Chapter 21: Immobility Nursing School Test Banks

Chapter 21: Immobility
Linton: Introduction to Medical-Surgical Nursing, 6th Edition

MULTIPLE CHOICE

1. What negative effects does immobilization have on the musculoskeletal system?
a. Demineralization of bone
b. Increase in aerobic capacity
c. Increased muscle oxidation
d. Lengthening of muscle fibers
ANS: A
Immobilization has negative effects on the musculoskeletal system such as demineralization of bone, a decrease in aerobic capacity, a decrease in muscle oxidation, and shortening of muscle fibers.

DIF: Cognitive Level: Comprehension REF: p. 326 OBJ: 1
TOP: Effects of Immobility KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. What should the nurse be aware is the best prevention of immobility-related disorders?
a. Dietary supplements
b. Fluids
c. Adequate fiber
d. Exercise
ANS: D
Exercise will help reduce the patients risk of immobility-related disorders.

DIF: Cognitive Level: Knowledge REF: p. 326-327 OBJ: 2
TOP: Preventing Complications of Immobility
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. A nurses assessment reveals an area of erythema on an immobilized patients sacrum. What is the initial nursing action?
a. Apply a wet-to-dry dressing.
b. Massage the reddened area.
c. Reposition the patient.
d. Rub the area with alcohol.
ANS: C
The first intervention is to reposition the patient with follow-up to ensure that the patient is repositioned often.

DIF: Cognitive Level: Application REF: p. 331 OBJ: 5
TOP: Treatment of Pressure Ulcers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

4. A nurse is providing discharge instructions to the family of an older adult patient who is unable to get out of bed. What should the nurse instruct the family regarding the most effective way to prevent urinary incontinence associated with immobility?
a. Use absorbent underpads.
b. Set up a toileting program.
c. Restrict fluid intake to 500 mL per 24 hours.
d. Restrict fluids after dinner and throughout the night.
ANS: B
Patients should have scheduled toileting times with adjustments in the schedule based on the patients voiding patterns. Studies have been inconclusive regarding the effectiveness of limiting fluids.

DIF: Cognitive Level: Application REF: p. 334 OBJ: 6
TOP: Urinary Incontinence KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. The care plan of an older adult patient states that the patient should be monitored while in the bathroom because of a history of vasovagal reflex. What should the nurse assess with this patient?
a. Extremely elevated blood pressure after ambulation
b. Nausea and vomiting after a meal
c. Lightheadedness and fainting during defecation
d. Inability to urinate
ANS: C
Constipated individuals may strain to defecate, causing an increase in intraabdominal pressure. This is called the Valsalva maneuver or vasovagal reflex, and it can lead to cardiovascular alterations.

DIF: Cognitive Level: Comprehension REF: p. 333 OBJ: 6
TOP: Vasovagal Reflex KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. What is the most effective intervention to prevent constipation in a patient who recently sustained a fractured femur and is currently in traction?
a. Get the patient up and to the bathroom at least twice each day.
b. Administer enemas each day until the patient has a bowel movement.
c. Administer pain medication to prevent pain during defecation.
d. Encourage a high-fiber diet and increased amounts of fluids.
ANS: D
Inactivity, decreased fluid intake, and a lack of adequate fiber in the diet can combine to cause constipation. Activity is not an option for this patient, but encouraging a high-fiber diet and increased fluids can help prevent or relieve constipation.

DIF: Cognitive Level: Application REF: p. 333 OBJ: 6
TOP: Constipation KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. A nurse caring for a patient who has been prescribed bed rest for 1 week notices a reddened area on the patients left hip. The skin is intact, but when the nurse presses on the area, the redness does not fade. How should this area of pressure be classified?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: A
The major characteristic of a stage I pressure ulcer is erythema (redness) that does not blanch when pressed.

DIF: Cognitive Level: Analysis REF: p. 331 OBJ: 4
TOP: Stages of Pressure Areas KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. What action should the nurse implement when positioning an immobile patient?
a. Ensure that the patients knees and hips are flexed.
b. Visualize how a person looks while standing and try to have the patient achieve that position while lying down.
c. Reposition the patient no more often than every 4 hours.
d. Always position the patient on his or her back with the head raised to prevent aspiration.
ANS: B
Positioning should be done to maintain joints in their functional positions so they are not abnormally flexed or extended.

