraging the patient to perform self-care and ROM exercises.This cannot be accomplished until comfort is achieved.

Question 12

The nurse is caring for a patient who has had a stroke that caused total paralysis of the right side.To help maintain joint function and to prevent contractures,passive ROM exercises will be initiated.When should therapy begin?

Accepted Answer

Passive ROM exercises should begin as soon as the patient's ability to move the extremity or joint is lost.The nurse should not wait for the acute phase to end.It may be some time before the patient enters the rehabilitation unit,and contractures could form by then.ROM exercise is certainly needed by this patient.

Question 13

Prevention of plantar flexion through the use of pillows to support the lower legs and elevate the toes is a priority intervention for which patient?

Accepted Answer

The patient who has suffered a CVA with resulting left-sided paralysis (hemiplegia)is at risk for footdrop.Neither the 54-year-old patient with osteoarthritis in all lower extremity joints nor the 25-year-old patient with a fractured pelvis as a result of a motorcycle accident would have damage to the nerve necessary to cause footdrop.There is little chance that the 15-year-old patient who has been comatose for 2 years as a result of a head injury sustained from a fall off a roof will ever be capable of mobility.

Question 14

When the nurse is preparing a plan of care for an immobilized patient,what should the nurse keep in mind?

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 the interventions that were not successful.The nurse should ask whether the patient's expectations of care are being met and use objective data to determine the success of interventions.

Question 15

The nurse is admitting a patient who has had a stroke.The physician writes orders for "ROM as needed." What does the nurse understand about this situation?

Accepted Answer

Further assessment of the patient is needed.Some patients are able to move some joints actively,whereas the nurse must help other joints with passive movement.With a weak patient,the nurse may have to support an extremity while the patient performs the movement.In general,exercises need to be as active as the patient's health and mobility allow.

Question 16

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

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 17

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

Accepted Answer

Disease,injury,pain,physical development (e.g. ,age),and life changes (e.g. ,pregnancy)compromise the ability to remain balanced.Medications that cause dizziness and prolonged immobility also affect balance.Although all of the options represent a potential risk for falling,the postoperative patient has both prolonged immobility and physical injury (surgery)and so is at greatest risk.The 16-year-old with a sprained ankle being discharged from the emergency department,the 54-year-old who has taken the initial dose of an antihypertensive medication,and the 81-year-old who is asthmatic and had a hip replaced 18 months ago do not receive priority for ambulation.

Question 18

While performing passive ROM exercises,the nurse stands at the side of the bed closest to the joint being exercised and does what else?

Accepted Answer

The nurse carries out movements slowly and smoothly,just to the point of resistance.ROM exercises should not cause pain.A joint should never be forced beyond its capacity.Each movement needs to be repeated five times during the session.

Question 19

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

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 perform these activities themselves.

Question 20

Many patients who experience an alteration in mobility have one or more nursing diagnoses.For whom would the nurse would use the diagnosis of Impaired physical mobility?

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.

Quiz 45: Mobility and Immobility