Chapter 047

Potter & Perry: Fundamentals of Nursing, 7th Edition
Test Bank
Chapter 47: Mobility and Immobility
MULTIPLE CHOICE
1. A client has been on prolonged bed rest, and the nurse is observing for signs associated
with immobility. In assessment of the client, the nurse is alert to a(n):
1. Increased blood pressure
2. Decreased heart rate
3. Increased urinary output
4. Decreased peristalsis
ANS: 4
Immobility causes gastrointestinal disturbances such as decreased appetite and slowing
of peristalsis. In the immobilized client, decreased circulating fluid volume, pooling of
blood in the lower extremities, and decreased autonomic response occur. These factors
result in decreased venous return, followed by a decrease in cardiac output, which is
reflected by a decline in blood pressure. Recumbency increases cardiac workload and
results in an increased pulse rate. Fluid intake can diminish with immobility, and this
combined with other causes, such as fever, increases the risk for dehydration. Urinary
output may decline on or about the fifth or sixth day after immobilization, and the urine is
often highly concentrated.
PTS:
1
DIF: A
REF: 1225
OBJ:
Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and
Comfort/Mobility/Immobility
2. A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident
(stroke). In planning care for this client, the nurse implements which one of the following
as an appropriate intervention?
1. Encourage an even gait when walking in place.
2. Assess the extremities for unilateral swelling and muscle atrophy.
3. Encourage holding the breath frequently to hyperinflate the client's lungs.
4. Teach the use of a two-point crutch technique for ambulation.
ANS: 2
Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
47-2
Because edema moves to dependent body regions, assessment of the immobilized client
should include the sacrum, legs, and feet. Unilateral increases in calf diameter can be an
early indication of thrombosis. The client who has suffered a cerebrovascular accident
with left-sided paralysis may not be capable of an even gait. To prevent stasis of
pulmonary secretions, the clients position should be changed every 2 hours, and fluids
should be increased to 2000 mL, if not contraindicated. The client should deep breathe
and cough every 1 to 2 hours to promote chest expansion. The client would most likely
ambulate safely with a walker, or a cane. If crutches are used, the client should use a
three-point support.
PTS:
1
DIF: A
REF: 1238
OBJ:
Comprehension
TOP: Nursing Process: Planning
3. Two nurses are standing on opposite sides of the bed to move the client up in bed with a
drawsheet. Where should the nurses be standing in relation to the clients body as they
prepare for the move?
1. Even with the thorax
2. Even with the shoulders
3. Even with the hips
4. Even with the knees
ANS: 2
The nurses should be standing even with the clients shoulders when they prepare to
move the client up in bed.
PTS:
1
DIF: A
REF: 1253
OBJ:
Comprehension
TOP: Nursing Process: Implementation
4. A client is leaving for surgery and because of preoperative sedation needs complete
assistance to transfer from the bed to the stretcher. Which of the following should the
nurse do first?
1. Elevate the head of the bed.
2. Explain the procedure to the client.
3. Place the client in the prone position.
4. Assess the situation for any potentially unsafe complications.
ANS: 4
Test Bank
47-3
Before transferring the client from the bed to the stretcher, the nurse should assess the
situation for any potentially unsafe complications. The sedated client is transferred most
easily in the supine position, unless contraindicated. The head of the bed should be at the
same level as the head of the stretcher. This client has had preoperative sedation, which
may impair his or her cognition. The nurse should simplify instructions when explaining
the procedure to the client, but this should be done immediately before transferring the
client.
PTS: 1
DIF: C
REF: 1268
OBJ: Analysis
5. A client has sequential compression stockings in place. The nurse evaluates that they are
implemented appropriately by the new staff nurse when the:
1. Initial measurement is made around the clients calves
2. Intermittent pressure is set at 40 mm Hg
3. Stockings are wrapped directly over the leg from ankle to knee
4. Stockings are removed every hour during application
ANS: 2
Inflation pressures average 40 mm Hg. Initial measurement is made around the largest
part of the clients thigh. A protective stockinette is placed over the clients leg; then the
stocking is wrapped around the leg, starting at the ankle, with the opening over the
patella. For optimal results, sequential compression devices (SCDs) or intermittent
pneumatic compression (IPC) are used as soon as possible and maintained until the client
becomes fully ambulatory. Stockings are not removed every hour but should be removed
periodically to assess the condition of the clients skin.
