Chapter 46: Mobility and Immobility Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the client, the nurse is alert to a(n):

a.

Increased blood pressure

b.

Decreased heart rate

c.

Increased urinary output

d.

Decreased peristalsis

ANS: d

d. Immobility causes gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.

a. In the immobilized client, decreased circulating fluid volume, pooling of blood in the lower extremities, and decreased autonomic response occur. These factors result in decreased venous return, followed by a decrease in cardiac output, which is reflected by a decline in blood pressure.

b. Recumbency increases cardiac workload and results in an increased pulse rate.

c. Fluid intake can diminish with immobility, and this, combined with other causes, such as fever, increases the risk of dehydration. Urinary output may decline on or about the fifth or sixth day after immobilization, and the urine is often highly concentrated.

REF: Text Reference: p. 1427

2. A 61-year-old client recently had left-sided paralysis from a cerebrovascular accident (stroke). In planning care for this client, the nurse implements which one of the following as an appropriate intervention?

a.

Encourage an even gait when walking in place.

b.

Assess the extremities for unilateral swelling and muscle atrophy.

c.

Encourage holding the breath frequently to hyperinflate his lungs.

d.

Teach the use of a two-point crutch technique for ambulation .

ANS: b

b. Because edema moves to dependent body regions, assessment of the immobilized client should include the sacrum, legs, and feet. Unilateral increases in calf diameter can be an early indication of thrombosis.

a. The client who has suffered a cerebrovascular accident with left-sided paralysis may not be capable of an even gait.

c. Having the client hold his or her breath frequently is not an appropriate nursing intervention to be implemented by the nurse. To prevent stasis of pulmonary secretions, the clients position should be changed every 2 hours, and fluids should be increased to 2000 ml, if not contraindicated. The client should deep breathe and cough every 1 to 2 hours to promote chest expansion.

d. Two-point crutch technique would not be appropriate for the client with left-sided paralysis. The client would most likely ambulate safely with a walker or a cane. If crutches are used, the client should use a three-point support.

REF: Text Reference: p. 1442

3. Two nurses are standing on opposite sides of the bed to move the client up in bed with a draw sheet. Where should the nurses be standing in relation to the clients body as they prepare for the move?

a.

Even with the thorax

b.

Even with the shoulders

c.

Even with the hips

d.

Even with the knees

ANS: b

b. The nurses should be standing even with the clients shoulders when they prepare to move the client up in bed.

a. This is not the correct position for the nurses.

c. This is not the correct position for the nurses.

d. This is not the correct position for the nurses.

REF: Text Reference: p. 1460

4. A client is leaving for surgery, and because of preoperative sedation, needs complete assistance to transfer from the bed to the stretcher. Which of the following should the nurse do first?

a.

Elevate the head of the bed

b.

Explain the procedure to the client

c.

Place the client in the prone position

d.

Assess the situation for any potentially unsafe complications

ANS: d

d. Before transferring the client from the bed to the stretcher, the nurse should assess the situation for any potentially unsafe complications.

a. The head of the bed should be at the same level as the head of the stretcher. The nurse should first assess the situation before changing the height of the head of the bed.

b. This client has had preoperative sedation, which may impair his or her cognition. The nurse should simplify instructions when explaining the procedure to the client, but this should be done immediately before transferring the client. The nurse should first assess the situation for any potential unsafe complications.

c. The sedated client is transferred most easily in the supine position, unless contraindicated. The nurse should first assess the situation for any potential unsafe complications.

REF: Text Reference: p. 1468

5. A client has sequential compression stockings in place. The nurse evaluates that they are implemented appropriately by the new staff nurse when the:

a.

Initial measurement is made around the clients calves

b.

Intermittent pressure is set at 40 mm Hg

c.

Stockings are wrapped directly over the leg from ankle to knee

d.

