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Mobility, Immobility and Positioning
Which term refers to the ability to move freely and independently?
Mobility refers to the ability to move freely and independently. It encompasses activities such as walking, transferring, and engaging in physical tasks.
a. Immobility refers to the inability to move freely and independently.
c. Positioning refers to the proper alignment and placement of a patient's body to optimize comfort and prevent complications.
d. Stability refers to the ability to maintain balance and equilibrium.
Which position is recommended for a patient who has difficulty breathing or respiratory distress?
Fowler's position, where the patient is sitting or semi-sitting with the head elevated, is recommended for patients with difficulty breathing or respiratory distress. This position helps maximize lung expansion and facilitates breathing.
a. The supine position refers to lying flat on the back and may not be optimal for patients with respiratory distress.
b. The prone position refers to lying flat on the stomach and is generally not recommended for patients with breathing difficulties.
d. The side-lying position may be appropriate for some patients, but Fowler's position is more suitable for respiratory distress.a
What is the primary purpose of repositioning a patient who is immobile?
Repositioning a patient who is immobile is primarily done to prevent the development of pressure ulcers. Regular repositioning helps relieve pressure on vulnerable areas and promotes blood circulation.
b. Promoting joint flexibility can be a secondary benefit of repositioning, but preventing pressure ulcers is the primary focus.
c. Increasing muscle strength may require specific exercises and therapies, not just repositioning alone.
d. Improving respiratory function may involve interventions such as deep breathing exercises and positioning techniques specific to respiratory care.
Which intervention is important for maintaining the safety of an immobile patient?
Implementing fall prevention measures is crucial for maintaining the safety of an immobile patient. This includes using appropriate assistive devices, ensuring a safe environment, and providing supervision and support during transfers.
a. Ambulation refers to walking or movement, which may not be feasible for an immobile patient. Alternative interventions are required.
b. Physical restraints should only be used as a last resort when all other measures have failed, and their use should be based on specific guidelines and regulations.
c. Soft restraints are not recommended for fall prevention and may pose additional risks and limitations for the patient.
What is the purpose of utilizing proper positioning techniques for patients?
Utilizing proper positioning techniques aims to maintain patient comfort by relieving pressure, supporting body alignment, and preventing discomfort and pain.
b. Promoting social interaction is important but not directly related to positioning techniques.
c. Facilitating ambulation involves assisting patients in walking and moving, which is different from positioning.
d. Improving coordination may be a desired outcome of rehabilitation but is not the primary purpose of positioning techniques.
Effects of Immobility on Body Systems
Which physiological effect of immobility can lead to impaired circulation and increased risk of deep vein thrombosis?
Immobility can lead to decreased cardiac output due to reduced activity and muscle contraction. This can result in impaired circulation, increased venous stasis, and an elevated risk of deep vein thrombosis (DVT).
a. Decreased respiratory function is a different effect of immobility and can lead to respiratory complications such as atelectasis or pneumonia.
b. Decreased muscle strength is another effect of immobility but is not directly associated with an increased risk of deep vein thrombosis.
d. Decreased bone density is a consequence of immobility, but it is not specifically related to impaired circulation and DVT.
Which respiratory complication is commonly associated with immobility?
Immobility can lead to reduced lung expansion, shallow breathing, and inadequate ventilation, which can result in hypoxia or decreased oxygenation of tissues.
a. Hyperventilation refers to an increased rate or depth of breathing and is not typically associated with immobility.
c. Hypotension refers to low blood pressure and is not directly related to respiratory complications caused by immobility.
d. Hypertension refers to high blood pressure and is not directly associated with respiratory complications caused by immobility.
Which gastrointestinal effect is commonly seen in immobile patients?
Immobility can disrupt normal bowel function, leading to decreased peristalsis and increased water absorption in the intestines, resulting in constipation.
a. Increased appetite is not a typical gastrointestinal effect of immobility.
b. Immobility generally leads to decreased peristalsis rather than increased peristalsis.
d. Diarrhea is not a typical gastrointestinal effect of immobility.
Which musculoskeletal complication can occur due to prolonged immobility?
Prolonged immobility can lead to a decrease in bone mineral density and the development of osteoporosis, a condition characterized by weak and brittle bones.
a. Immobility typically results in decreased muscle strength rather than increased muscle strength.
b. Joint flexibility may decrease due to immobility and the development of joint contractures.
d. Prolonged immobility increases the risk of contractures, which are permanent shortening of muscles and tendons leading to limited joint mobility.
Which psychological effect is commonly observed in patients experiencing immobility?
Immobility can lead to psychological distress, including increased risk of anxiety and depression due to limitations in mobility, decreased independence, and decreased social interaction.
a. Immobility often leads to decreased motivation due to the physical limitations it imposes.
b. Immobility increases the risk of depression rather than decreasing it.
c. Immobility typically decreases the sense of independence due to reliance on others for assistance.
Assessment and Prevention of Immobility Complications
Which assessment finding indicates a potential complication of immobility related to the respiratory system?
