Exam 1 - Mobilization - Potter/Perry

Study online at quizlet.com/_b3ybi

1.

A patient on bed rest

for several days
attempts to walk with
assistance. He
becomes dizzy and
nauseated. His pulse
rate jumps from 85 to
110 beats/min. These
are most likely
symptoms of which of
the following?

B (Orthostatic hypotension)
(Signs and symptoms of orthostatic
hypotension include dizziness, lightheadedness, nausea, tachycardia,
pallor, and even fainting.)

A) Rebound
hypertension
B) Orthostatic
hypotension
C) Dysfunctional
proprioception.
D) Central nervous
system rebound
hypotension
2.

Which action(s) are

appropriate for the
nurse to implement
when a patient
experiences
orthostatic
hypotension? (Select
all that apply.)
A) Call for
assistance.
B) Allow patient to sit
down.
C) Take patient's
blood pressure and
pulse.
D) Continue to
ambulate patient to
build endurance.
E) If patient begins to
faint, allow him to
slide against the
nurse's leg to the
floor.

A, B, C, E
(If the patient has a fainting "syncope"
episode or begins to fall, assume a
wide base of support with one foot in
front of the other, thus supporting the
patient's body weight see Fig. 38-5, A
to C. Extend one leg and let the
patient slide against it; gently lower the
patient to the floor, protecting his or
her head. Take the patient's blood
pressure and pulse as soon as
possible after incident.)

3.

Which of the
following best
motivates a
patient to
participate in
an exercise
program?
A) Giving a
patient
information
on exercise
B) Providing
information to
the patient
when the
patient is
ready to
change
behavior
C) Explaining
the
importance of
exercise
when a
patient is
diagnosed
with a
chronic
disease such
as diabetes
D) Following
up with
instructions
after the
health care
provider tells
a patient to
begin an
exercise
program

B (Providing information to the patient when the

patient is ready to change behavior)
(Patients are more open to developing an
exercise program when they are at a stage of
readiness to change their behavior. Once the
patient is at the stage of readiness, collaborate
with him or her to develop an exercise program
that fits his or her needs and provide continued
follow-up support and assistance until the
exercise program becomes a daily routine.)

4.

Which of the following is

a principle of proper
body mechanics when
lifting or carrying
objects?
A) Keep the knees in a
locked position.
B) Bend at the waist to
maintain a center of
gravity.
C) Maintain a wide base
of support.
D) Hold objects away
from the body for
improved leverage.

5.

Which group of patients

is at most risk for
severe injuries related
to falls?
A)
B)
C)
D)

6.

Adolescents
Older adults
Toddlers
Young children

A nurse plans to provide

education to the parents
of school-aged children
and includes which of
the following result of
children being less
physically active outside
of school?
A) An increase in
obesity
B) An increase in heart
disease
C) Higher computer
literacy
D) Improved school
attendance and grades

C (Maintain a wide base of support.)

7.

(Maintaining a wide base of support

allows for proper body mechanics.
Locking the knees or bending at the
waist causes strain on the lower
back. Holding objects close to the
body helps use the center of
gravity for leverage.)

A) "As long as we use proper

body mechanics, no one will
get hurt."
B) "The patient only weighs
125 lb. You don't need my
assistance."
C) "Call the lift-team for
additional assistance."
D) "The two of us can easily
lift the patient."

B (Older Adults)
(Some older adults walk more slowly
and are less coordinated. They also
take smaller steps, keeping their
feet closer together, which
decreases the base of support.
Thus body balance is unstable, and
they are at greater risk for falls and
injuries)

8.

A (An increase in obesity)

(It is increasingly clear that children
are less active, resulting in an
increase in childhood obesity.
Strategies for physical activity
incorporated early into a child's
daily routine may provide a
foundation for lifetime commitment
to exercise and physical fitness.)

A nursing assistive
personnel asks for help to
transfer a patient who is 125
pounds (56.8 kg) from the bed
to a wheelchair. The patient
is unable to assist. What is
the nurse's best response?

You are transferring a patient

who weighs 320 lb (145.5 kg)
from his bed to a chair. The
patient has an order for
partial weight bearing as a
result of bilateral
reconstructive knee surgery.
Which of the following is the
best technique for transfer?

C ("Call the lift-team for

additional assistance.")
(Body mechanics alone are not
sufficient to prevent
musculoskeletal injuries when
positioning or transferring
patients see Table 38-1.
Teaching the use of patienthandling equipment or the use
of a lift-team in combination
with proper body mechanics is
more effective.)

D (Use the ceiling-mounted

lift.)
(The use of patient-handling
equipment helps prevent injury
to health care workers and
patients.)

A) Use a transfer board.