DIF: Cognitive Level: Application REF: p. 328 OBJ: 2
TOP: Positioning KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

9. What intervention is most appropriate to prevent respiratory complications resulting from immobility?
a. Suction every 4 to 6 hours.
b. Administer pain medications as frequently as possible.
c. Teach the patient the technique of pursed lip breathing.
d. Reposition the patient, and encourage him or her to cough and deep breathe at least every 2 hours.
ANS: D
When a person remains immobile or does not take deep breaths, thick secretions can accumulate and pool in the lower respiratory structures.

DIF: Cognitive Level: Application REF: p. 333 OBJ: 6
TOP: Respiratory Complications KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

10. A nurse transcribes a discharge order for the patient with left-sided weakness after having a stroke indicating to teach the patient to perform range-of-motion exercises on affected extremities. The patient asks why she needs to do range-of-motion exercises. What is the nurses best response?
a. Because the physician has ordered it.
b. You will regain full use of your arm and leg if you will do the exercises correctly.
c. They prevent the muscles and tendons from shortening and becoming unmovable.
d. It will give you something to do because you cant work anymore.
ANS: C
Muscular activity maintains range of motion by allowing the joint to remain flexible and functional. When little or no movement of a joint occurs, the muscles shorten and lose their elasticity.

DIF: Cognitive Level: Application REF: p. 328 OBJ: 2
TOP: Exercises KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

11. A nurse assesses a patients risk for developing a pressure ulcer using the Norton scale. The patients score is 18. What nursing action should be implemented?
a. Call the physician immediately.
b. Implement a pressure ulcer prevention program.
c. Document the score.
d. Order an alternating air mattress.
ANS: C
If the total score on the Norton scale is greater than 14, then little risk exists for the development of pressure ulcers. If the total score is less than 14, then significant risk exists.

DIF: Cognitive Level: Application REF: p. 330 OBJ: 3
TOP: Norton Scale KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. A patient in traction with a fractured hip is diagnosed with a stage I pressure ulcer. She asks the nurse how a pressure ulcer could occur after only 2 days of immobility. On what knowledge should the nurse base a response?
a. Erythema can occur in 1 to 2 hours even in a person with healthy skin and adequate circulation.
b. It takes several days for a pressure ulcer to form.
c. The pressure ulcer probably occurred when you fell.
d. The cause of pressure ulcers isnt really known.
ANS: A
Because of impaired blood flow, capillaries in the area of pressure can become congested, and erythema can occur in 1 to 2 hours.

DIF: Cognitive Level: Comprehension REF: p. 329 OBJ: 3
TOP: Pressure Ulcers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. A patient is complaining to the nurse that he feels the need to have a bowel movement but has not been able to defecate. He has had cramping and even a small amount of brown watery stool. What should the nurse recognize these symptoms as?
a. Diarrhea
b. Fecal incontinence
c. Fecal impaction
d. Flatulence
ANS: C
Symptoms of a fecal impaction include painful defecation, a feeling of fullness in the rectum, abdominal distention, and sometimes cramps and a watery stool.

DIF: Cognitive Level: Comprehension REF: p. 333 OBJ: 6
TOP: Fecal Impaction KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. During the shift report, a nurse is told that a patient she will be caring for has a stage II pressure ulcer. What should the nurse expect to visualize during the dressing change?
a. Ulcer that appears black with possible signs of infection
b. Shallow ulcer that appears blistered, cracked, or abraded
c. Craterlike sore with a distinct outer margin formed as the epidermis thickens and rolls over the edge toward the ulcer base
d. Redness of skin with no ulceration
ANS: B
In a stage II pressure ulcer, some skin loss in the epidermis and dermis has occurred.

DIF: Cognitive Level: Comprehension REF: p. 331 OBJ: 4
TOP: Stages of Pressure Ulcers KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. When preparing a plan care for an older adult patient, a nurse should consider the common problems associated with immobility. What should these problems be classified as?
a. Environmental and intellectual
b. Internal and external
c. Mental and medical
d. Physical and psychosocial
ANS: D
Immobility can have a profound impact on both the mind and the body. Psychosocial problems include depression, fear, anxiety, social withdrawal, and apathy. Physically, immobility can have an adverse effect on every body system.

DIF: Cognitive Level: Comprehension REF: p. 325 OBJ: 1
TOP: Problems Associated with Immobility
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

16. How does the National Pressure Ulcer Advisory Panel prefer to refer to skin breakdown?
a. Bed sores
b. Pressure ulcers
c. Decubitus ulcers
d. Decubiti
ANS: B
Decubitus means lying down; therefore, decubitus ulcers and bed sores are associated with lying in a bed. Skin breakdown can also develop from sitting.