PTS:
1
DIF: A
REF: 1238
OBJ:
Comprehension
TOP: Nursing Process: Evaluation
6. The nurse assesses that the client has torticollis and that this may adversely influence the
clients mobility. This individual has a(n):
1. Exaggeration of the lumbar spine curvature
2. Increased convexity of the thoracic spine
3. Abnormal anteroposterior and lateral curvature of the spine
4. Contracture of the sternocleidomastoid muscle with a head incline
ANS: 4
Torticollis is inclining of the head to the affected side, in which the sternocleidomastoid
muscle is contracted. Lordosis is an exaggeration of the lumbar spine curvature. Kyphosis
is an increased convexity in the curvature of the thoracic spine. Kyphoscoliosis is an
abnormal anteroposterior and lateral curvature of the spine.
Test Bank
47-4
PTS:
1
DIF: A
REF: 1224
OBJ:
Comprehension
7. An immobilized client is suspected of having atelectasis. This is assessed by the nurse
upon auscultation as:
1. Harsh crackles
2. Wheezing on inspiration
3. Diminished breath sounds
4. Bronchovesicular whooshing
ANS: 3
Atelectasis is the collapse of alveoli. In atelectasis, secretions block a bronchiole or a
bronchus, and the distal lung tissue (alveoli) collapses as the existing air is absorbed,
producing hypoventilation. If the client were suspected of having atelectasis, the nurse
would expect diminished breath sounds in the area of hypoventilation. Harsh crackles
indicate excessive airway secretion. Wheezing on inspiration indicates narrowing of the
lumen of a respiratory passageway. Bronchovesicular sounds are a mixture of bronchial
and vesicular sounds. Bronchovesicular whooshing would not be an expected sound
indicating atelectasis.
PTS:
1
DIF: A
REF: 1226
OBJ:
Comprehension
8. The best approach for the nurse to use to assess the presence of thrombosis in an
immobilized client is to:
1. Measure the calf and thigh circumferences
2. Attempt to elicit Homans sign
3. Palpate the temperature of the feet
4. Observe for a loss of hair and skin turgor in the lower legs
ANS: 1
Calf and thigh circumferences should be measured daily. Unilateral increases in calf or
thigh circumference can be an early indication of thrombosis. Homans sign is not always
positive in the presence of thrombosis. Assessing the temperature of the feet is not the
best approach to determine the presence of thrombosis. Observing for hair loss and skin
turgor of the lower legs is not the best approach to determine the presence of thrombosis.
A lack of hair may indicate a chronic lack of oxygen. Skin turgor is a measure of
hydration.
PTS:
DIF:
REF: 1238
OBJ:
Test Bank
47-5
Comprehension
9. A client is getting up for the first time after a period of bed rest. The nurse should first:
1. Assess respiratory function
2. Obtain a baseline blood pressure
3. Assist the client with sitting at the edge of the bed
4. Ask the client if he or she feels light-headed
ANS: 2
When getting the client up for the first time after a period of bed rest, the nurse should
document orthostatic changes. The nurse first obtains a baseline blood pressure.
Assessing the clients respiratory function is not the nurses first intervention when
getting a client up for the first time after prolonged bed rest. After the nurse assesses the
clients blood pressure, the nurse can assist the client to a sitting position at the side of the
bed. After the client is in the sitting position at the side of the bed, the nurse should ask
the client if he or she feels light-headed.
PTS: 1
DIF: C
REF: 1238
OBJ: Analysis
10. To promote respiratory function in the immobilized client, the nurse should:
1. Change the clients position every 4 to 8 hours
2. Encourage deep breathing and coughing every hour
3. Use oxygen and nebulizer treatments regularly
4. Suction the clients secretions every hour
ANS: 2
The nurse should actively work with the immobilized client to deep breathe and cough
every 1 to 2 hours to promote chest expansion. The clients position should be changed
every 2 hours to reduce stagnation of secretions. The health care provider must order
oxygen and nebulizer treatments, which are primarily used to treat the client who is
experiencing an impaired air exchange, not to promote respiratory function in the
immobilized client. The clients secretions should only be suctioned as needed.