Diminished breath sounds may indicate decreased ventilation and impaired respiratory function, which can be a complication of immobility such as atelectasis or pneumonia.
a. Increased muscle strength is not typically associated with respiratory complications of immobility.
b. Increased lung expansion is not commonly observed in individuals with immobility-related respiratory complications.
d. Although the respiratory rate can be normal, it does not provide direct information about potential complications of immobility on the respiratory system.
Which intervention is important in preventing pressure ulcers in immobilized patients?
Frequent repositioning is an important intervention in preventing pressure ulcers in immobilized patients. Regular changes in position help to relieve pressure on vulnerable areas and promote circulation.
b. Encouraging immobility is not a suitable intervention as it can lead to further complications and increase the risk of pressure ulcers.
c. Maintaining prolonged periods of immobility is detrimental and increases the risk of pressure ulcers.
d. Applying tight dressings over bony prominences can contribute to pressure and damage the skin, increasing the risk of pressure ulcers.
Which assessment finding indicates a potential musculoskeletal complication of immobility?
Contractures, which are permanent shortening of muscles and tendons, can occur as a musculoskeletal complication of immobility. Contractures limit joint mobility and flexibility.
a. Increased muscle tone is not typically associated with immobility and can be a manifestation of other conditions such as spasticity.
b. Active range of motion (ROM) suggests preserved joint mobility, which is not indicative of musculoskeletal complications of immobility.
d. Strong and flexible joints are not commonly observed in individuals experiencing immobility-related musculoskeletal complications.
Which nursing intervention is important in preventing urinary complications in immobilized patients?
Implementing bladder training programs, which involve scheduled voiding and promoting continence, is important in preventing urinary complications in immobilized patients, such as urinary retention or urinary tract infections.
a. Encouraging increased fluid intake alone may not address the specific urinary complications associated with immobility.
b. Limiting toileting assistance can lead to urinary retention and complications.
d. Providing a bedpan or urinal for all voiding may not promote independence and can contribute to urinary complications.
Which assessment finding indicates a potential cardiovascular complication of immobility?
Dependent edema, characterized by swelling in the dependent parts of the body, is a potential cardiovascular complication of immobility. It can occur due to impaired venous return and increased capillary permeability.
a. Increased heart rate may or may not be present in individuals with cardiovascular complications of immobility, and it is not a specific indicator.
b. Increased cardiac output is not typically associated with immobility-related cardiovascular complications.
d. Although the blood pressure can be normal, it does not provide specific information about potential cardiovascular complications of immobility.a
Mobilization and Safe Transfer Techniques
Which nursing intervention promotes safe transfer techniques for a patient with limited mobility?
Using a transfer belt is an effective nursing intervention to promote safe transfer techniques. It provides stability and support to the patient while allowing the caregiver to maintain proper body mechanics and reduce the risk of injury.
a. Encouraging the patient to perform transfers independently without assistance can increase the risk of falls and injuries.
c. While sliding boards may be appropriate for some transfers, they may not be suitable for all patients or situations. The use of sliding boards should be based on the individual's assessment and care plan.
d. Rapidly lifting the patient is unsafe and can lead to injury for both the patient and the caregiver. Transfers should be performed with controlled movements and without haste.
Which assessment finding indicates the need for assistive devices during mobilization and transfers?
A history of falls and an unsteady gait indicate an increased risk of falls and the need for assistive devices during mobilization and transfers to ensure safety and prevent injuries.
Incorrect choices: a. Increased muscle strength and coordination may not necessarily require the use of assistive devices during mobilization and transfers. However, individual assessment is still necessary.
b. Having a normal range of motion in all joints does not directly indicate the need for assistive devices during mobilization and transfers.
d. Adequate upper body strength may be beneficial for certain transfers, but it does not solely determine the need for assistive devices. The overall safety and stability of the patient are more important considerations.
Which nursing action promotes safe mobilization and transfers for a patient with a lower extremity injury?
Providing a firm and stable surface for transfers promotes safe mobilization and transfers for a patient with a lower extremity injury. It enhances stability, reduces the risk of falls, and ensures the patient's safety during movement.
a. Encouraging the patient to avoid weight-bearing on the affected leg may be necessary initially, but as the patient progresses in their recovery, weight-bearing may be encouraged under healthcare provider guidance.
c. Assisting the patient with rapid and sudden movements during transfers is unsafe and increases the risk of falls and injuries.
d. Assistive devices should be utilized as appropriate to enhance the patient's safety and independence during mobilization and transfers. Avoiding their use may compromise the patient's safety.
What is the primary purpose of using a drawsheet during patient repositioning?
The primary purpose of using a drawsheet during patient repositioning is to facilitate the use of mechanical lifts. A drawsheet helps in sliding and transferring the patient using mechanical lift devices, ensuring both patient and healthcare provider safety during transfers.
a. While using a drawsheet can contribute to pressure ulcer prevention by minimizing shear and friction, it is not the primary purpose.
c. Patient comfort is important but not the primary purpose of using a drawsheet during repositioning.
d. Protecting the healthcare provider from injury is not the primary purpose of using a drawsheet during repositioning, although it may provide some assistance in reducing the risk of injury.
