Chapter 21: Immobility
Linton: Introduction to Medical–Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. What negative effects does immobilization have on the musculoskeletal system?
a.
Demineralization of bone
b.
Increase in aerobic capacity
c.
Increased muscle oxidation
d.
Lengthening of muscle fibers
2. What should the nurse be aware is the best prevention of immobility-related disorders?
a.
Dietary supplements
b.
Fluids
c.
Adequate fiber
d.
Exercise
3. A nurse’s assessment reveals an area of erythema on an immobilized patient’s sacrum. What
is the initial nursing action?
a.
Apply a wet-to-dry dressing.
b.
Massage the reddened area.
c.
Reposition the patient.
d.
Rub the area with alcohol.
4. A nurse is providing discharge instructions to the family of an older adult patient who is
unable to get out of bed. What should the nurse instruct the family regarding the most
effective way to prevent urinary incontinence associated with immobility?
a.
Use absorbent underpads.
b.
Set up a toileting program.
c.
Restrict fluid intake to 500 mL per 24 hours.
d.
Restrict fluids after dinner and throughout the night.
5. The care plan of an older adult patient states that the patient should be monitored while in the
bathroom because of a history of vasovagal reflex. What should the nurse assess with this
patient?
a.
Extremely elevated blood pressure after ambulation
b.
Nausea and vomiting after a meal
c.
Lightheadedness and fainting during defecation
d.
Inability to urinate
6. What is the most effective intervention to prevent constipation in a patient who recently
sustained a fractured femur and is currently in traction?
a.
Get the patient up and to the bathroom at least twice each day.
b.
Administer enemas each day until the patient has a bowel movement.
c.
Administer pain medication to prevent pain during defecation.
d.
Encourage a high-fiber diet and increased amounts of fluids.
7. A nurse caring for a patient who has been prescribed bed rest for 1 week notices a reddened
area on the patient’s left hip. The skin is intact, but when the nurse presses on the area, the
redness does not fade. How should this area of pressure be classified?
a.
Stage I
b.
Stage II
c.
Stage III
d.
Stage IV
8. What action should the nurse implement when positioning an immobile patient?
a.
Ensure that the patient’s knees and hips are flexed.
b.
Visualize how a person looks while standing and try to have the patient achieve
that position while lying down.
c.
Reposition the patient no more often than every 4 hours.
d.
Always position the patient on his or her back with the head raised to prevent
aspiration.
9. What intervention is most appropriate to prevent respiratory complications resulting from
immobility?
a.
Suction every 4 to 6 hours.
b.
Administer pain medications as frequently as possible.
c.
Teach the patient the technique of pursed lip breathing.
d.
Reposition the patient, and encourage him or her to cough and deep breathe at least
every 2 hours.
10. A nurse transcribes a discharge order for the patient with left-sided weakness after having a
stroke indicating to teach the patient to perform range-of-motion exercises on affected
extremities. The patient asks why she needs to do range-of-motion exercises. What is the
nurse’s best response?
a.
“Because the physician has ordered it.”
b.
“You will regain full use of your arm and leg if you will do the exercises
correctly.”
c.
“They prevent the muscles and tendons from shortening and becoming
unmovable.”
d.
“It will give you something to do because you can’t work anymore.”
11. A nurse assesses a patient’s risk for developing a pressure ulcer using the Norton scale. The
patient’s score is 18. What nursing action should be implemented?
a.
Call the physician immediately.
b.
Implement a pressure ulcer prevention program.
c.
Document the score.
d.
Order an alternating air mattress.
12. A patient in traction with a fractured hip is diagnosed with a stage I pressure ulcer. She asks
the nurse how a pressure ulcer could occur after only 2 days of immobility. On what
knowledge should the nurse base a response?
a.
“Erythema can occur in 1 to 2 hours even in a person with healthy skin and
adequate circulation.”
b.
“It takes several days for a pressure ulcer to form.”
c.
“The pressure ulcer probably occurred when you fell.”
d.
“The cause of pressure ulcers isn’t really known.”
13. A patient is complaining to the nurse that he feels the need to have a bowel movement but has
not been able to defecate. He has had cramping and even a small amount of brown watery
stool. What should the nurse recognize these symptoms as?
a.
Diarrhea
b.
Fecal incontinence
c.
Fecal impaction
d.
Flatulence
14. During the shift report, a nurse is told that a patient she will be caring for has a stage II
pressure ulcer. What should the nurse expect to visualize during the dressing change?
a.
Ulcer that appears black with possible signs of infection
b.
Shallow ulcer that appears blistered, cracked, or abraded
c.
Craterlike sore with a distinct outer margin formed as the epidermis thickens and
rolls over the edge toward the ulcer base
d.