PTS:
1
DIF: A
REF: 1247
OBJ:
Comprehension
Test Bank
47-6
11. Antiembolic stockings (thromboembolic device [TED] hose) are ordered for the client on
bed rest following surgery. The nurse explains to the client that the primary purpose for
the TEDs is to:
1. Keep the skin warm and dry
2. Prevent abnormal joint flexion
3. Apply external pressure
4. Prevent bleeding
ANS: 3
The primary purpose of antiembolic stockings is to maintain external pressure on the
muscles of the lower extremities and thus promote venous return. Antiembolic stockings
are not primarily used to prevent bleeding but are used to prevent clot formation caused
by venous stasis.
PTS: 1
DIF: C
REF: 1248
OBJ: Analysis
12. To provide for the psychosocial needs of an immobilized client, an appropriate statement
by the nurse is which of the following?
1. The staff will limit your visitors so that you will not be bothered.
2. A roommate can be a real bother. Youd probably rather have a private room.
3. Lets discuss the routine to see if there are any changes we can make.
4. I think you should have your hair done and put on some makeup.
ANS: 3
To meet the psychosocial needs of immobilized clients, the nurse should encourage
clients to be involved in their care whenever possible. Asking the client if there are
changes the staff can make in routine care is an appropriate question. Visitors should not
be limited for the immobilized client. The client needs socialization throughout the day. If
possible, the client should be placed in a room with others who are mobile and
interactive. Clients should be encouraged to wear their glasses or artificial teeth and to
shave or apply makeup. These are activities through which people maintain their body
image. The nurse provides for the psychosocial needs of an immobilized client by having
the client perform as much self-care as possible.
PTS:
1
DIF: A
REF: 1229
OBJ:
Comprehension
13. To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse
should implement the use of a:
1. Footboard
2. Trochanter roll
Test Bank
47-7
3. Trapeze bar
4. Bed board
ANS: 2
A trochanter roll prevents external rotation of the hips when the client is in a supine
position. The footboard prevents footdrop by maintaining the feet in dorsiflexion. The
trapeze bar allows the client to pull with the upper extremities to raise the trunk off the
bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises. A bed
board is used to increase back support and alignment, especially with a soft mattress.
PTS:
1
DIF: A
REF: 1251
OBJ:
Comprehension
14. To reduce the chance of plantar flexion (footdrop) in a client on prolonged bed rest, the
nurse should implement the use of:
1. Trapeze bars
2. High-top sneakers
3. Trochanter rolls
4. Thirty-degree lateral positioning
ANS: 2
High-top tennis shoes or an ankle-foot orthotic may be used to help maintain dorsiflexion
and prevent footdrop. A trapeze bar is used to assist the client in mobility. A trochanter
roll prevents external rotation of the hips when the client is in a supine position. Thirtydegree lateral positioning may be used for clients at risk for pressure ulcers.
PTS:
1
DIF: A
REF: 1254
OBJ:
Comprehension
15. Which of the following is the most important to consider when assisting the client in
passive range-of-motion exercises?
1. Flex the joint to the point of discomfort.
2. Work from the proximal joints to the distal joints.
3. Quickly work through the range of motion.
4. Support the distal joints while performing range-of-motion exercises.
ANS: 4
While performing range-of-motion exercises, support should be provided for the distal
joints. The joint should be flexed to the point of resistance, not to the point of discomfort.
When performing range-of-motion exercises, begin at distal joints and work toward
proximal joints. Joints should be moved slowly through their range of motion. Quick
movement could cause injury.
Test Bank
47-8
PTS:
1
DIF: A
REF: 1274
OBJ:
Comprehension
16. Which of the following clients is most at risk for losing his or her balance?
1. A woman who is 9 months pregnant walking down a flight of stairs
2. A 16-year-old skate boarding down a 15-degree slope
3. A 45-year-old taking hypertensive medication
4. A 4-year-old riding a tricycle
ANS: 1
Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy)
compromise the ability to remain balanced. Medications that cause dizziness and
prolonged immobility also affect balance. Impaired balance is a major threat to physical
safety and contributes to a fear of falling and self-imposed restrictions on activity.
