ACTUAL EXAM WITH CORRECT

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NUR-215 EXAM 2

ACTUAL EXAM WITH CORRECT

SOLUTIONS.

Discuss the three components of mobility - correct answer- - ROM -gait -exercise

Write nursing interventions and rationale for the following

nursing diagnoses: Impaired physical mobility, and activity

intolerance r/t excess weight - correct answer-

Describe "helping a pt to walk" in the acute care setting - correct answer- - asses patient risk to determine how much assistance is needed

• explain procedure to pt
• begin by sitting pt on side of bed for a few minutes w/ leg

dangling (ensure proper footwear)

• (apply gait belt if required) walk behind pt in case of falling risk

Describe positioning pt's and what the nurse might do before doing so - correct answer- - assess pt strength, vital signs, coordination, and balance 1 / 3

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• carefully lay pt on side and assist to sitting position
• allow pt to sit on bed for 1-2 mins with feet dangling (prevent

injury and maintain safety)

Discuss the use of canes and walkers in the healthcare setting and teaching pts - correct answer- - assistive devices are used when pt cannot bear full weight

• can reduce the risk of falling, decrease pain with mobility,

improve balance

- Walkers: can be used by pt who has lower extremity

weakness or has problems with balance, walkers w/ wheels are useful for pts who have difficulty lifting/advancing the walker b/c of limited balance or endurance

Disadvantage: walker can roll forwards when eight is applied,

teach pt ow to use walkers safely and avoid risk of falling

- Canes: canes provide less support than a walker and are less

stable, most common is straight legged cane, have pt keep cane on stronger side of body, cane should be placed forward keeping body weight on both legs

Define passive and active ROM: How does an RN provide

passive ROM? When would they provide it? Purpose of ROM?

- correct answer- - active ROM: exercise to the joint by pt while

doing ADLs or during joint assessment

- passive ROM: range of movement through which a joint is

moved with ASSISTANCE 2 / 3

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• RN provides passive rom by assisting pt with joint movement,

it is provided when pt cannot perform active ROM

• Purpose of ROM is to assess for max amount of movement

available at joint in one of three planes of body (sagittal, frontal, transverse)

Concerning mobility (turning pts) what can you delegate to NAP? - correct answer- NAP can use effective transfer

techniques ie: bed to chair, sitting, log rolling, bed to

bed/stretcher Can also move/position pts in bed (lateral, semi fowler, supine)

Discuss how pts in acute care are affected by immobility by system (respiratory, cardiac, etc.) and the nursing interventions to combat each. What assessment types might you use for

each system? - correct answer- - METABOLIC CHANGES:

decreased metabolic rate (altering the metabolism of nutrients, fluid, electrolyte and calcium imbalance, decreased appetite, slowing peristalsis)

INTERVENTIONS: assess, monitor lab work, encourage

intake, provide high protein, high salorie diet w/ vitamin B and C supplements

- RESPIRATORY CHANGES: atelectasis (partial/complete

collapse of lung), hypostatic pneumonia

INTERVENTIONS: assess, encourage pts to cough and deep

breath ever 1-2 hrs, assist in mobilizing secretions

- CARDIOVASCULAR CHANGES: orthostatic hypotension,

increased cardiac workload, thrombus (clot) formation

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