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Chapter 33

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Mobility

Pregunta 1 de 58

1

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?

Selecciona una de las siguientes respuestas posibles:

  • Tendons

  • Ligaments

  • Cartilage

  • Joints

Explicación

Pregunta 2 de 58

1

Why are mechanical aids necessary for patient handling and movement?

Selecciona una de las siguientes respuestas posibles:

  • 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.

Explicación

Pregunta 3 de 58

1

A patient performs rehabilitative exercises with resistance after a knee injury. The nurse interprets this type of exercise as which of the following?

Selecciona una de las siguientes respuestas posibles:

  • Isotonic

  • Isokinetic

  • Isometric

  • Aerobic

Explicación

Pregunta 4 de 58

1

Which of the following would the nurse expect to assess when a patient experiences a greater breakdown of protein than that which is manufactured?

Selecciona una de las siguientes respuestas posibles:

  • Fluid volume excess

  • A contracture

  • Osteoporosis

  • Negative nitrogen balance

Explicación

Pregunta 5 de 58

1

When explaining the cause of frequent urinary tract infections related to immobility, the nurse understands that immobility may result in which of the following?

Selecciona una de las siguientes respuestas posibles:

  • Improved renal blood supply to the kidneys

  • Urinary stasis

  • Decreased urinary calcium

  • Acidic urine formation

Explicación

Pregunta 6 de 58

1

Mr. Brown is experiencing some difficulty breathing. The nurse most appropriately assists him into which position?

Selecciona una de las siguientes respuestas posibles:

  • Dorsal recumbent position

  • Lateral position

  • Fowler’s position

  • Sims’ position

Explicación

Pregunta 7 de 58

1

While doing range-of-motion exercises with a patient who is bedridden, the nurse is aware of which of the following considerations?

Selecciona una de las siguientes respuestas posibles:

  • 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.

Explicación

Pregunta 8 de 58

1

The nurse is assisting a patient with conditioning exercises to prepare for ambulation. The nurse correctly instructs the patient to do what?

Selecciona una de las siguientes respuestas posibles:

  • 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

Explicación

Pregunta 9 de 58

1

In many situations, a patient has sufficient strength to walk if he or she can do which of the following?

Selecciona una de las siguientes respuestas posibles:

  • Lie prone for 1 hour

  • Bathe him- or herself

  • Raise the foot off the bed 1 inch

  • Sit up in bed for 1 hour

Explicación

Pregunta 10 de 58

1

Mrs. Eden tells the nurse she feels faint while walking in the corridor with the nurse. What should the nurse do?

Selecciona una de las siguientes respuestas posibles:

  • 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

Explicación

Pregunta 11 de 58

1

When a patient is using a cane for maximal support, the nurse is aware that the patient should do which of the following?

Selecciona una de las siguientes respuestas posibles:

  • 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

Explicación

Pregunta 12 de 58

1

The use of patient care ergonomics is associated with which of the following patient outcomes?

Selecciona una de las siguientes respuestas posibles:

  • 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

Explicación

Pregunta 13 de 58

1

Which of the following should the nurse do when assisting the patient to ambulate?

Selecciona una de las siguientes respuestas posibles:

  • 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

Explicación

Pregunta 14 de 58

1

When working with an older patient to develop an exercise program, the nurse would recommend which of the following?

Selecciona una de las siguientes respuestas posibles:

  • 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

Explicación

Pregunta 15 de 58

1

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?

Selecciona una de las siguientes respuestas posibles:

  • 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

Explicación

Pregunta 16 de 58

1

During the evaluation phase of the nursing process, which finding indicates that the nursing care plan for the immobilized patient has been ineffective?

Selecciona una de las siguientes respuestas posibles:

  • 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.

Explicación

Pregunta 17 de 58

1

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:

Selecciona una de las siguientes respuestas posibles:

  • 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.

Explicación

Pregunta 18 de 58

1

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?

Selecciona una de las siguientes respuestas posibles:

  • 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.

Explicación

Pregunta 19 de 58

1

A physiologic risk associated with immobility is:

Selecciona una de las siguientes respuestas posibles:

  • Increased cardiac workload

  • Decreased serum calcium level.

  • Increased peristalsis

  • Increased fibrinolysis

Explicación

Pregunta 20 de 58

1

Which assessment of the immobilized patient would prompt the nurse to take further action?

Selecciona una de las siguientes respuestas posibles:

  • Patient complains of fatigue.

  • Urinary output of 50 ml an hour.

  • Whilte blood cell count of 9.5

  • Absence of bowel sounds

Explicación

Pregunta 21 de 58

1

When caring for a patient on prolonged bedrest, the nurse can help prevent the formation of kidney stones (renal calculi) by:

Selecciona una de las siguientes respuestas posibles:

  • Decreasing calcium intake.

  • Making the urine more alkaline.

  • Monitoring intake and output.

  • Encouraging Kegel's exercises.

Explicación

Pregunta 22 de 58

1

The patient tells the nurse she feel faint while walking in the hall with the nurse. The nurse

Selecciona una de las siguientes respuestas posibles:

  • 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.

