Question 1

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

Accepted Answer

Kyphoscoliosis is a condition that involves both kyphosis (abnormal anteroposterior curvature) and scoliosis (abnormal lateral curvature) of the spine.

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?

Accepted Answer

A wedge pillow is used to maintain the patient's legs in abduction after total hip replacement surgery to prevent dislocation of the hip joint.

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?

Accepted Answer

Providing support to the extremity is essential to prevent injury and ensure proper alignment during ROM exercises.

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?

Accepted Answer

A foot boot is the best choice to reduce the chance of plantar flexion in a patient on prolonged bed rest as it helps to maintain the foot in a neutral position and prevents the foot from dropping. A trapeze bar is used to assist with mobility and transferring, a trochanter roll is used to prevent external rotation of the hip, and 30-degree lateral positioning helps to prevent pressure ulcers.

Question 5

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

Accepted Answer

When a patient with impaired physical mobility is in the recumbent position,the 30-degree lateral position reduces pressure from the sacral area and reduces the risk of skin breakdown.For a patient in the recumbent position with impaired physical mobility,the correct angle for a patient in the recumbent position with impaired physical mobility is not 15,45,or 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?

Accepted Answer

Antiembolism stockings are designed to apply external pressure to the legs, which helps to promote venous blood return and prevent blood clots (thromboembolism) from forming in the deep veins of the legs. They do not serve to keep the skin warm and dry, prevent abnormal joint flexion, or 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?

Accepted Answer

Torticollis is a condition characterized by a contracture of the sternocleidomastoid muscle, causing the head to incline to one side. This can lead to difficulty with mobility and range of motion. Options A and B are not related to torticollis, while option C describes scoliosis, another spinal condition.

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?

Accepted Answer

The nurses should face the direction of movement to use proper body mechanics and reduce the risk of injury.

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?

Accepted Answer

Patients who have experienced paralysis after a stroke (CVA) are at high risk for developing footdrop due to the inability to dorsiflex their feet. Using pillows to support their lower legs and elevate their toes helps prevent this complication. The other patients listed do not have the same level of risk for footdrop.

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?

Accepted Answer

The trochanter roll is the best choice to reduce the chance of external hip rotation in a patient on prolonged bed rest. It is a foam or rolled towel that is placed along the lateral thigh to prevent the hips from rotating outward. The footboard, trapeze bar, and bed board do not specifically address external hip rotation.

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?

Accepted Answer

Measuring the calf and thigh diameters can help assess for the presence of thrombosis as the affected limb may become swollen due to the formation of a blood clot. This is a common tool used in clinical practice known as the Wells score. Attempting to elicit Homans' sign, palpating foot temperature, and observing for skin turgor and hair loss may be useful in other assessments, but are not as effective in assessing for thrombosis in an immobilized patient.

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?

Accepted Answer

Sequential compression stockings are typically set to apply intermittent pressure around 40 mm Hg to help prevent deep vein thrombosis.

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?

Accepted Answer

Prolonged bed rest can lead to decreased peristalsis and bowel motility, which may result in constipation or bowel impaction. Increased blood pressure and urinary output are not typically associated with immobility. While heart rate can decrease due to immobility, it is not as commonly observed as 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?

Accepted Answer

Contractures can form within 8 hours in an immobile older adult patient.

Question 15

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

Accepted Answer

The answer of Which of the following body mass index...

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?

Accepted Answer

Assessing the extremities for unilateral swelling and muscle atrophy is important to monitor for complications such as deep vein thrombosis and muscle wasting due to immobility.

Question 17

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

Accepted Answer

Encouraging deep breathing and coughing every hour is the best choice as it helps to promote respiratory function in immobilized patients by preventing atelectasis and improving oxygenation. Changing the patient's position every four to eight hours also helps prevent atelectasis formation, but it should be done in combination with deep breathing and coughing. Using oxygen and nebulizer treatments regularly and suctioning the patient every hour may not be necessary for all immobilized patients and should only be done if indicated by the patient's condition.

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?

Accepted Answer

The postoperative patient up for the first time since knee surgery requires the nurse's priority for ambulation as they are likely weak, unsteady and have impaired mobility and balance. This increases their risk of falling and potentially causing injury to the surgical site. The other patients may also be at risk for falling but their conditions do not necessarily require immediate ambulation or mobility assistance.

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?

Accepted Answer

The basic crutch stance involves placing the crutches approximately 15 cm in front and to the side of each foot for optimal balance and support.

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?

Accepted Answer

The answer of The patient is getting up for the...

Quiz 45: Mobility and Immobility