Although all the options represent a risk, the situation of the pregnant woman places her
at greatest risk.
PTS: 1
DIF: C
REF: 1220
OBJ: Analysis
17. It has been determined that all of the following clients are at risk for falling. Which one
requires the nurses priority for ambulation?
1. A 16-year-old with a sprained ankle being discharged from the emergency
department
2. A 54-year-old who has taken the initial dose of an antihypertensive medication
3. A 45-year-old postoperative client up for the first time since knee surgery
4. An 81-year-old who is asthmatic and had a hip replaced 18 months ago
ANS: 3
Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy)
compromise the ability to remain balanced. Medications that cause dizziness and
prolonged immobility also affect balance. Although all the options represent a potential
risk for falling, the postoperative client has both prolonged immobility and physical
injury (surgery) and so is at greatest risk.
PTS: 1
DIF: C
REF: 1220
OBJ: Analysis
Test Bank
47-9
18. Which of the following statements made by ancillary staff reflects the most informed
knowledge regarding the benefit of having a client assist with his or her own activities of
daily living (ADLs) to that clients activity tolerance?
1. The more he does for himself, the more he will be able to do for himself.
2. He doesnt like washing and dressing himself, but it makes him stronger.
3. Doing for himself makes him tired, but in the long run he has more energy and
strength when he does.
4. By washing and dressing himself he is building muscle strength that lets him
actually walk a little better.
ANS: 4
Muscle tone helps maintain functional positions such as sitting or standing without excess
muscle fatigue and is maintained through continual use of muscles. ADLs require muscle
action and help maintain muscle tone. When a client is immobile or on prolonged bed
rest, activity level, activity tolerance, and muscle tone decrease. The remaining options
do not explain the reason for the additional activity tolerance as does the answer.
PTS: 1
DIF: C
REF: 1250
OBJ: Analysis
19. Which of the following statements regarding physical activity and its effect on activity
tolerance made by a client shows the most informed knowledge regarding the connection
between the two?
1. I know I need to walk more if I want to get stronger.
2. I dont like walking, but I do it because I know it will make me stronger.
3. I try to walk a little farther each afternoon so I can dance at my grandsons
wedding.
4. I walk with my son three evenings a week because its good for his weight and for
my bones.
ANS: 3
muscle fatigue and is maintained through continual use of muscles. The better the muscle
tone, the more stamina the client will experience. The remaining options do not state the
connection between activity and stamina as well as the answer.
PTS: 1
DIF: C
REF: 1244
OBJ: Analysis
20. A client recovering from hip surgery tells the nurse that she wants to get better so she can
walk down the aisle to her seat at her granddaughters wedding. Which of the following
nursing interventions will have the greatest impact on achieving that goal?
1. Informing physical therapists that the client has expressed that goal
Test Bank
47-10
2. Reminding the ancillary staff to offer to walk with the client after her bath
3. Regularly praising the client for the efforts she is making to reach her goal
4. Walking with the client to and from the dining room where she eats her meals
ANS: 4
muscle fatigue and is maintained through continual use of muscles. ADLs require muscle
action and help maintain muscle tone. When a client is immobile or on prolonged bed
rest, activity level, activity tolerance, and muscle tone decrease. The better the muscle
tone, the more stamina the client will experience. Although all the interventions are
appropriate, actually walking with the client will have the greatest impact on her ability
to achieve the goal.
PTS: 1
DIF: B
REF: 1241
OBJ: Application
21. An infant born via cesarean section because of a breech presentation is diagnosed with
bilateral congenital hip dysplasia. The primary nursing intervention directed toward this
diagnosis is:
1. Assessing the infant frequently to determine abduction of the thighs
2. Maintaining the infant in the position of continuous abduction of both hips
3. Educating the parents about the importance of positioning the infant so that the
head of the femurs are in alignment with the hip sockets
4. Providing pain management so that the infant is comfortable in the therapeutic
position required
ANS: 2
Maintenance of continuous abduction of the thigh so that the head of the femur presses
into the center of the acetabulum is critical in the care and treatment of this infant.