Explicación

Pregunta 23 de 58

1

If you are working alone, the best way to support an unstable patient when assisting with ambulation is which of the following?

Selecciona una de las siguientes respuestas posibles:

  • 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.

Explicación

Pregunta 24 de 58

1

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:

Selecciona una de las siguientes respuestas posibles:

  • 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.

Explicación

Pregunta 25 de 58

1

Immobility impacts the cardiovascular system by:

Selecciona una de las siguientes respuestas posibles:

  • Decreasing the cardiac response to activity.

  • Improving venous return.

  • Increasing cardiac output.

  • Increasing cardiac efficiency.

Explicación

Pregunta 26 de 58

1

Passive range of motion for the immobilized older patient:

Selecciona una de las siguientes respuestas posibles:

  • 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.

Explicación

Pregunta 27 de 58

1

Ankylosis is a fixation or immobilization of a joint.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 28 de 58

1

Atrophy is an increase in the size of a body structure.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 29 de 58

1

Contracture is a permanently contracted state of a muscle.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 30 de 58

1

Flaccidity is decreased muscle tone.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 31 de 58

1

Isokinetic exercise involves muscle contractions with resistance varying at a constant rate.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 32 de 58

1

Isometric exercise is when muscle tension occurs without a significant change in muscle length.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 33 de 58

1

Isotonic exercise is when muscles shorten and move.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 34 de 58

1

Cartilage is tough fibrous bands that bind joints together and connect bones.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 35 de 58

1

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

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 36 de 58

1

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).

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 37 de 58

1

Passive exercise is manual or mechanical means of moving the joints.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 38 de 58

1

Spasticity is decreased muscle tone.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 39 de 58

1

Tendons are strong, flexible, inelastic fibrous bands that attach muscle to bone.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 40 de 58

1

Effects of exercise on the cardiovascular system (select all that apply):

Selecciona una o más de las siguientes respuestas posibles:

  • 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.

Explicación

Pregunta 41 de 58

1

Effects of exercise on the respiratory system (select all that apply):

Selecciona una o más de las siguientes respuestas posibles:

  • 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

Explicación

Pregunta 42 de 58

1

Effects of immobility on the respiratory system:

Selecciona una de las siguientes respuestas posibles:

  • 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

Explicación

Pregunta 43 de 58

1

Effects on immobility on the cardiovascular system (select all that apply):

Selecciona una o más de las siguientes respuestas posibles:

  • Increased cardiac workload

  • Orthostatic hypertension

  • Decrease in thrombus formation

Explicación

Pregunta 44 de 58

1

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

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 45 de 58

1

Effects of immobility on the metabolic process (select all that apply):

Selecciona una o más de las siguientes respuestas posibles:

  • Muscle wasting

  • Increased appetite

  • Fluid and Electrolyte balance

  • GI disturbances

Explicación

Pregunta 46 de 58

1

Effects of exercise on the gastrointestinal system (select all that apply):

Selecciona una o más de las siguientes respuestas posibles:

  • Decreased tone and motility

  • Decreases digestion

  • Improves elimination

  • Strengthens abdominals

Explicación

Pregunta 47 de 58

1

Effects of immobility on the gastrointestinal system are:

Selecciona una de las siguientes respuestas posibles:

  • 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

Explicación

Pregunta 48 de 58

1

Effects of exercise on the musculoskeletal system (select all that apply):

Selecciona una o más de las siguientes respuestas posibles:

  • Increases muscle mass, tone, and strength

  • Improves coordination

  • Prevents osteoporosis

  • Prevents contractures

  • Improves joint flexibility

  • Increases fatigue

Explicación

Pregunta 49 de 58

1

Immobility to the musculoskeletal system can cause (select all that apply):

Selecciona una o más de las siguientes respuestas posibles:

  • Osteoporosis

  • Contractures

  • Improved muscle coordination

  • Muscle weakness and atrophy

Explicación

Pregunta 50 de 58

1

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

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 51 de 58

1

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

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 52 de 58

1

Effects of exercise on the urinary system improves flow to the kidneys and decreases efficiency of waste excretions.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 53 de 58

1

For a cardiovascular intervention, you would teach the patient to (select all that apply):

Selecciona una o más de las siguientes respuestas posibles:

  • Put pillows under your knees

  • Massage the calves

  • No tight knee high socks

  • Isometric exercises and ankle circles

  • Cross your legs for comfort

Explicación

Pregunta 54 de 58

1

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.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 55 de 58

1

Musculoskeletal changes in aging patients (select all that apply):

Selecciona una o más de las siguientes respuestas posibles:

  • Decline in muscle strength

  • Decreased respiratory vital capacity

  • Increase in transport of oxygenated blood of tissue

  • Decreased range of motion

  • Increase stability of gait

Explicación

Pregunta 56 de 58

1

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

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 57 de 58

1

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

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 58 de 58

1

Differentiate the roles of the RN and the LPN in the care of patients with altered mobility:

Selecciona una de las siguientes respuestas posibles:

  • 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.

Explicación

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