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Mobility

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Chapter 33
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Resumen del Recurso

Pregunta 1

Pregunta
What term would the nurse use to identify the strong, flexible, inelastic fibrous bands and flattened sheets of connective tissue that attach muscle to bone?
Respuesta
  • Tendons
  • Ligaments
  • Cartilage
  • Joints

Pregunta 2

Pregunta
Why are mechanical aids necessary for patient handling and movement?
Respuesta
  • Nurses do not have sufficient training using proper body mechanics to be safe.
  • Manual lifting techniques are not sufficient to protect nurses from injury.
  • They reduce the time and number of staff needed to move the patient.
  • Nurses are not as physically fit as they should be.

Pregunta 3

Pregunta
A patient performs rehabilitative exercises with resistance after a knee injury. The nurse interprets this type of exercise as which of the following?
Respuesta
  • Isotonic
  • Isokinetic
  • Isometric
  • Aerobic

Pregunta 4

Pregunta
Which of the following would the nurse expect to assess when a patient experiences a greater breakdown of protein than that which is manufactured?
Respuesta
  • Fluid volume excess
  • A contracture
  • Osteoporosis
  • Negative nitrogen balance

Pregunta 5

Pregunta
When explaining the cause of frequent urinary tract infections related to immobility, the nurse understands that immobility may result in which of the following?
Respuesta
  • Improved renal blood supply to the kidneys
  • Urinary stasis
  • Decreased urinary calcium
  • Acidic urine formation

Pregunta 6

Pregunta
Mr. Brown is experiencing some difficulty breathing. The nurse most appropriately assists him into which position?
Respuesta
  • Dorsal recumbent position
  • Lateral position
  • Fowler’s position
  • Sims’ position

Pregunta 7

Pregunta
While doing range-of-motion exercises with a patient who is bedridden, the nurse is aware of which of the following considerations?
Respuesta
  • Neck hyperextension should be encouraged, particularly in older people.
  • Exercises should be continued until the patient is fatigued.
  • Exercises should be done frequently to lessen pain for the patient.
  • Each joint is exercised to the point of resistance but not pain.

Pregunta 8

Pregunta
The nurse is assisting a patient with conditioning exercises to prepare for ambulation. The nurse correctly instructs the patient to do what?
Respuesta
  • Do full-body pushups in bed six to eight times daily
  • Breathe in and out smoothly during quadriceps drills
  • Dangle on the side of the bed for 30 to 60 minutes
  • Allow the nurse to bathe the patient completely to prevent fatigue

Pregunta 9

Pregunta
In many situations, a patient has sufficient strength to walk if he or she can do which of the following?
Respuesta
  • Lie prone for 1 hour
  • Bathe him- or herself
  • Raise the foot off the bed 1 inch
  • Sit up in bed for 1 hour

Pregunta 10

Pregunta
Mrs. Eden tells the nurse she feels faint while walking in the corridor with the nurse. What should the nurse do?
Respuesta
  • Instruct the patient to quicken her pace so they can return to her room
  • Leave her momentarily to find another nurse to help
  • Advise her to look down at her feet to help maintain her balance
  • Guide her to a nearby chair, easing her onto it to rest

Pregunta 11

Pregunta
When a patient is using a cane for maximal support, the nurse is aware that the patient should do which of the following?
Respuesta
  • Hold the cane on the weaker side
  • Distribute weight evenly between the feet and the cane
  • Keep the elbow that is holding the cane straight and stiff
  • Advance the weaker foot ahead of the cane

Pregunta 12

Pregunta
The use of patient care ergonomics is associated with which of the following patient outcomes?
Respuesta
  • Increased patient comfort, security, and dignity during lifts and transfers
  • Increased patient falls, skin tears, and abrasions
  • Decreased patient movement and independence
  • Increased friction and shearing

Pregunta 13

Pregunta
Which of the following should the nurse do when assisting the patient to ambulate?
Respuesta
  • Place a hand under the axilla to provide support
  • Ensure the patient walks as far as possible for as long as possible
  • Use a gait belt to provide support
  • Encourage the patient to watch their feet to ensure a steady gait