Although the other options are appropriate, they are not primary interventions in this
scenario.
PTS: 1
DIF: C
REF: 1224
OBJ: Analysis
22. A 16-year-old had a full leg cast for 4 months, and it is being removed today. Which of
the following statements made by the client shows the most informed understanding of
the effects of immobilization of a muscle on its strength and stamina?
1. Im hoping to be back at soccer practice in 3 weeks.
2. Walking and riding my bike will help regain the muscle.
3. Ill practice the strengthening routine the physical therapist taught me, so I can
play baseball in the spring.
4. There was a good bit of muscle and strength loss, but Ill work at getting it back
Test Bank
47-11
like it was before the break.

ANS: 3
Even this temporary immobilization results in some muscle atrophy, loss of muscle tone,
and joint stiffness. When a client is immobile or on prolonged bed rest, activity level,
activity tolerance, and muscle tone decrease. Appropriate general exercise and specific
exercise of the atrophied muscle will increase both muscle tone and overall stamina.
Although the remaining options are not incorrect, the answer shows the greatest insight
because it provides both a plan and a time line for recovery.
PTS: 1
DIF: C
REF: 1223
OBJ: Analysis
23. A staff member experienced a shoulder injury while assisting with a client transfer. The
nurse managers most therapeutic response to this situation is to:
1. Thoroughly review the accident report filed by the injured personnel to determine
the factors that contributed to the injury
2. Have a nonpunitive meeting with all the involved staff to discuss correcting the
factors that resulted in the injury
3. Require that mechanical lifts be used in the transfer of all clients incapable of
assisting with the transfer
4. Implement new policies and procedures to correct the factors that resulted in the
injury
ANS: 2
An after-action review allows the health care team to apply knowledge about safe client
moving to the situation to identify safety factors contributing to the problem and make
suggestions for the implementation of strategies to minimize risk to both client and staff.
PTS: 1
DIF: C
REF: 1225
OBJ: Analysis
24. Which of the following statements made by a nurse caring for a client who experienced a
myocardial infarction 8 hours ago shows the greatest insight as to the purpose for keeping
the client on bed rest?
1. This has been exhausting; she needs a period of uninterrupted rest.
2. The pain she experienced is exhausting; its imperative that she rest.
3. Keeping her on bed rest decreases the need her body has for oxygen
4. She needs complete rest; she is really very ill, especially her heart.
ANS: 3
Although all of the options are correct, the primary reason for bed rest in this scenario is
to minimize the need for oxygen to both the heart and the body in general.
Test Bank
47-12
PTS: 1
DIF: C
REF: 1224
OBJ: Analysis
25. The nurse recognizes that a client who is inactive is at a risk for decreased muscle mass
as a result of increased muscle atrophy and:
1. Decrease metabolic rate
2. Catabolic tissue breakdown
3. Inactivity-induced depression
4. Anorexia caused by decreased peristalsis
ANS: 2
Weight loss, decreased muscle mass, and weakness result from tissue catabolism (tissue
breakdown).
PTS:
1
DIF: A
REF: 1227
OBJ:
Comprehension
26. A 78-year-old inactive client diagnosed with acute renal failure is at risk for which of the
following skeletal maladies?
1. Rickets
2. Osteomyelitis
3. Pathological fractures of long bones
4. Compression fractures of the spinal column
ANS: 3
Immobility causes the release of calcium into the circulation, where normally the kidneys
excrete the excess calcium. If the kidneys are unable to respond appropriately,
hypercalcemia results. Pathological fractures occur if calcium reabsorption continues as
the client remains on bed rest or continues to be immobile. Bed rest is not a direct
causative factor for the other options.
PTS:
1
DIF: A
REF: 1228
OBJ:
Comprehension
27. Prevention of plantar flexion (footdrop) through the application of high-topped shoes is a
primary intervention for which of the following mobility-impaired clients?