Redness of skin with no ulceration
15. When preparing a plan care for an older adult patient, a nurse should consider the common
problems associated with immobility. What should these problems be classified as?
a.
Environmental and intellectual
b.
Internal and external
c.
Mental and medical
d.
Physical and psychosocial
16. How does the National Pressure Ulcer Advisory Panel prefer to refer to skin breakdown?
a.
Bed sores
b.
Pressure ulcers
c.
Decubitus ulcers
d.
Decubiti
17. A patient complains that his “bottom” is sore. The nurse assesses the area and finds an open
area on the sacrum that appears blistered. What action should the nurse implement?
a.
Document the cause of the burn.
b.
Clean with alcohol, apply moisturizer, and cover with a set dressing.
c.
Massage the area to promote circulation.
d.
Clean with mild soap, dry, and apply a light dressing.
18. A nurse is performing a wet-to-dry dressing change on a stage IV pressure ulcer. What is the
purpose of this type of dressing?
a.
Keep the wound moist.
b.
Prevent infection.
c.
Débride necrotic tissue.
d.
Increase circulation to the tissue.
19. A nursing assistant is bathing a patient who has a stage I pressure ulcer on the right shoulder.
What action by the health care team could cause that the tissue to become more damaged?
a.
Positioning the patient on the left side
b.
Massaging the reddened area
c.
Cleaning the area with mild soap and water
d.
Positioning the patient in a prone position
20. A nurse is planning the care of a patient who is immobile. Why should the nurse consider this
patient to be at risk for urinary tract infection?
a.
Urine will pool in the bladder when the patient remains in a supine position.
b.
The patient is likely to have urinary incontinence.
c.
The patient’s appetite may be decreased.
d.
The patient may not be able to move quickly enough to get to the bathroom.
21. What should the nurse instruct a patient in a wheelchair to do to decrease risk for pressure
ulcers?
a.
Use a ring pillow on the seat of the chair.
b.
Lift the weight of the body using the arms of the wheelchair every 15 minutes.
c.
Scoot forward and back in the seat to stimulate circulation.
d.
Wear underwear that holds moisture close to skin.
22. A nurse is instructing a patient on performing isometric exercises. What instruction should the
nurse include?
a.
Contract the muscle for several seconds, then relax the muscle for a few seconds,
and contract it again.
b.
Perform full range-of-motion exercises of each joint.
c.
Have a family member perform full range-of-motion exercises on each of the
patient’s joints.
d.
Stand in front of a wall and push with the arms without bending the elbow.
23. A nurse is talking with a patient who recently became paraplegic as a result of a cervical
spinal cord injury. When some home equipment is discussed, the patient becomes angry and
says, “I don’t need to worry about any kind of home equipment.” What is the best response by
the nurse?
a.
“I know you will be walking soon, but you may need some equipment until then.”
b.
“There is very little chance that you will ever walk.”
c.
“Tell me what it is about this equipment that bothers you.”
d.
“Let me call the physician to come explain your injuries to you.”
24. During a skin integrity assessment, a nurse notices an area on the right heel that is black and
draining purulent, foul-smelling exudate. How should the nurse document this as a pressure
ulcer?
a.
Stage I
b.
Stage II
c.
Stage III
d.
Stage IV
25. What is the classification of incontinence in older adults related to the inability to get to the
bathroom in time?
a.
Stress incontinence
b.
Urge incontinence
c.
Functional incontinence
d.
Sporadic incontinence
26. Which are characteristics of a stage I pressure ulcer? (Select all that apply.)
a.
The area is regular and well defined.
b.
Tissue hardening is present.
c.
Swelling has occurred at the site.
d.
The condition is reversible.
e.
Nonblanching erythema is observed.
27. What should a nurse document when assessing a new pressure ulcer? (Select all that apply.)
a.
Precise measurement of the ulcer
b.
Location of the wound and its description
c.
Color of the ulcer
d.
Amount and characteristics of the drainage
e.
Probable cause of the ulcer
28. What therapeutic reasons exist that explain why a patient might become immobile? (Select all
that apply.)
a.
Reduction of the workload of the heart
b.
Fear of falling
c.
Reversal of the effects of gravity
d.
Bereavement
e.
Healing of a fracture
COMPLETION
29. A home health nurse instructs a family about boosting the patient in bed so that a(n) _____
type of skin injury will not occur.
30. A nurse evaluates the effectiveness of the treatment for a stage III pressure ulcer as
satisfactory when the bed of the ulcer is pink, indicating the presence of _____, which is an
indicator of tissue perfusion.
31. A nurse takes into consideration that such emotions as worry, anxiety, and depression can
contribute to the common nutritional problem of _____.
32. When bacteria are localized at the site of a stage III pressure ulcer, it is said to be _____.
33. The negative impact of immobilization on a patient depends on the duration, degree, and type
of _____.