B) Obtain a stand assist
device.
C) Implement a three-person
carry.
D) Use the ceiling-mounted
lift.
9.

Which is the correct gait

when a patient is ascending
stairs on crutches?
A) A modified two-point gait.
The affected leg is advanced
between the crutches to the
stairs.
B) A modified three-point
gait. The unaffected leg is
advanced between the
crutches to the stairs.
C) A swing-through gait.
D) A modified four-point gait.
Both legs advance between
the crutches to the stairs.

B (A modified three-point gait.

The unaffected leg is
advanced between the
crutches to the stairs.)
(When ascending stairs on
crutches, the patient usually
uses a modified three-point
gait see Fig. 38-13)

10.

A patient recovering from

bilateral knee replacements
is prescribed bilateral
partial weight bearing. You
reinforce crutch walking
knowing that which of the
following crutch gaits is
most appropriate for this
patient?
A)
B)
C)
D)

11.

12.

13.

(The two-point gait requires at

least partial weight bearing on
each foot see Fig. 38-12. The
patient moves a crutch at the
same time as the opposing
leg, so that the crutch
movements are similar to arm
motion during normal walking.)

Two-point gait
Three-point gait
Four-point gait
Swing-through gait

A patient on week-long bed

rest is now performing
isometric exercises. Which
nursing diagnosis best
addresses the safety of this
patient?
A) Disturbed thought
processes
B) Impaired skin integrity
C) Disturbed body image
D) Risk for activity
intolerance

B (Three-point gait)
(Three-point alternating, or
three-point, gait requires the
patient to bear all of the weight
on one foot. In a three-point
gait, the patient bears weight
on both crutches and then on
the uninvolved leg, repeating
the sequence see Fig. 38-12,
B)

D (Risk for activity intolerance)

(The nursing diagnosis, risk for
activity intolerance, best
relates to patient safety
because of the potential for
orthostatic hypotension
associated with prolonged bed
rest.)

Which of the following

activities does the
nurse delegate to
nursing assistive
personnel in regard to
crutch walking?
(Select all that apply.)
A) Notify nurse if
patient reports pain
before, during, or
after exercise.
B) Notify nurse of
patient complaints of
increased fatigue,
dizziness, lightheadedness when
obtaining vital signs
before and/or after
exercise.
C) Notify nurse of vital
sign values.
D) Evaluate the
patient's ability to use
crutches properly.
E) Prepare the patient
for exercise by
assisting in dressing
and putting on shoes.

Two-point gait
Three-point gait
Four-point gait
Swing-through gait

A patient with a right knee

replacement is prescribed
no weight bearing on the
right leg. You reinforce
crutch walking knowing that
which of the following crutch
gaits is most appropriate for
this patient?
A)
B)
C)
D)

A (Two-point gait)

14.

Select statements that

apply to the proper
use of a cane. (Select
all that apply.)
A) For maximum
support when walking,
the
patient places the
cane forward 15 to 25
cm (6 to 10 inches),
keeping body weight
on both legs. The
weaker leg is moved
forward to the cane so
body weight is divided
between the cane and
the stronger leg.
B) A person's cane
length is equal to the
distance between the
elbow and the floor.
C) Canes provide less
support than a walker
and are less stable.
D) The patient needs
to learn that two
points of support such
as both feet or one
foot and the cane need
to be present at all
times.

A, B, C, E
(These are all correct as they are
within the nursing assistive personnel
activities e.g., notifying the nurse or
completing assigned activities.
Evaluation is within the scope of
professional nursing practice and is
not delegated.)

A, C, D
(A person's cane length is equal to
the distance between the greater
trochanter and the floor. For
maximum support when walking, the
patient places the cane forward 15 to
25 cm 6 to 10 inches, keeping body
weight on both legs. The patient
needs to learn that two points of
support i.e., both feet or one foot
and the cane are present at all
times.)

15.

A patient is discharged
after an exacerbation of
chronic obstructive
pulmonary disease
(COPD). She states, "I'm
afraid to go to pulmonary
rehabilitation." What is
your best response?
A) Pulmonary
rehabilitation provides a
safe environment for
monitoring your
progress.
B) You have to
participate or you will be
back in the hospital.
C) Tell me more about
your concerns with going
to pulmonary
rehabilitation.
D) The staff at our
pulmonary rehabilitation
facility are professionals
and will not cause you
any harm.

16.

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
B) Respirations 26 per
minute on room air
C) HR 114
D) Crackles heard on
auscultation
E) Pain reported as 3 on
scale of 0 to 10 after
medication

A (Pulmonary rehabilitation
provides a safe environment for
monitoring your progress.)

17.

