Test bank chapter 28 for there of nursing -TEST-BANK\\ 28 PDF

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Chapter 28: Activity, Immobility, and Safe Movement Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative Practice, 2nd Edition MULTIPLE CHOICE 1. What response would the nurse give the patient when questioned about the effect of

rheumatoid arthritis on the musculoskeletal system? a. Muscle weakness b. Muscle wasting c. Joint inflammation d. Joint spasticity ANS: C

Rheumatoid arthritis and osteoarthritis cause inflammation of joints, resulting in pain and limited joint mobility, not muscle mobility. Genetic disorders such as muscular dystrophy result in muscle weakness and gradual muscle wasting. Spasticity (increased muscle tone) occurs in developmental disorders, such as cerebral palsy, and results in reduced range of motion (ROM) and abnormal movement patterns. DIF: Understanding OBJ: 28.2 MSC: NCLEX Client Needs Category: Physiological Integrity

TOP: Assessment NOT: Concepts: Mobility

2. The nurse is implementing generalized falls precautions for patients who are at risk for falls.

Which intervention indicates a lack of understanding of these precautions? The bed is placed in the low position. The patient is wearing socks. The patient’s cell phone is by the bedside. The patient’s call light is within reach.

a. b. c. d.

ANS: B

If the patient is ambulatory, require the use of nonskid footwear. Socks can be slippery unless they have a grip surface on them. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient’s reach. Keep the call light in reach and remind the patient to use it and keep the bed in the low position. DIF: Understanding OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment NOT: Concepts: Mobility 3. The nurse is educating the family of a patient on falls risk precautions. Which statement by

the family indicates a need for further education? a. “I should keep the wheelchair locked unless using it to move Mom.” b. “I should leave the bathroom light on as she does at her home.” c. “I should leave her slippers by the wheelchair.” d. “I should keep her cell phone close to her bed.” ANS: C

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Leave lights on or off at night, depending on the patient’s cognitive status and personal preference. Keep the wheels of any wheeled device (e.g., bed, wheelchair) in the locked position. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient’s reach. If the patient is ambulatory, require the use of nonskid footwear (socks or shoes). DIF: Applying OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment NOT: Concepts: Mobility 4. The nurse is performing passive range-of-motion exercises on a patient when the patient

begins to complain of pain. What is the first thing the nurse should do? a. Notify the health care provider. b. Hyperextend the joint. c. Stop the range of motion. d. Switch to active range of motion. ANS: C

Stop range-of-motion exercises if the patient begins to complain of pain or if resistance to movement is experienced. Never hyperextend or flex a patient’s joints beyond the position of comfort. Active range of motion is when the patient moves the joint. Notifying the health care provider would happen later. DIF: Understanding OBJ: 28.3 MSC: NCLEX Client Needs Category: Physiological Integrity

TOP: Implementation NOT: Concepts: Mobility

5. The nurse recognizes which goal to be appropriate for the patient who is postoperative day

one from a hip fracture with the nursing diagnosis Impaired mobility? a. Patient will interact with others. b. Patient will ambulate to the bathroom with assistance. c. Patient will have no skin breakdown. d. Patient will have a physical therapy consult. ANS: B

Patients with a diagnosis of Impaired mobility should have a goal aimed at improving their mobility. Although immobility can impact social isolation and skin breakdown, those goals are not appropriate for this diagnosis. Have a physical therapy consult is not a goal but an intervention. DIF: Applying OBJ: 28.5 TOP: Diagnosis MSC: NCLEX Client Needs Category: Physiological Integrity

NOT: Concepts: Mobility

6. The nurse identifies which goal to be appropriate for the patient who is postoperative day one

from abdominal surgery and on bed rest with the nursing diagnosis impaired skin integrity? a. Patient will ambulate twice a day. b. Patient will eat 50% of meals. c. Patient will have no further skin breakdown. d. Patient will interact with others. ANS: C

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The patient already has a wound, so the goal is focused on no further skin breakdown as a result of the bed rest and immobility. Although nutrition is important to wound healing, it is not the focus of this Nursing diagnosis. Ambulating and interacting with others are not goals for this diagnosis. DIF: Analyzing OBJ: 28.5 TOP: Diagnosis MSC: NCLEX Client Needs Category: Physiological Integrity

NOT: Concepts: Mobility

7. The nurse is providing education to the patient about isometric exercises. Which statement by

the patient indicates a good understanding of these exercises? “An example of this type of exercise is walking.” “An example of this type of exercise is running.” “An example of this type of exercise is Kegels.” “An example of this type of exercise is weight lifting.”

a. b. c. d.