DIF: Cognitive Level: Knowledge REF: p. 329 OBJ: 1
TOP: Pressure Ulcers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. A patient complains that his bottom is sore. The nurse assesses the area and finds an open area on the sacrum that appears blistered. What action should the nurse implement?
a. Document the cause of the burn.
b. Clean with alcohol, apply moisturizer, and cover with a set dressing.
c. Massage the area to promote circulation.
d. Clean with mild soap, dry, and apply a light dressing.
ANS: D
If pressure ulcers develop despite all preventive measures, proper and early treatment improves the chance for reversal. A stage II ulcer should be cleaned with mild soap and water or with sterile normal saline, patted dry, and covered with a dressing that allows airflow.

DIF: Cognitive Level: Application REF: p. 332 OBJ: 4
TOP: Pressure Ulcers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

18. A nurse is performing a wet-to-dry dressing change on a stage IV pressure ulcer. What is the purpose of this type of dressing?
a. Keep the wound moist.
b. Prevent infection.
c. Dbride necrotic tissue.
d. Increase circulation to the tissue.
ANS: C
Wet-to-dry dressings and a whirlpool are used for small amounts of dbridement of necrotic tissue. Dbridement is necessary to promote granulation of new, healthy tissue.

DIF: Cognitive Level: Comprehension REF: p. 332 OBJ: 5
TOP: Wet-to-Dry Dressing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. A nursing assistant is bathing a patient who has a stage I pressure ulcer on the right shoulder. What action by the health care team could cause that the tissue to become more damaged?
a. Positioning the patient on the left side
b. Massaging the reddened area
c. Cleaning the area with mild soap and water
d. Positioning the patient in a prone position
ANS: B
Any type of massage around or on a reddened area of skin can damage fragile capillaries.

DIF: Cognitive Level: Comprehension REF: p. 331 OBJ: 5
TOP: Treatment of Pressure Ulcers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. A nurse is planning the care of a patient who is immobile. Why should the nurse consider this patient to be at risk for urinary tract infection?
a. Urine will pool in the bladder when the patient remains in a supine position.
b. The patient is likely to have urinary incontinence.
c. The patients appetite may be decreased.
d. The patient may not be able to move quickly enough to get to the bathroom.
ANS: A
If the body remains in a supine position for even a few days, the flow becomes sluggish, and the urine pools in the bladder, which will increase the risk of a urinary tract infection.

DIF: Cognitive Level: Comprehension REF: p. 334 OBJ: 6
TOP: Urinary Tract Infection KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

21. What should the nurse instruct a patient in a wheelchair to do to decrease risk for pressure ulcers?
a. Use a ring pillow on the seat of the chair.
b. Lift the weight of the body using the arms of the wheelchair every 15 minutes.
c. Scoot forward and back in the seat to stimulate circulation.
d. Wear underwear that holds moisture close to skin.
ANS: B
Using the arms of the wheelchair to lift the weight off the buttocks and coccyx is beneficial to reduce the risk of pressure ulcers in patients using wheelchairs.

DIF: Cognitive Level: Comprehension REF: p. 330 OBJ: 5
TOP: Pressure Ulcer in a Wheelchair KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

22. A nurse is instructing a patient on performing isometric exercises. What instruction should the nurse include?
a. Contract the muscle for several seconds, then relax the muscle for a few seconds, and contract it again.
b. Perform full range-of-motion exercises of each joint.
c. Have a family member perform full range-of-motion exercises on each of the patients joints.
d. Stand in front of a wall and push with the arms without bending the elbow.
ANS: A
Isometric exercises maintain muscle tone without moving the joint. This type of exercise is helpful in maintaining muscle strength after a fracture.

DIF: Cognitive Level: Comprehension REF: p. 328 OBJ: 2
TOP: Isometric Exercises KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

23. A nurse is talking with a patient who recently became paraplegic as a result of a cervical spinal cord injury. When some home equipment is discussed, the patient becomes angry and says, I dont need to worry about any kind of home equipment. What is the best response by the nurse?
a. I know you will be walking soon, but you may need some equipment until then.
b. There is very little chance that you will ever walk.
c. Tell me what it is about this equipment that bothers you.
d. Let me call the physician to come explain your injuries to you.
ANS: C
The nurse should use therapeutic communication techniques to explore the patients feelings.