1. A 54-year-old diagnosed with osteoarthritis in all lower extremity joints
2. A 25-year-old with a fractured pelvis as a result of a motorcycle accident
3. A 78-year-old who has experienced left-sided paralysis resulting from a cerebral
Test Bank
47-13
vascular accident (CVA)

4. A 15-year-old who has been comatose for 2 years as a result of a head injury
sustained from a fall off a roof
ANS: 2
The client who has suffered a CVA with resulting left-sided paralysis (hemiplegia) is at
risk for footdrop. In two of the options, the client would not damage the nerve necessary
to cause the condition, and the remaining option is not the correct answer because there is
little chance this client will ever be capable of mobility.
PTS: 1
DIF: C
REF: 1254
OBJ: Analysis
28. The nurse is providing ancillary personnel with instructions regarding the performance of
passive range-of-motion (ROM) exercises for a client experiencing paralysis from the
waist down (paraplegia) as a result of an automobile accident. Which of the following
statements made by the ancillary personnel reflects the greatest insight regarding the
frequency with which the intervention should be provided for this client?
1. I will do a whole body range of motion as I complete her daily bath.
2. Bath time, bedtime, after lunch, and at least once more; she can pick when.
3. It works well with her bath and when she is being prepared for bed at night.
4. Ill ask her when she wants me to exercise her joints in addition to bath time.
ANS: 2
If the client is unable to move part or all of the body, perform passive ROM exercises for
all immobilized joints while bathing the client and at least 2 or 3 more times a day.
PTS: 1
DIF: C
REF: 1249
OBJ: Analysis
29. The nurse is discussing joint mobility exercises with a client who experienced a stroke
and now has left-sided weakness. Which of the following statements made by the client
reflects the greatest insight regarding the best method for him to maintain mobility of the
joints on his left side?
1. My wife knows how to do those exercises for the joints on my left side.
2. Physical therapy really exercises my left side when I go there every afternoon.
3. Ill remind the staff to exercise my left side when they come to help me with my
bath and getting dressed.
4. I will do those passive range of motion exercises you taught me to my left side at
least 3 times a day.
ANS: 4
If one extremity is paralyzed, teach the client to put each joint independently through its
ROM.
Test Bank
47-14
PTS: 1
DIF: C
REF: 1261
OBJ: Analysis
30. The nurse caring for a 38-year-old female client with multiple fractures in the trauma
intensive care unit knows that this client is at high risk for pulmonary complications such
as atelectasis from her immobility. One of the interventions that the nurse can do to help
prevent this from occurring is to:
1. Keep the PaO2 level at or above 94%
2. Instruct the client to deep breathe and cough every hour while awake
3. Turn the client every 2 hours
4. Keep the client on the ventilator as long as possible
ANS: 2
In atelectasis, secretions block a bronchiole or a bronchus, and the distal lung tissue
(alveoli) collapses as the existing air is absorbed, producing hypoventilation. The site of
the blockage affects the severity of atelectasis. Sometimes an entire lung lobe or a whole
lung collapses. At some point in the development of these complications, there is a
proportional decline in the clients ability to cough productively. Turning the client is an
excellent way to help prevent the accumulation of mucus in the dependent regions of the
airways causing hypostatic pneumonia. Mucus is an excellent place for bacteria to grow.
Keeping a client on a ventilator longer than necessary has the potential to cause multiple
other complications and is not the best choice.
PTS:
1
DIF: A
REF: 1220
OBJ:
Comprehension
31. The nurse is caring for a 48-year-old male client who was involved in a motor vehicle
accident and had a fractured pelvis, a ruptured spleen, and multiple contusions. The client
has been in the hospital for 5 days on bed rest. The nurse knows that this client is at risk
for venous thrombus formation because of prolonged bed rest, potential damage to vessel
walls during surgery, and the platelets he received in the trauma unit. These three factors
are also known as:
1. Trigeminy
2. Virchows triad
3. Trigone
4. Hutchinsons triad
ANS: 2
Test Bank
47-15
There are three factors that contribute to venous thrombus formation: (1) damage to the
vessel wall (e.g., injury during surgical procedures), (2) alterations of blood flow (e.g.,
slow blood flow in calf veins associated with bed rest), and (3) alterations in blood
constituents (e.g., a change in clotting factors or increased platelet activity. These three
factors are sometimes referred to as Virchows triad
PTS: 1
DIF: A
REF: 1260
OBJ: Knowledge
32. The nurse caring for a 73-year-old female client who has been hospitalized with a stroke
instructs the clients daughter to continue to do passive range-of-motion exercises with
her mother on her affected side to prevent contractures. The nurse explains to the
daughter that this is very important in an immobile older adult client because contractures
can form in as little as:
1. 8 hours
2. 24 hours
3. 1 week
4. 1 month
ANS: 1
Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. When a
contracture occurs, the joint cannot obtain full ROM. Contractures sometimes leave a
joint or joints in a nonfunctional position, as seen in clients who are permanently curled
in a fetal position. Early prevention of contractures is key; they can begin to form after
only 8 hours of immobility in the older adult client.
