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?
Why are mechanical aids necessary for patient handling and movement?
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.
A patient performs rehabilitative exercises with resistance after a knee injury. The nurse interprets this type of exercise as which of the following?
Which of the following would the nurse expect to assess when a patient experiences a greater breakdown of protein than that which is manufactured?
Fluid volume excess
Negative nitrogen balance
When explaining the cause of frequent urinary tract infections related to immobility, the nurse understands that immobility may result in which of the following?
Improved renal blood supply to the kidneys
Decreased urinary calcium
Acidic urine formation
Mr. Brown is experiencing some difficulty breathing. The nurse most appropriately assists him into which position?
Dorsal recumbent position
While doing range-of-motion exercises with a patient who is bedridden, the nurse is aware of which of the following considerations?
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.
The nurse is assisting a patient with conditioning exercises to prepare for ambulation. The nurse correctly instructs the patient to do what?
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
In many situations, a patient has sufficient strength to walk if he or she can do which of the following?
Lie prone for 1 hour
Bathe him- or herself
Raise the foot off the bed 1 inch
Sit up in bed for 1 hour
Mrs. Eden tells the nurse she feels faint while walking in the corridor with the nurse. What should the nurse do?
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
When a patient is using a cane for maximal support, the nurse is aware that the patient should do which of the following?
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
The use of patient care ergonomics is associated with which of the following patient outcomes?
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
Which of the following should the nurse do when assisting the patient to ambulate?
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
When working with an older patient to develop an exercise program, the nurse would recommend which of the following?
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
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?
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
During the evaluation phase of the nursing process, which finding indicates that the nursing care plan for the immobilized patient has been ineffective?
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.
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:
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.
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?
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.
A physiologic risk associated with immobility is:
Increased cardiac workload
Decreased serum calcium level.
Which assessment of the immobilized patient would prompt the nurse to take further action?
Patient complains of fatigue.
Urinary output of 50 ml an hour.
Whilte blood cell count of 9.5
Absence of bowel sounds
When caring for a patient on prolonged bedrest, the nurse can help prevent the formation of kidney stones (renal calculi) by:
Decreasing calcium intake.
Making the urine more alkaline.
Monitoring intake and output.
Encouraging Kegel's exercises.
The patient tells the nurse she feel faint while walking in the hall with the nurse. The nurse
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.
If you are working alone, the best way to support an unstable patient when assisting with ambulation is which of the following?
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.
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:
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.
Immobility impacts the cardiovascular system by:
Decreasing the cardiac response to activity.
Improving venous return.
Increasing cardiac output.
Increasing cardiac efficiency.
Passive range of motion for the immobilized older patient:
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.
Ankylosis is a fixation or immobilization of a joint.
Atrophy is an increase in the size of a body structure.
Contracture is a permanently contracted state of a muscle.
Flaccidity is decreased muscle tone.
Isokinetic exercise involves muscle contractions with resistance varying at a constant rate.
Isometric exercise is when muscle tension occurs without a significant change in muscle length.
Isotonic exercise is when muscles shorten and move.
Cartilage is tough fibrous bands that bind joints together and connect bones.
Ligaments are hard nonvascular connective tissue found in the joints as well as in the nose, ear, thorax, trachea, and larynx.
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).
Passive exercise is manual or mechanical means of moving the joints.
Spasticity is decreased muscle tone.
Tendons are strong, flexible, inelastic fibrous bands that attach muscle to bone.
Effects of exercise on the cardiovascular system (select all that apply):
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.
Effects of exercise on the respiratory system (select all that apply):
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
Effects of immobility on the respiratory system:
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
Effects on immobility on the cardiovascular system (select all that apply):
Increased cardiac workload
Decrease in thrombus formation
Increased metabolic rate, triglyceride breakdown increased, gastric motility, and increased production of body heat are effects of exercise on the metabolic process.
Effects of immobility on the metabolic process (select all that apply):
Fluid and Electrolyte balance
Effects of exercise on the gastrointestinal system (select all that apply):
Decreased tone and motility
Effects of immobility on the gastrointestinal system are:
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
Effects of exercise on the musculoskeletal system (select all that apply):
Increases muscle mass, tone, and strength
Improves joint flexibility
Immobility to the musculoskeletal system can cause (select all that apply):
Improved muscle coordination
Muscle weakness and atrophy
Effects of exercise on the integument system can cause a decrease in circulation to the skin and causes prolonged pressure to part.
Decubitus ulcers are pressure from bed or chair, decreased blood flow to skin, less oxygen and nutrients to skin=ischemia, decreased intake of nutrients.
Effects of exercise on the urinary system improves flow to the kidneys and decreases efficiency of waste excretions.
For a cardiovascular intervention, you would teach the patient to (select all that apply):
Put pillows under your knees
Massage the calves
No tight knee high socks
Isometric exercises and ankle circles
Cross your legs for comfort
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.
Musculoskeletal changes in aging patients (select all that apply):
Decline in muscle strength
Decreased respiratory vital capacity
Increase in transport of oxygenated blood of tissue
Decreased range of motion
Increase stability of gait
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
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
Differentiate the roles of the RN and the LPN in the care of patients with altered mobility:
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.