Pregunta 14

Pregunta
When working with an older patient to develop an exercise program, the nurse would recommend which of the following?
Respuesta
  • A frequency of six times a week
  • Exercising to the point of breathlessness when trying to speak
  • Maintaining a target heart rate of 220 plus age
  • Obtaining medical clearance before beginning the program

Pregunta 15

Pregunta
A bedridden patient who is blind is admitted to a healthcare facility from his or her home with pressure ulcers on the sacral area. Which nursing diagnosis would be a priority?
Respuesta
  • Risk for Imbalanced Body Temperature related to stage 2 pressure ulcer
  • Impaired Skin Integrity related to immobility
  • Feeding Self-Care Deficit related to blindness
  • Activity Intolerance related to prolonged bed rest

Pregunta 16

Pregunta
During the evaluation phase of the nursing process, which finding indicates that the nursing care plan for the immobilized patient has been ineffective?
Respuesta
  • The patient instructs the nurses how to do his care.
  • The patient exhibits a negative Homan sign and bilaterally equal calf measurements.
  • The patient exhibits decreased breath sounds in the bases and adventitious sounds are present on expiration in the lower lobes.
  • During passive ROM, the patient's ankle will perform eversion, inversion, dorsiflexion and plantar flexion.

Pregunta 17

Pregunta
The nurse is preparing to assist an adult patient to move from the bed to the chair. To increase balance and stabililty, the nurse should:
Respuesta
  • Use minor muscle groups to their fullest advantage.
  • Increase the base of support and lower the center of gravity.
  • Rock forward and help push the client to the chair.
  • Alter the client's center of gravity by raising his arms.

Pregunta 18

Pregunta
A patient has been on bedrest in cervical traction for 2 weeks. The traction is discontinued and the patient is to ambulate. Prior to getting the patient out of bed, it is imperative for the nurse to do which of the following initially?
Respuesta
  • Get a neck brace for the patient.
  • Provide the patient with a cane.
  • Raise the head of the bed slowly.
  • Assess lower leg muscle strength.
  • Remove elastic stockings (TED) hose to improve circulation to the legs.

Pregunta 19

Pregunta
A physiologic risk associated with immobility is:
Respuesta
  • Increased cardiac workload
  • Decreased serum calcium level.
  • Increased peristalsis
  • Increased fibrinolysis

Pregunta 20

Pregunta
Which assessment of the immobilized patient would prompt the nurse to take further action?
Respuesta
  • Patient complains of fatigue.
  • Urinary output of 50 ml an hour.
  • Whilte blood cell count of 9.5
  • Absence of bowel sounds

Pregunta 21

Pregunta
When caring for a patient on prolonged bedrest, the nurse can help prevent the formation of kidney stones (renal calculi) by:
Respuesta
  • Decreasing calcium intake.
  • Making the urine more alkaline.
  • Monitoring intake and output.
  • Encouraging Kegel's exercises.

Pregunta 22

Pregunta
The patient tells the nurse she feel faint while walking in the hall with the nurse. The nurse
Respuesta
  • Instructs the patient to quicken her pace so they can return her to her room.
  • Leaves her momentarily to find another nurse to help.
  • Advises her to look down at her feet to help maintain her balance.
  • Guides her to a chair in the hall and eases her onto the chair.

Pregunta 23

Pregunta
If you are working alone, the best way to support an unstable patient when assisting with ambulation is which of the following?
Respuesta
  • Stand behind the patient.
  • Hold the patient's hand.
  • Stand on the patient's weak side.
  • Use a transfer belt with both hands at the patient's waist.

Pregunta 24

Pregunta
The physician orders that a patient with one-sided weakness (hemiparesis) be transferred out of bed to a chair twice a day. The nurse plans to:
Respuesta
  • Pivot the patient on the unaffected leg.
  • Stand next to the patient's affected side.
  • Stand next to the patient's strong side.
  • Keep the patient's feet together.