PTS: 1
DIF: B
REF: 1225
OBJ: Application
33. The nurse understands that a pressure ulcer is an impairment of the skin as a result of
prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in
an immobile client is to:
1. Keep the skin dry
2. Provide range of motion every shift
3. Use lift equipment when transferring a client
4. Turn the client a minimum of every 2 hours
ANS: 4
Test Bank
47-16
Implement a comprehensive skin care program to prevent skin breakdown in all clients,
from neonates to older adults. Effective skin care programs include accurate and
consistent assessment and documentation as well as interventions to protect the skin (e.g.,
turn the client at least every 2 hours). Keeping the skin dry is very important in
preventing skin breakdown, range-of-motion exercises will help prevent contractures
from occurring, lift equipment will help decrease harm to both clients and staff, but
turning the client will best help prevent pressure ulcers.
PTS: 1
DIF: B
REF: 1225
OBJ: Application
34. The nurse caring for a 78-year-old male client recovering from hip replacement surgery is
assessing for signs of improvement of the clients activity tolerance. The nurse
determined a baseline for ongoing assessments by:
1. Determining how much time it takes the client to recover from an activity
2. Assessing how much the client can do at one time
3. Determining the level of pain experienced by the client during the activity
4. Asking the client how much the client feels like doing
ANS: 1
When the client experiences decreased activity tolerance, carefully assess how much time
the client needs to recover. Decreasing recovery time indicates improving activity
tolerance. Pain should not be an assessment of activity tolerance. Asking the client how
much he feels like doing before an activity will not tell the nurse if he is improving over
time. The client may be able to do more (or less) than he thinks he is capable of doing
before an activity.
PTS:
1
DIF: A
REF: 1225
OBJ:
Comprehension
35. The nurse and a nursing assistive personnel (NAP) are going to move an older adult
client up in bed. Before moving the client, the nurse explains to the NAP that they will
need to lift the client off the bed with an assistive device instead of using the drawsheet.
The most important reason for using the assistive device is:
1. To avoid frightening the client
2. To avoid shearing the clients skin
3. To avoid getting written up for not following lift procedures
4. Because the nurse is tired
ANS: 2
Test Bank
47-17
The greater the surface area of the object that is moved, the greater the friction. A larger
object produces greater resistance to movement. To decrease surface area and reduce
friction when clients are unable to assist with moving up in bed, nurses use an ergonomic
assistive device, such as a full body sling. It mechanically lifts the client off the surface of
the bed, thereby preventing friction, tearing, or shearing of the clients delicate skin. The
client may also be frightened by the use of the equipment. It is important to explain what
will be going on and what the client can expect to experience when using any piece. Lift
policies are put in place to protect both clients and staff; however, the nurse should not be
as concerned with being written up as with protecting himself or herself, the NAP, and
the client from harm. The most important reason for using the lift equipment is to protect
the client and staff from harm.
PTS: 1
DIF: B
REF: 1220
OBJ: Application
36. The nurse understands that using metabolic functioning, measures of height, weight, and
skinfold thickness, to evaluate muscle atrophy in an immobilized client is known as:
1. Anthropometric measurements
2. Anhydrous measurements
3. Balke test
4. Calorimetry
ANS: 1
When assessing metabolic functioning, use anthropometric measurements (measures of
height, weight, and skinfold thickness) to evaluate muscle atrophy. Anhydrous means
without water, the Balke test determines maximum oxygen utilization, and calorimetry is
the determination of heat loss or gain.