DIF: Cognitive Level: Application REF: p. 326 OBJ: 1
TOP: Therapeutic Communication KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

24. During a skin integrity assessment, a nurse notices an area on the right heel that is black and draining purulent, foul-smelling exudate. How should the nurse document this as a pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: D
In a stage IV pressure ulcer, full-thickness skin loss has occurred with extensive destruction of the deeper underlying muscle and, possibly, the bone tissue.

DIF: Cognitive Level: Analysis REF: p. 331-332 OBJ: 4
TOP: Stages of Pressure Ulcers KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

25. What is the classification of incontinence in older adults related to the inability to get to the bathroom in time?
a. Stress incontinence
b. Urge incontinence
c. Functional incontinence
d. Sporadic incontinence
ANS: C
Functional incontinence occurs when the older adult patient cannot move quickly enough to reach the toilet in time.

DIF: Cognitive Level: Knowledge REF: p. 334 OBJ: 6
TOP: Functional Incontinence KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

MULTIPLE RESPONSE

26. Which are characteristics of a stage I pressure ulcer? (Select all that apply.)
a. The area is regular and well defined.
b. Tissue hardening is present.
c. Swelling has occurred at the site.
d. The condition is reversible.
e. Nonblanching erythema is observed.
ANS: B, C, D, E
A stage I ulcer has irregular and poorly defined margins, with swelling and hardening at the site of the nonblanching erythema. At this stage, the ulcer is reversible.

DIF: Cognitive Level: Knowledge REF: p. 331 OBJ: 4
TOP: Characteristics of Stage I Pressure Ulcer
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. What should a nurse document when assessing a new pressure ulcer? (Select all that apply.)
a. Precise measurement of the ulcer
b. Location of the wound and its description
c. Color of the ulcer
d. Amount and characteristics of the drainage
e. Probable cause of the ulcer
ANS: A, B, C, D
Documentation should include the precise location, color, size, shape, and drainage, as well as treatment applications.

DIF: Cognitive Level: Comprehension REF: p. 331-332 OBJ: 4
TOP: Documentation of Pressure Ulcers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

28. What therapeutic reasons exist that explain why a patient might become immobile? (Select all that apply.)
a. Reduction of the workload of the heart
b. Fear of falling
c. Reversal of the effects of gravity
d. Bereavement
e. Healing of a fracture
ANS: A, C, E
A reduction of the hearts workload, a reversal of the effects of gravity (as in the treatment of a hernia or prolapse), and the healing of a fracture are all therapeutic reasons for immobilization. The fear of falling and bereavement are not therapeutic reasons.

DIF: Cognitive Level: Comprehension REF: p. 325 OBJ: 1
TOP: Therapeutic Rationale for Immobilization
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

29. A home health nurse instructs a family about boosting the patient in bed so that a(n) _____ type of skin injury will not occur.

ANS:
shearing force
Shearing force injuries occur when a patient is dragged up in bed, causing the skin to be abraded against the bed linens.

DIF: Cognitive Level: Knowledge REF: p. 329 OBJ: 1
TOP: Shear Force KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

30. A nurse evaluates the effectiveness of the treatment for a stage III pressure ulcer as satisfactory when the bed of the ulcer is pink, indicating the presence of _____, which is an indicator of tissue perfusion.

ANS:
granulation tissue
The appearance of healthy pink granulation tissue in the bed of a pressure ulcer is a positive sign for improved perfusion and the beginning of closure.

DIF: Cognitive Level: Knowledge REF: p. 332 OBJ: 5
TOP: Presence of Granulation Tissue KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

31. A nurse takes into consideration that such emotions as worry, anxiety, and depression can contribute to the common nutritional problem of _____.

ANS:
anorexia
Anorexia can be caused by emotional factors such as worry, anxiety, and depression.

DIF: Cognitive Level: Knowledge REF: p. 333 OBJ: 6
TOP: Anorexia KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

32. When bacteria are localized at the site of a stage III pressure ulcer, it is said to be _____.

ANS:
colonized
Colonized bacteria are those who are in one location, such as an ulcer, and not systemic.

DIF: Cognitive Level: Knowledge REF: p. 332 OBJ: 3
TOP: Colonization of bacteria KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

33. The negative impact of immobilization on a patient depends on the duration, degree, and type of _____.

ANS:
mobility limitation
Duration, degree, and type of mobility limitation have the greatest impact. The other choices may affect the impact of immobilization when the mobility limitation becomes an issue.

DIF: Cognitive Level: Knowledge REF: p. 325 OBJ: 2
TOP: Impact of Immobility KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

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