Pregunta 25

Pregunta
Immobility impacts the cardiovascular system by:
Respuesta
  • Decreasing the cardiac response to activity.
  • Improving venous return.
  • Increasing cardiac output.
  • Increasing cardiac efficiency.

Pregunta 26

Pregunta
Passive range of motion for the immobilized older patient:
Respuesta
  • Replaces the need for ambulation.
  • Decreases the risk of falls and skin breakdown.
  • Maintains joint flexibility and delays muscle wasting.
  • Increases the risk of deep vein thrombosis.

Pregunta 27

Pregunta
Ankylosis is a fixation or immobilization of a joint.
Respuesta
  • True
  • False

Pregunta 28

Pregunta
Atrophy is an increase in the size of a body structure.
Respuesta
  • True
  • False

Pregunta 29

Pregunta
Contracture is a permanently contracted state of a muscle.
Respuesta
  • True
  • False

Pregunta 30

Pregunta
Flaccidity is decreased muscle tone.
Respuesta
  • True
  • False

Pregunta 31

Pregunta
Isokinetic exercise involves muscle contractions with resistance varying at a constant rate.
Respuesta
  • True
  • False

Pregunta 32

Pregunta
Isometric exercise is when muscle tension occurs without a significant change in muscle length.
Respuesta
  • True
  • False

Pregunta 33

Pregunta
Isotonic exercise is when muscles shorten and move.
Respuesta
  • True
  • False

Pregunta 34

Pregunta
Cartilage is tough fibrous bands that bind joints together and connect bones.
Respuesta
  • True
  • False

Pregunta 35

Pregunta
Ligaments are hard nonvascular connective tissue found in the joints as well as in the nose, ear, thorax, trachea, and larynx.
Respuesta
  • True
  • False

Pregunta 36

Pregunta
Negative nitrogen balance is a condition resulting in muscle wasting and decreased physical energy for movement and work (e.g., anorexia nervosa and certain cancers).
Respuesta
  • True
  • False

Pregunta 37

Pregunta
Passive exercise is manual or mechanical means of moving the joints.
Respuesta
  • True
  • False

Pregunta 38

Pregunta
Spasticity is decreased muscle tone.
Respuesta
  • True
  • False

Pregunta 39

Pregunta
Tendons are strong, flexible, inelastic fibrous bands that attach muscle to bone.
Respuesta
  • True
  • False

Pregunta 40

Pregunta
Effects of exercise on the cardiovascular system (select all that apply):
Respuesta
  • Increased cardiac output.
  • Increased resting heart rate.
  • Increased heart efficiency/ improved myocardial contraction.
  • Increased fibrinolysin- removes small clots
  • Decreased venous return-decreased return to the heart.

Pregunta 41

Pregunta
Effects of exercise on the respiratory system (select all that apply):
Respuesta
  • Increased rate and depth followed by quicker return to resting rate
  • Decreased gas exchange
  • Increased work of breathing
  • Improved diaphragmatic excursion
  • Quicker return to resting rate

Pregunta 42

Pregunta
Effects of immobility on the respiratory system:
Respuesta
  • Hypostatic Pneumonia: pulmonary congestion due to the stagnation of blood in the dependent portions of the lungs in old persons or in those who are ill and lie in the same position for long periods
  • Atelectasis: complete or partial collapse of the lungs
  • Decreased lung expansion
  • Generalized respiratory muscle weakness
  • Stasis of secretions
  • All of the above

Pregunta 43

Pregunta
Effects on immobility on the cardiovascular system (select all that apply):
Respuesta
  • Increased cardiac workload
  • Orthostatic hypertension
  • Decrease in thrombus formation

Pregunta 44

Pregunta
Increased metabolic rate, triglyceride breakdown increased, gastric motility, and increased production of body heat are effects of exercise on the metabolic process.
Respuesta
  • True
  • False