PTS: 1
DIF: A
REF: 1247
OBJ: Knowledge
MULTIPLE RESPONSE
1. The nurse recognizes that facilitating correct body alignment for a dependent client may
well result in which of the following positive client outcomes? (Select all that apply.)
1. A comfortable nights sleep
2. Minimized activity intolerance
3. Muscle tone that promotes ambulation
4. Reduction of falls caused by general weakness
5. Minimal strain placed on the spinal column
6. Increased socialization, resulting in peace of mind
ANS: 1, 2, 3, 4, 5
Test Bank
47-18
Correct body alignment reduces strain on musculoskeletal structures, aids in maintaining

adequate muscle tone, promotes comfort, and contributes to balance and conservation of
energy. Although a client experiencing the benefits of proper body alignment and thus
experiencing the positive outcomes may well experience increased peace of mind, there
is not a clear connection between the two.
PTS: 1
DIF: C
REF: 1227
OBJ: Analysis
2. The nurse chooses to use a mechanical lift to move an obese immobile client. The nurse
recognizes that the positive outcomes for both the client and the staff resulting from this
intervention will be: (Select all that apply.)
1. Less of the clients body will be dragged along the sheets during the transfer
2. There will be less chance of injuring the skin on the clients elbows and buttocks
3. The staff involved in the transfer will have less likelihood of self-injury
4. The staff will have a greater degree of control over the move
5. The client will feel physically safer during the transfer
6. The move will be accomplished more quickly
ANS: 1, 2, 3, 4
Mechanical lifts raise the client off the surface of the bed, thereby preventing friction,
tearing, or shearing of the clients delicate skin; it also protects the nurse and other staff
from injury. There is no guarantee that the move will be quicker or that the client will feel
safer.
PTS: 1
DIF: C
REF: 1228
OBJ: Analysis
3. A 16-year-old has had a full leg cast in place for 2 months, and it is being removed today.
Which of the following assessment findings would be expected following the removal of
the cast? (Select all that apply.)
1. Popliteal pulse equal in both legs
2. Slight footdrop noted on affected leg
3. Swelling noted at ankle on affected leg
4. Weight bearing less stable on affected leg
5. Calf circumference greater in unaffected leg
6. Greater range of motion of knee of unaffected leg
ANS: 1, 4, 5, 6
Even this temporary immobilization results in some muscle atrophy, loss of muscle tone,
and joint stiffness. Pulses should be equal, and there should not be swelling or footdrop
on either foot.
Test Bank
47-19
PTS: 1
DIF: C
REF: 1229
OBJ: Analysis
4. Which of the following factors has an impact on the severity of physical impairment a
client will experience from a period of immobility? (Select all that apply.)
1. The clients age
2. Prior overall health
3. Length of immobility
4. The degree of immobility
5. Situation requiring the inactivity
6. Clients mental attitude about the limitations
ANS: 1, 2, 3, 4
The severity of the impairment depends on the clients overall health, degree and length
of immobility, and age. The resulting effects are not dictated by situation or attitude.
PTS: 1
DIF: C
REF: 1236
OBJ: Analysis
5. A client who experienced a myocardial infarction has been placed on bed rest. The nurse
caring for the client recognizes that the inactivity will result in certain assessment
findings that include: (Select all that apply.)
1. Lethargy
2. Confusion
3. Depression
4. Poor appetite
5. Hypoactive bowel sounds
6. Decrease in baseline respiratory rate
ANS: 1, 4, 5, 6
Immobility disrupts normal metabolic functioning; decreasing the metabolic rate; altering
the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and
calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite
and slowing of peristalsis. Cognitive and psychological alterations are not directly caused
by the inactivity.
PTS: 1
DIF: C
REF: 1238
OBJ: Analysis

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Potter & Perry: Fundamentals of Nursing, 7th Edition

like it was before the break.

vascular accident (CVA)

Correct body alignment reduces strain on musculoskeletal structures, aids in maintaining

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