Stockings are removed every hour during application

ANS: b

b. Inflation pressures average 40 mm Hg.

a. Initial measurement is made around the largest part of the clients thigh.

c. A protective stockinette is placed over the clients leg. Then the stocking is wrapped around the leg, starting at the ankle, with the opening over the patella.

d. Stockings are not removed every hour. For optimal results, SCD/IPCs are used as soon as possible and maintained until the client becomes fully ambulatory. The stockings should be removed periodically to assess the condition of the clients skin.

REF: Text Reference: p. 1451

6. The nurse assesses that the client has torticollis, and that this may adversely influence the clients mobility. This individual has a(n):

a.

Exaggeration of the lumbar spine curvature

b.

Increased convexity of the thoracic spine

c.

Abnormal anteroposterior and lateral curvature of the spine

d.

Contracture of the sternocleidomastoid muscle with a head incline

ANS: d

d. Torticollis is inclining of the head to the affected side, in which the sternocleidomastoid muscle is contracted.

a. Lordosis is an exaggeration of the lumbar spine curvature.

b. Kyphosis is an increased convexity in the curvature of the thoracic spine.

c. Kyphoscoliosis is an abnormal anteroposterior and lateral curvature of the spine.

REF: Text Reference: p. 1426

7. An immobilized client is suspected as having atelectasis. This is assessed by the nurse, on auscultation, as:

a.

Harsh crackles

b.

Wheezing on inspiration

c.

Diminished breath sounds

d.

Bronchovesicular whooshing

ANS: c

c. Atelectasis is the collapse of alveoli. In atelectasis, secretions block a bronchiole or a bronchus, and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. If the client were suspected of having atelectasis, the nurse would expect diminished breath sounds in the area of hypoventilation.

a. Harsh crackles indicate excessive airway secretion.

b. Wheezing on inspiration indicates narrowing of the lumen of a respiratory passageway.

d. Bronchovesicular sounds are a mixture of bronchial and vesicular sounds. Bronchovesicular whooshing would not be an expected sound indicating atelectasis.

REF: Text Reference: p. 1428, Text Reference: p. 1441

8. The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to:

a.

Measure the calf and thigh diameters

b.

Attempt to elicit Homans sign

c.

Palpate the temperature of the feet

d.

Observe for a loss of hair and skin turgor in the lower legs

ANS: a

a. Calf and thigh circumference should be measured daily. Unilateral increases in calf or thigh diameter can be an early indication of thrombosis.

b. Homans sign is not always positive in the presence of thrombosis.

c. Assessing the temperature of the feet is not the best approach to determine the presence of thrombosis.

d. Observing for hair loss and skin turgor of the lower legs is not the best approach to determine the presence of thrombosis. A lack of hair may indicate a chronic lack of oxygen. Skin turgor is a measure of hydration.

REF: Text Reference: p. 1442

9. A client is getting up for the first time after a period of bed rest. The nurse should first:

a.

Assess respiratory function

b.

Obtain a baseline blood pressure

c.

Assist the client to sit at the edge of the bed

d.

Ask the client if he or she feels lightheaded

ANS: b

b. When getting the client up for the first time after a period of bed rest, the nurse should document orthostatic changes. The nurse first obtains a baseline blood pressure.

a. Assessing the clients respiratory function is not the nurses first intervention when getting a client up for the first time after prolonged bed rest.

c. After the nurse assesses the clients blood pressure, the nurse can assist the client to a sitting position at the side of the bed.

d. After the client is in the sitting position at the side of the bed, the nurse should ask the client if he or she feels lightheaded.

REF: Text Reference: p. 1441

10. To promote respiratory function in the immobilized client, the nurse should:

a.

Change the clients position q4-8h.

b.

Encourage deep breathing and coughing every hour

c.

Use oxygen and nebulizer treatments regularly

d.

Suction the client every hour

ANS: b

b. The nurse should actively work with the immobilized client to deep breathe and cough every 1 to 2 hours to promote chest expansion.

a. The clients position should be changed every 2 hours to reduce stagnation of secretions.

c. The physician must order oxygen and nebulizer treatments. These interventions are used primarily to treat the client who is experiencing an impaired air exchange, not to promote respiratory function in the immobilized client.

d. The client should be suctioned as needed, not every hour.