(Pulmonary rehabilitation is
beneficial in helping patients reach
an optimal level of functioning.
Some patients are fearful of
participating in exercise because
of the potential of worsening
dyspnea difficulty breathing.
Pulmonary rehabilitation provides a
safe environment for monitoring
the progress of patients.)

A) Call the health care

provider to report this
change in condition.
B) Give the patient a paper
bag to breathe into to
decrease her anxiety.
C) Assess her vital signs,
perform a respiratory
assessment, and be
prepared to start oxygen.
D) Explain that this is
normal after such trauma
and administer the ordered
pain medication.
18.

B, C
(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:

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:
A) Prevent varicose veins.
B) Prevent muscular
atrophy.
C) Ensure joint mobility
and prevent contractures.
D) Promote venous return
to the heart.

C (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.)

D (Promote venous return to the

heart.)
(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.)

19.

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?
A) "I usually go swimming
with my family at the YMCA
3 times a week."
B) "I need to ask my doctor
if I should have a bone
mineral density check this
year."
C) "If I don't drink milk at
dinner, I'll eat broccoli or
cabbage to get the calcium
that I need in my diet."
D) "I'll check the label of my
multivitamin. If it has
calcium, I can save money
by not taking another pill. "

20.

21.

D ("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.)

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?
A) Pale yellow urine
B) Unilateral neglect
C) Slight movement noted on
the R side
D) Coffee ground-like aspirate
from the feeding tube

23.

The patient at greatest risk

for developing multiple
adverse effects of
immobility is a:

B (80-year-old woman who has

suffered a hemorrhagic
cerebrovascular accident
CVA.)

A) 1-year-old child with a

hernia repair.
B) 80-year-old woman who
has suffered a hemorrhagic
cerebrovascular accident
(CVA).
C) 51-year-old woman
following a thyroidectomy.
D) 38-year-old woman
undergoing a hysterectomy.

(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?

D (Risk for activity intolerance)

A) Chronic pain
B) Impaired skin integrity
C) Risk for ineffective
cerebral tissue perfusion
D) Risk for activity
intolerance

22.

(Patients on bed rest are at

risk for activity intolerance,
which increases patients' risk
for falling.)

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.)
A) The rubber mat in the walkin shower
B) The three-legged stool on
wheels in the kitchen
C) The braided throw rugs in
the entry hallway and between
the bedroom and bathroom
D) The night-lights in the
hallways, bedroom, and
bathroom
E) The cordless phone next to
the patient's bed

D (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 groundlike matter. These are signs
of bleeding in the
gastrointestinal tract.)

B, C
(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.)

24.

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?

A (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.)

A) Cream of broccoli
soup with whole
wheat crackers and
tapioca for dessert
B) Hamburger on
soft roll with a side
salad and an apple
for dessert
C) Low-fat turkey
chili with sour
cream and fresh
pears for dessert
D) Chicken salad on
toast with tomato
and lettuce and
honey bun for
dessert
25.

Before transferring
a patient from the
bed to a stretcher,
which assessment
data does the nurse
need to gather?
(Select all that
apply.)
A) Patient's weight
B) Patient's level of
cooperation
C) Patient's ability
to assist
D) Presence of
medical equipment
E) 24-hour calorie
intake

A, B, C, D
(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 patient's 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.)

26.

A patient of
any age can
develop a
contracture
of a joint
when:
A) The
adductors
muscles are
weakened
as a result
of
immobility.
B) The
muscle
fibers
become
shortened
because of
disuse.
C) The
calcium-tophosphorus
ratio
becomes
disrupted.
D) There is
a deficiency
in vitamin
D.

B (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.)

27.

Immobilized
patients are
at risk for
impaired
skin
integrity.
Which of the
following
interventions
would reduce
this risk?
(Select all
that apply.)
A)
Repositioning
patient every
1 to 2 hours
while awake
B) Using an
objective,
valid scale to
assess
patient's risk
for pressure
ulcer
development
C) 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

B, C, D, E

28.

(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 patient's 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?
A) The patient is 5 feet 6
inches and weighs 120 lbs.
B) The patient speaks and
understands English.
C) The patient received an
injection of morphine 30
minutes ago for pain.
D) You feel comfortable
handling a patient of his
size and with his level of
cooperation.

29.

C (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?

D ("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.)

A) "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."
B) "Would you like me to
walk on your right side so
you feel more secure?"
C) "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."
D) "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.)

30.

Which is an outcome for a patient

diagnosed with osteoporosis?
A) Maintain serum level of calcium.
B) Maintain independence with
activities of daily living (ADLs).
C) Reduce supplemental sources of
vitamin D.
D) Reverse bone loss through dietary
manipulation.

B (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.)