Mobility and Immobility Nclex

Mobility and Immobility Nclex 4.7 (9 reviews) Students also studied Terms in this set (15) Science MedicineNursing Save CH 28 Immobility NCLEX questions 14 terms jennfasPreview Medication Administration NCLEX Q...60 terms Spiritinthesky67 Preview Mobility Practice for NCLEX Questio...15 terms lizzyohmesPreview NCLEX 15 terms Tine An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.)

A. B/P = 128/84

• Respirations 26 per minute on room air

C. HR 114

• Crackles heard on auscultation
• Pain reported as 3 on scale of 0 to 10 after medication
• Respirations 26 per minute on room air

C. HR 114

• Crackles heard on auscultation

Patients with reduced mobility are at risk for retained pulmonary secretions, and this risk increases in postoperative patients. As a result of retained secretions, the respiratory rate increases. The heart rate also increases because the heart is trying to improve oxygen levels. These symptoms are of concern for older adults because, if left untreated, further complications such as heart failure can occur.A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my breath." Your first action

is to:

• Call the health care provider to report this change in

condition.

• Give the patient a paper bag to breathe into to

decrease her anxiety.

• Assess her vital signs, perform a respiratory

assessment, and be prepared to start oxygen.

• Explain that this is normal after such trauma and

administer the ordered pain medication.

• Assess her vital signs, perform a respiratory assessment, and be prepared to

start oxygen.These are signs of possible pulmonary emboli, which can be life threatening. You must assess your patient, be prepared to start oxygen, and have someone call the surgeon while you stay with the patient to continue to monitor her status.

The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient

that the stockings are used after a surgical procedure to:

• Prevent varicose veins.
• Prevent muscular atrophy.
• Ensure joint mobility and prevent contractures.
• Promote venous return to the heart.
• Ensure joint mobility and prevent contractures.

Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces the risk for deep vein thrombosis (DVT) formation in the lower extremities.A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education?

• "I usually go swimming with my family at the YMCA 3

times a week."

• "I need to ask my doctor if I should have a bone

mineral density check this year."

• "If I don't drink milk at dinner, I'll eat broccoli or

cabbage to get the calcium that I need in my diet."

• "I'll check the label of my multivitamin. If it has calcium,

I can save money by not taking another pill. "

• "I'll check the label of my multivitamin. If it has calcium, I can save money by not

taking another pill. " Just because a multivitamin has calcium in it does not mean that the woman is receiving enough to meet her needs. She must know her requirement and make the decision based on that rather than on the value for calcium on the label.The patient at greatest risk for developing multiple

adverse effects of immobility is a:

• 1-year-old child with a hernia repair.
• 80-year-old woman who has suffered a hemorrhagic

cerebrovascular accident (CVA).

• 51-year-old woman following a thyroidectomy.
• 38-year-old woman undergoing a hysterectomy.
• 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident

(CVA).

The older the patient and the greater the period of immobility, which can be significant following a hemorrhagic stroke, the greater is the number of systems that can be affected by the immobility.An older adult who was in a car accident and fractured his femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time?

• Chronic pain
• Impaired skin integrity
• Risk for ineffective cerebral tissue perfusion
• Risk for activity intolerance
• Risk for activity intolerance

Patients on bed rest are at risk for activity intolerance, which increases patients' risk for falling.A patient had a left-sided cerebrovascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore nasogastric (NG) tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately?

• Pale yellow urine
• Unilateral neglect
• Slight movement noted on the R side
• Coffee ground-like aspirate from the feeding tube
• Coffee ground-like aspirate from the feeding tube

When patients are receiving medications such as heparin or enoxaparin (Lovenox), you must assess for signs of bleeding. These include overt signs such as bleeding from their gums or covert signs, which can be detected by testing their stool or observing their aspirate from NG tubes for coffee ground-like matter. These are signs of bleeding in the gastrointestinal tract.

A home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke.The patient is cooperative and can ambulate with a quad- cane. Which of the following must be corrected or removed for the patient's safety? (Select all that apply.)

• The rubber mat in the walk-in shower
• The three-legged stool on wheels in the kitchen
• The braided throw rugs in the entry hallway and

between the bedroom and bathroom

• The night-lights in the hallways, bedroom, and

bathroom

• The cordless phone next to the patient's bed
• The three-legged stool on wheels in the kitchen
• The braided throw rugs in the entry hallway and between the bedroom and

bathroom Stools on wheels and braided throw rugs are hazards that put the patient at risk for falls. By planning ahead and collaborating, the home care nurse can provide a safe home environment for the patient after discharge The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. The nurse would recommend which of the following menus?