Pregunta 45

Pregunta
Effects of immobility on the metabolic process (select all that apply):
Respuesta
  • Muscle wasting
  • Increased appetite
  • Fluid and Electrolyte balance
  • GI disturbances

Pregunta 46

Pregunta
Effects of exercise on the gastrointestinal system (select all that apply):
Respuesta
  • Decreased tone and motility
  • Decreases digestion
  • Improves elimination
  • Strengthens abdominals

Pregunta 47

Pregunta
Effects of immobility on the gastrointestinal system are:
Respuesta
  • Disturbances in appetite, decreased food intake, altered protein metabolism, and poor digestion and utilization of food.
  • Weight gain, if food intake increases and energy expenditure decreases
  • Normal muscular activity in the GI tract also slows down resulting in: constipation, poor defecation reflexes, and inability to expel feces and gas adequately
  • Weak muscles, decreased peristalsis, decreased defecation stimulus, postponed defecation, lack of dietary fiber, dehydration
  • All of the above

Pregunta 48

Pregunta
Effects of exercise on the musculoskeletal system (select all that apply):
Respuesta
  • Increases muscle mass, tone, and strength
  • Improves coordination
  • Prevents osteoporosis
  • Prevents contractures
  • Improves joint flexibility
  • Increases fatigue

Pregunta 49

Pregunta
Immobility to the musculoskeletal system can cause (select all that apply):
Respuesta
  • Osteoporosis
  • Contractures
  • Improved muscle coordination
  • Muscle weakness and atrophy

Pregunta 50

Pregunta
Effects of exercise on the integument system can cause a decrease in circulation to the skin and causes prolonged pressure to part.
Respuesta
  • True
  • False

Pregunta 51

Pregunta
Decubitus ulcers are pressure from bed or chair, decreased blood flow to skin, less oxygen and nutrients to skin=ischemia, decreased intake of nutrients.
Respuesta
  • True
  • False

Pregunta 52

Pregunta
Effects of exercise on the urinary system improves flow to the kidneys and decreases efficiency of waste excretions.
Respuesta
  • True
  • False

Pregunta 53

Pregunta
For a cardiovascular intervention, you would teach the patient to (select all that apply):
Respuesta
  • Put pillows under your knees
  • Massage the calves
  • No tight knee high socks
  • Isometric exercises and ankle circles
  • Cross your legs for comfort

Pregunta 54

Pregunta
Interventions to Prevent/Manage Postural Hypotension are apply graduated compression stockings and Pneumatic Compression Devices, move patient slowly out of bed: allow to sit on side of bed, then slowly stand, and the first time the person is up, have a second person available for support.
Respuesta
  • True
  • False

Pregunta 55

Pregunta
Musculoskeletal changes in aging patients (select all that apply):
Respuesta
  • Decline in muscle strength
  • Decreased respiratory vital capacity
  • Increase in transport of oxygenated blood of tissue
  • Decreased range of motion
  • Increase stability of gait

Pregunta 56

Pregunta
Gastrointestinal Interventions: 1) Collaborate with nutritionist to provide high fiber foods 2) Consult physician about bulk laxative, stool softener, or stimulant laxative if needed 3) Help to bathroom, use bedside commode, put bedpan on chair 4) Encourage fluid intake 5) Early mobility
Respuesta
  • True
  • False

Pregunta 57

Pregunta
Respiratory Interventions: 1) Turn q2h to inflate lungs and move secretions 2) Dry air 3) Provide 500 ml of fluids daily 4) Instruct patient in use of incentive spirometer 5) Suction machine at bedside if patient is weak
Respuesta
  • True
  • False

Pregunta 58

Pregunta
Differentiate the roles of the RN and the LPN in the care of patients with altered mobility:
Respuesta
  • RN will perform the patient goals and LPN will determine what the patients goals are.
  • RN will determine what the patients goals are and the LPN will perform the patient goals.
  • RN will determine what the patient goals are and perform them, the LPN will observe.
  • LPN will determine what the patient goals are and perform them, the RN will observe.
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