ANS: C

Isometric exercise requires tension and relaxation of muscles without joint movement. An example is tension and relaxation of pelvic floor muscles (i.e., Kegel exercise). Isotonic exercise involves active movement with constant muscle contraction, such as walking, turning in bed, and self-feeding. Aerobic exercise requires oxygen metabolism to produce energy. Patients may engage in rigorous walking or repeated stair climbing to achieve the positive effects of aerobic exercise. Anaerobic exercise builds power and body mass. Without oxygen to produce energy for activity, anaerobic exercise takes place, such as heavy weight lifting. DIF: Applying OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: Concepts: Mobility 8. The nurse is preparing to assist the patient to walk to the bathroom after medicating the

patient with a narcotic for pain management. What possible adverse effect should the nurse be immediately aware? a. Constipation b. Depression c. Dizziness d. Pain relief ANS: C

Potential adverse side effects of narcotics include respiratory depression, hypotension, confusion, sedation, constipation, and dizziness. The nurse should be immediately aware of dizziness during ambulation because of the safety risks. Pain relief is expected. Depression is not an immediate adverse side effect. Constipation will not impact the nurse’s ability to safely ambulate the patient. DIF: Applying OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment NOT: Concepts: Mobility 9. The nurse correctly selects which intervention to avoid causing shear or friction when moving

a patient in bed? a. Using an airflow bed b. Using a slide board c. Using a trochanter roll

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d. Using a gel mattress ANS: B

A transfer or slide board is made of plastic-like material that reduces friction. Linens easily slide over the board, facilitating bed linen changes. Patients can be repositioned or transferred with a minimum of force required. A trochanter roll prevents outward rolling of the hip when a patient is lying on his/her back. An air-fluidized bed uses airflow to move silicone particles in the bed, creating a watery, fluid-like movement and resulting in lower pressure to avoid or alleviate decubitus ulcers. A foam or gel combination mattress reduces pressure. DIF: Applying OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment NOT: Concepts: Mobility 10. Which explanation by the nurse best describes active assistive range of motion? a. The patient independently moves all joints. b. The patient to partially moves all joints. c. The caregiver must move the patient’s joints. d. The patient performs isotonic exercises. ANS: B

Active assistive range of motion occurs when the caregiver minimally assists the patient, or the patient minimally assists himself/herself in the movement of joints through a full motion. Active range of motion occurs when the patient has full independent movement of all joints; this is also known as isotonic exercise. Passive range of motion occurs when the caregiver moves the patient’s joints through a full motion. This exercise does not maintain or improve strength but maintains flexibility and prevents contractures and atrophy. DIF: Understanding OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment NOT: Concepts: Mobility 11. The nurse identifies which instruction to be appropriate to delegate to the UAP (Unlicensed

assistive personnel)? a. Assess the patient’s skin during a bath. b. Reposition the patient using the trapeze. c. Assess the patient’s ability to perform range-of-motion exercises. d. Notify the health care provider of any changes. ANS: B

Repositioning a patient can be delegated to unlicensed assistive personnel (UAP); the nurse should provide proper instruction regarding specific positioning techniques, individualized patient concerns, and circumstances that require notifying a nurse. UAP may not perform assessments or evaluations but should notify the nurse about any skin or musculoskeletal issues (not the health care provider). DIF: Understanding OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment NOT: Concepts: Mobility 12. The nurse knows that manual lifting should only be done in which situation? a. Patients who are less than 150 lb