• Cream of broccoli soup with whole wheat crackers

and tapioca for dessert

• Hamburger on soft roll with a side salad and an apple

for dessert

• Low-fat turkey chili with sour cream and fresh pears for

dessert

• Chicken salad on toast with tomato and lettuce and

honey bun for dessert

• Cream of broccoli soup with whole wheat crackers and tapioca for dessert

The dairy and broccoli in the soup, the whole grain crackers, plus the tapioca are all great sources of calcium.Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather?(Select all that apply.)

• Patient's weight
• Patient's level of cooperation
• Patient's ability to assist
• Presence of medical equipment
• 24-hour calorie intake
• Patient's weight
• Patient's level of cooperation
• Patient's ability to assist
• Presence of medical equipment

By assessing the patient thoroughly you make the correct decision concerning your ability to manage him or her safely, the need for additional personnel, the patients ability or inability to assist you with the transfer, and the proper equipment to use for the transfer. The calorie intake for the past 24 hours does not affect safe transfer.A patient of any age can develop a contracture of a joint

when:

• The adductors muscles are weakened as a result of

immobility.

• The muscle fibers become shortened because of

disuse.

• The calcium-to-phosphorus ratio becomes disrupted.
• There is a deficiency in vitamin D.
• The muscle fibers become shortened because of disuse.

The adductor muscles are stronger than the abductor muscles; when patients are immobile and the joint is not exercised through their ROM, the adductor muscle fibers shorten, resulting in the contracture of that joint, which is usually permanent.

Immobilized patients are at risk for impaired skin integrity.Which of the following interventions would reduce this risk? (Select all that apply.)

• Repositioning patient every 1 to 2 hours while awake
• Using an objective, valid scale to assess patient's risk

for pressure ulcer development

• Using a device to relieve pressure when patient is

seated in chair D.Teaching patient how to shift weight at regular intervals while sitting in a chair

E. A good rule is: the higher the risk for skin breakdown,

the shorter the interval between position changes

• Using an objective, valid scale to assess patient's risk for pressure ulcer

development

• Using a device to relieve pressure when patient is seated in chair

D.Teaching patient how to shift weight at regular intervals while sitting in a chair

• A good rule is: the higher the risk for skin breakdown, the shorter the interval

between position changes Patients must be repositioned around the clock, not just when they are awake. An objective assessment scale allows the nurse to assess for pressure ulcer risk over time. Once the risk is identified, the assessment tool guides the nurse in selecting appropriate pressure-relief devices. Showing the patient how to reduce his or her risk by shifting pressure is also important. Frequent and meaningful position changes that are in concert with the patients condition and risk factors are necessary to reduce pressure ulcer developments.Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher?

• The patient is 5 feet 6 inches and weighs 120 lbs.
• The patient speaks and understands English.
• The patient received an injection of morphine 30

minutes ago for pain.

• You feel comfortable handling a patient of his size and

with his level of cooperation.

• The patient received an injection of morphine 30 minutes ago for pain.

The morphine injection would change the patient's ability to safely follow directions and participate in the transfer; therefore additional help would be needed to safely transfer the patient from the bed to the stretcher.A patient with left-sided weakness asks his nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." What would be your best therapeutic response?

• "Walking on your left side lets me use my right hand to

hold on to your arm. In case you start to fall, I can still hold you."

• "Would you like me to walk on your right side so you

feel more secure?"

• "Either side is appropriate, but I prefer the left side. If

you like, I can have another nurse walk with you who will hold you on the right side."

• "By walking on your left side I can support you and

help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.

• "By walking on your left side I can support you and help keep you from injury if

you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.Walking on the affected (weak side) side and holding the patient around the waist or using a gait belt gives you better control if the patient starts to fall. If you were holding the patient's arm as he was falling, you might dislocate his shoulder.Which is an outcome for a patient diagnosed with osteoporosis?

• Maintain serum level of calcium.
• Maintain independence with activities of daily living

(ADLs).

• Reduce supplemental sources of vitamin D.
• Reverse bone loss through dietary manipulation.
• Maintain independence with activities of daily living (ADLs).

The main goal is to maintain independence in ADLs once osteoporosis is diagnosed. It is best to identify individuals at risk and work toward preventing the disease.