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Chapter 33

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Mobility

Questão 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?

Selecione uma das seguintes:

  • Tendons

  • Ligaments

  • Cartilage

  • Joints

Explicação

Questão 2 de 58

1

Why are mechanical aids necessary for patient handling and movement?

Selecione uma das seguintes:

  • 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.

Explicação

Questão 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?

Selecione uma das seguintes:

  • Isotonic

  • Isokinetic

  • Isometric

  • Aerobic

Explicação

Questão 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?

Selecione uma das seguintes:

  • Fluid volume excess

  • A contracture

  • Osteoporosis

  • Negative nitrogen balance

Explicação

Questão 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?

Selecione uma das seguintes:

  • Improved renal blood supply to the kidneys

  • Urinary stasis

  • Decreased urinary calcium

  • Acidic urine formation

Explicação

Questão 6 de 58

1

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

Selecione uma das seguintes:

  • Dorsal recumbent position

  • Lateral position

  • Fowler’s position

  • Sims’ position

Explicação

Questão 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?

Selecione uma das seguintes:

  • 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.

Explicação

Questão 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?

Selecione uma das seguintes:

  • 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

Explicação

Questão 9 de 58

1

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

Selecione uma das seguintes:

  • Lie prone for 1 hour

  • Bathe him- or herself

  • Raise the foot off the bed 1 inch

  • Sit up in bed for 1 hour

Explicação

Questão 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?

Selecione uma das seguintes:

  • 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

Explicação

Questão 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?

Selecione uma das seguintes:

  • 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

Explicação

Questão 12 de 58

1

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

Selecione uma das seguintes:

  • 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

Explicação

Questão 13 de 58

1

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

Selecione uma das seguintes:

  • 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

Explicação

Questão 14 de 58

1

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

Selecione uma das seguintes:

  • 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

Explicação

Questão 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?

Selecione uma das seguintes:

  • 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

Explicação

Questão 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?

Selecione uma das seguintes:

  • 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.

Explicação

Questão 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:

Selecione uma das seguintes:

  • 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.

Explicação

Questão 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?

Selecione uma das seguintes:

  • 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.

Explicação

Questão 19 de 58

1

A physiologic risk associated with immobility is:

Selecione uma das seguintes:

  • Increased cardiac workload

  • Decreased serum calcium level.

  • Increased peristalsis

  • Increased fibrinolysis

Explicação

Questão 20 de 58

1

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

Selecione uma das seguintes:

  • Patient complains of fatigue.

  • Urinary output of 50 ml an hour.

  • Whilte blood cell count of 9.5

  • Absence of bowel sounds

Explicação

Questão 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:

Selecione uma das seguintes:

  • Decreasing calcium intake.

  • Making the urine more alkaline.

  • Monitoring intake and output.

  • Encouraging Kegel's exercises.

Explicação

Questão 22 de 58

1

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

Selecione uma das seguintes:

  • 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.

Explicação

Questão 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?

Selecione uma das seguintes:

  • 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.

Explicação

Questão 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:

Selecione uma das seguintes:

  • 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.

Explicação

Questão 25 de 58

1

Immobility impacts the cardiovascular system by:

Selecione uma das seguintes:

  • Decreasing the cardiac response to activity.

  • Improving venous return.

  • Increasing cardiac output.

  • Increasing cardiac efficiency.

Explicação

Questão 26 de 58

1

Passive range of motion for the immobilized older patient:

Selecione uma das seguintes:

  • 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.

Explicação

Questão 27 de 58

1

Ankylosis is a fixation or immobilization of a joint.

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 28 de 58

1

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

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 29 de 58

1

Contracture is a permanently contracted state of a muscle.

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 30 de 58

1

Flaccidity is decreased muscle tone.

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 31 de 58

1

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

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 32 de 58

1

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

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 33 de 58

1

Isotonic exercise is when muscles shorten and move.

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 34 de 58

1

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

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 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.

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 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).

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 37 de 58

1

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

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 38 de 58

1

Spasticity is decreased muscle tone.

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 39 de 58

1

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

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 40 de 58

1

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

Selecione uma ou mais das seguintes:

  • 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.

Explicação

Questão 41 de 58

1

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

Selecione uma ou mais das seguintes:

  • 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

Explicação

Questão 42 de 58

1

Effects of immobility on the respiratory system:

Selecione uma das seguintes:

  • 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

Explicação

Questão 43 de 58

1

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

Selecione uma ou mais das seguintes:

  • Increased cardiac workload

  • Orthostatic hypertension

  • Decrease in thrombus formation

Explicação

Questão 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.

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 45 de 58

1

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

Selecione uma ou mais das seguintes:

  • Muscle wasting

  • Increased appetite

  • Fluid and Electrolyte balance

  • GI disturbances

Explicação

Questão 46 de 58

1

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

Selecione uma ou mais das seguintes:

  • Decreased tone and motility

  • Decreases digestion

  • Improves elimination

  • Strengthens abdominals

Explicação

Questão 47 de 58

1

Effects of immobility on the gastrointestinal system are:

Selecione uma das seguintes:

  • 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

Explicação

Questão 48 de 58

1

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

Selecione uma ou mais das seguintes:

  • Increases muscle mass, tone, and strength

  • Improves coordination

  • Prevents osteoporosis

  • Prevents contractures

  • Improves joint flexibility

  • Increases fatigue

Explicação

Questão 49 de 58

1

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

Selecione uma ou mais das seguintes:

  • Osteoporosis

  • Contractures

  • Improved muscle coordination

  • Muscle weakness and atrophy

Explicação

Questão 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.

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 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.

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 52 de 58

1

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

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 53 de 58

1

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

Selecione uma ou mais das seguintes:

  • Put pillows under your knees

  • Massage the calves

  • No tight knee high socks

  • Isometric exercises and ankle circles

  • Cross your legs for comfort

Explicação

Questão 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.

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 55 de 58

1

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

Selecione uma ou mais das seguintes:

  • Decline in muscle strength

  • Decreased respiratory vital capacity

  • Increase in transport of oxygenated blood of tissue

  • Decreased range of motion

  • Increase stability of gait

Explicação

Questão 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

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 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

Selecione uma das opções:

  • VERDADEIRO
  • FALSO

Explicação

Questão 58 de 58

1

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

Selecione uma das seguintes:

  • 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.

Explicação

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