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b. Life-threatening situations c. Postsurgical patients d. Patients who are less than 200 lb ANS: B

Many manual patient handling tasks are unsafe, because the weights lifted and movements required are beyond the ability of most caregivers. The key is to identify the task to be accomplished, and then use the required equipment and personnel so that the task fits the capabilities of the staff (U.S. Department of Veterans Affairs, 2016). The patient’s level of cooperation is taken into consideration when using the safe patient-handling and mobility (SPHM) algorithms to decide the best method of moving the patient. The patient’s weight, medical conditions, and ability to assist are also considered (U.S. Department of Veterans Affairs, 2016). Postsurgical patients as well as patients less than 150 or 200 lb may not fit the criteria. DIF: Understanding OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment NOT: Concepts: Mobility 13. The nurse is preparing to reposition the patient in bed. What is the first step in this process? a. Position the patient’s arms across his/her chest. b. Lower the side rails. c. Grasp the draw sheet. d. Raise the bed to a working height. ANS: D

Raising the bed to a working height is the first step before beginning the procedure. Proper positioning of equipment prevents provider discomfort and reduces the chance of possible injury. Then lower the side rails as appropriate and safe and ensure that the bed wheels are locked. Then you can have the patient position his/her arms and/or grasp the draw sheet. DIF: Applying OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment NOT: Concepts: Mobility 14. The nurse has delegated to the UAP to assist a patient with ambulating in the hallway with a

cane. Which statement by the UAP indicates a need for further education? a. “I should report any complaints of soreness to the nurse.” b. “I should watch for indications that the patient has difficulties using the cane.” c. “I should let the nurse or PT know if the cane doesn’t seem to fit correctly.” d. “I should teach the patient how to walk with the cane.” ANS: D

Educating patients on how to walk with assistive devices may not be delegated to unlicensed assistive personnel (UAP). UAP should report any of the following: noticeable incorrect usage or fit of assistive devices, complaints of soreness or weakness, difficulties involving balance or strength, or difficulties in performing the procedure or other concerns verbalized by the patient. DIF: Applying OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment NOT: Concepts: Mobility

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15. The nurse correctly teaches the patient to rise from a chair using crutches when which

intervention is used? a. Patient starts from the back of the chair. b. The weak leg is closest to the chair. c. The hand on the strong side holds the hand bar of the crutch. d. The strong leg is closest to the chair. ANS: D

The patient’s strongest leg needs to be closest to the chair. The patient’s hand on the weak side holds the hand bar of the crutches, and the hand on the patient’s strong side holds onto the armrest of the chair. The patient moves to the front edge of the chair. DIF: Applying OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment NOT: Concepts: Mobility MULTIPLE RESPONSE 1. The nurse is teaching a patient about ways to decrease risk of bone fractures. Which

statements by the patient indicate a good understanding of decreasing this risk? (Select all that apply.) a. “I should do weight-bearing exercises.” b. “I should get adequate intake of calcium and vitamin D.” c. “I should exercise regularly.” d. “I need to do yoga exercises.” e. “I wish I could reduce my risk but I can’t do anything.” ANS: A, B, C

Inadequate dietary intake of calcium and vitamin D or impaired calcium metabolism may result in osteoporosis, which increases bone fragility and may lead to fractures. Decreased physical exercise and lack of weight-bearing exercise also contribute to bone fragility, deterioration, and loss of strength. Any type of exercise will help; it does not need to be yoga, but it does need to include weight-bearing exercise. DIF: Applying OBJ: 28.2 TOP: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: Concepts: Mobility 2. The nurse knows that a patient with a compromised cardiopulmonary system has a diminished

capacity for exercise because of which conditions? (Select all that apply.) a. Decreased tissue perfusion b. Loss of sensation c. Hemiparesis d. Diminished respiratory capacity e. Muscle weakness ANS: A, D

Compromised cardiac function, decreased tissue perfusion, and diminished respiratory capacity directly affect a person’s ability to perform activities of daily living (ADLs) and exercise. Hemiparesis and loss of sensation are associated with nervous system disorders. Muscle weakness can be from a number of causes.