REF: Text Reference: p. 1451

11. Antiembolytic stockings (TEDs) are ordered for the client on bed rest after surgery. The nurse explains to the client that the primary purpose for the elastic stockings is to:

a.

Keep the skin warm and dry

b.

Prevent abnormal joint flexion

c.

Apply external pressure

d.

Prevent bleeding

ANS: c

c. The primary purpose of antiembolytic stockings (TEDs) is to maintain external pressure on the muscles of the lower extremities and thus promote venous return.

a. The primary purpose of antiembolytic stockings is not to keep the skin warm and dry.

b. Antiembolytic stockings are not used to prevent abnormal joint flexion.

d. Antiembolytic stockings are not primarily used to prevent bleeding. They are used to prevent clot formation due to venous stasis.

REF: Text Reference: p. 1451, Text Reference: p. 1452

12. To provide for the psychosocial needs of an immobilized client, an appropriate statement by the nurse is:

a.

The staff will limit your visitors so that you will not be bothered.

b.

A roommate can be a real bother. Youd probably rather have a private room.

c.

Lets discuss the routine to see if there are any changes we can make.

d.

I think you should have your hair done and put on some make-up.

ANS: c

c. To meet the psychosocial needs of an immobilized client, the nurse should encourage the client to be involved in his or her care whenever possible. Asking the client if the staff can make changes in routine care is an appropriate question.

a. Visitors should not be limited for the immobilized client. The client needs socialization throughout the day.

b. If possible, the client should be placed in a room with others who are mobile and interactive.

d. Clients should be encouraged to wear their glasses or artificial teeth and to shave or apply makeup. These are activities through which people maintain their body image. The nurse provides for the psychosocial needs of an immobilized client by having the client perform as much self-care as possible.

REF: Text Reference: p. 1455

13. To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse should implement the use of a:

a.

Footboard

b.

Trochanter roll

c.

Trapeze bar

d.

Bed board

ANS: b

b. A trochanter roll prevents external rotation of the hips when the client is in a supine position.

a. The footboard prevents footdrop by maintaining the feet in dorsiflexion.

c. The trapeze bar allows the client 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.

d. A bed board is used to increase back support and alignment, especially with a soft mattress.

REF: Text Reference: p. 1455

14. To reduce the chance of plantar flexion (foot drop) in a client on prolonged bed rest, the nurse should implement the use of:

a.

Trapeze bars

b.

High-top sneakers

c.

Trochanter rolls

d.

30-degree lateral positioning

ANS: b

b. High-top tennis shoes or an ankle/foot orthotic may be used to help maintain dorsiflexion and prevent footdrop.

a. A trapeze bar is not used to keep the foot in dorsiflexion. A trapeze bar is used to assist the client in mobility.

c. A trochanter roll prevents external rotation of the hips when the client is in a supine position. It is not used to prevent footdrop.

d. Thirty-degree lateral positioning does not prevent plantar flexion. It may be used for clients at risk for pressure ulcers.

REF: Text Reference: p. 1455

15. A client is admitted to the medical unit following a cerebrovascular accident (CVA). There is evidence of left-sided hemiparesis and the nurse will be following up on range of motion and other exercises performed in physical therapy. The nurse correctly teaches the client and family members which one of the following principles of range-of-motion exercises?

a.

Flex the joint to the point of discomfort

b.

Work from proximal to distal joints

c.

Move the joints quickly

d.

Provide support for distal joints

ANS: d

d. While the client is performing range of motion exercises, support should be provided for the distal joints.

a. The joint should be flexed to the point of resistance, not to the point of discomfort.

b. When performing range-of-motion exercises, begin at distal joints and work toward proximal joints.

c. Joints should be moved slowly through the range of motion. Quick movement could cause injury.

REF: Text Reference: p. 1434

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