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DIF: Understanding OBJ: 28.2 MSC: NCLEX Client Needs Category: Physiological Integrity

TOP: Assessment NOT: Concepts: Mobility

3. The nurse is educating the patient about the effects of immobility on the body. Which

statements by the patient indicate a need for further education? (Select all that apply.) a. “I can become very weak.” b. “I will gain weight.” c. “I will lose muscle tone.” d. “I can get bed sores.” e. “I won’t have any lung problems.” ANS: B, E

Immobility may cause weakness, instability, anorexia, elimination alterations, decreased muscle tone, circulatory stasis, DVTs, pulmonary embolism, and skin breakdown. Knowing the effects of immobility on various body systems allows the nurse to quickly assess a patient’s risk and recognize signs of impending complications. DIF: Applying OBJ: 28.3 TOP: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: Concepts: Mobility 4. The nurse knows which items are included in the documentation for a patient on fall

precautions? (Select all that apply.) a. History of any falls b. Falls risk assessment scores c. Patient and family education d. Use of assist devices e. Any fall or reported fall ANS: A, B, C, D, E

The nurse should document the general assessment, include the patient’s medical history, subjective and objective data, medication review, musculoskeletal status, and history of falls. Falls assessment and reassessment, patient family education and use of assist devices are also documented. Thoroughly document a fall or reported fall. DIF: Applying OBJ: 28.2 TOP: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: Concepts: Mobility 5. The nurse knows which findings indicate orthostatic hypotension? (Select all that apply.) a. A decrease in systolic blood pressure by 30 mm Hg b. A decrease in diastolic blood pressure by 10 mm Hg c. An increase in heart rate by 30 beats/min d. An increase in systolic blood pressure by 20 mm Hg e. A decrease in heart rate by 20 beats/min ANS: B, D

A drop in systolic blood pressure of 20 mm Hg, an increase in heart rate of 20 beats/min, or a drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as orthostatic hypotension. DIF: Understanding OBJ: 28.3 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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NOT: Concepts: Mobility 6. The nurse appropriately delegates care of the unit’s patients to the properly trained UAP when

that UAP is assigned which tasks? (Select all that apply.) a. UAP assigned to reposition the patient. b. UAP assigned to complete the MORSE falls risk scale. c. UAP assigned to provide range-of-motion exercises. d. UAP assigned to ambulate the patient in the hallway. e. UAP assigned to time the patient on a TUG test. ANS: A, C, D

UAPs provide hands-on care for immobilized patients under the direct supervision of registered nurses. Turning and positioning of patients, range-of-motion exercises, transfers, and assistance with ambulation may be delegated to properly trained UAP. UAPs may not assess patients because that is a nursing responsibility. The MORSE falls risk scale is a risk assessment as is the Timed Up and Go (TUG) test. DIF: Applying OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment NOT: Concepts: Mobility 7. The nurse is correctly demonstrating the use of a transfer belt when engaging in which

actions? (Select all that apply.) a. The belt is placed around the patient’s hips. b. The belt is secure, leaving only enough room for the nurse to grasp the belt. c. The nurse stands on the weaker side. d. The nurse holds the belt on the side of the patient. e. The nurse stands behind the patient while ambulating. ANS: B, C

Transfer belts are used for patients with an unsteady gait or generalized weakness. Canvas transfer or gait belts are applied snugly around the patient’s waist, leaving only enough room for the nurse to grasp the belt firmly during ambulation. Some belts may have handles. If the patient has a weaker side, the nurse should stand on that side and hold the gait belt firmly at the back of the patient’s waist while ambulating. DIF: Applying OBJ: 28.6 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment NOT: Concepts: Mobility 8. The nurse is correctly assisting the patient in using a cane when the patient demonstrates

which activities? (Select all that apply.) a. The top of the cane is level with the patient’s bent elbow. b. The patient holds the cane on his/her weaker side. c. The patient moves the cane forward first. d. The pa...