Which nursing intervention is important for preventing falls during patient transfers?
Providing clear instructions and explanations to the patient is an important nursing intervention for preventing falls during transfers. It helps ensure that the patient understands the transfer process, follows safety precautions, and cooperates during the transfer.
b. Using a single caregiver for all transfers may not be feasible or safe in all situations. The number of caregivers required should be based on the patient's needs and the complexity of the transfer.
c. Assistive devices should be utilized when necessary to promote safety during transfers. Encouraging independence does not mean avoiding their use altogether.
d. Transferring the patient quickly can compromise safety and increase the risk of falls and injuries. Transfers should be performed with controlled and deliberate movements, ensuring the patient's stability and safety throughout the process.
Which nursing intervention promotes mobility for a patient who has been on bed rest for an extended period?
Assisting the patient with passive range of motion exercises promotes joint mobility and prevents contractures and muscle atrophy when the patient is unable to move independently.
Incorrect choices: a. Encouraging the patient to remain in bed perpetuates immobility and can lead to further complications such as deconditioning and reduced muscle strength.
c. Restricting the patient's movement can worsen immobility-related complications and increase the risk of falls. Appropriate interventions should be implemented to facilitate safe mobility.
d. Restraints should be avoided as much as possible and only used as a last resort to ensure patient safety. Restraints do not promote mobility and can have negative physical and psychological effects.
Which positioning technique should the nurse use to prevent pressure ulcers in a patient with limited mobility?
Supporting bony prominences with pillows or foam pads helps distribute pressure and reduces the risk of pressure ulcers in patients with limited mobility.
a. Placing the patient in a prone position for extended periods increases the risk of pressure ulcers, especially on the anterior aspects of the body.
b. Elevating the head of the bed to 90 degrees can lead to shearing forces and increase the risk of pressure ulcers.
d. Encouraging the patient to sit in a chair for long periods without adequate repositioning can also increase the risk of pressure ulcers.
Which patient is at the greatest risk for developing deep vein thrombosis (DVT) due to immobility?
Patients who undergo surgery are at an increased risk for developing deep vein thrombosis (DVT) due to the immobility associated with the postoperative period.
a. While hypertension is a risk factor for cardiovascular diseases, it does not increase the risk of DVT specifically.
c. Regular exercise is a protective factor against DVT, as it promotes circulation and venous return.
d. Diabetes is a risk factor for peripheral vascular disease, but it does not directly increase the risk of DVT.
Which intervention should the nurse prioritize for a patient with impaired mobility to prevent respiratory complications?
Encouraging deep breathing and coughing techniques helps prevent respiratory complications such as atelectasis and pneumonia in patients with impaired mobility.
a. Administering oxygen therapy may be indicated in some cases, but it does not directly address the prevention of respiratory complications associated with impaired mobility.
b. Incentive spirometry exercises are useful for promoting lung expansion and preventing atelectasis, but they are not the highest priority intervention for preventing respiratory complications.
d. Prophylactic antibiotics are not routinely administered to all patients with impaired mobility. Their use should be based on specific indications determined by the healthcare provider.
Which nursing intervention is appropriate for preventing falls in a hospitalized patient with impaired mobility?
Providing a clutter-free environment with clear pathways reduces the risk of falls and promotes a safe ambulatory environment for patients with impaired mobility.
b. Bed rails are not recommended as a fall prevention measure due to the potential for entrapment and other associated risks. They should only be used when necessary and based on an individualized assessment.
c. Administering sedatives can increase the risk of falls by causing drowsiness and impaired cognition. It is not a suitable fall prevention intervention.
d. Leaving the patient unattended during ambulation increases the risk of falls. Patients with impaired mobility should not be left unattended.
Which position should the nurse use for a patient who is immobile to promote lung expansion and prevent respiratory complications?
The semi-Fowler's position with the knees slightly flexed promotes lung expansion by allowing the diaphragm to descend fully and reducing the risk of respiratory complications in immobile patients.
a. The supine position with the head of the bed elevated may cause the diaphragm to be restricted, limiting lung expansion and potentially leading to respiratory complications.
b. The prone position is not suitable for immobile patients and may increase the risk of pressure ulcers and respiratory difficulties.
c. The lateral position with the affected side down may compromise lung expansion and increase the risk of respiratory complications in immobile patients.
Which intervention should the nurse implement to prevent contractures in a patient who is immobile?
Encouraging frequent changes in position helps prevent contractures by promoting joint mobility and preventing prolonged pressure on specific areas.
b. Applying heat packs to stiff joints may provide temporary relief but does not address the underlying issue of immobility or prevent contractures.
c. Administering muscle relaxants is not the standard intervention for preventing contractures. The focus should be on promoting mobility and range of motion exercises.
d. Using soft restraints to immobilize the extremities is not an appropriate intervention for preventing contractures. Restraints should only be used when necessary and as a last resort, considering the patient's safety and autonomy.
Which nursing intervention is essential to prevent pressure ulcers in a patient with limited mobility?
Performing frequent and thorough skin assessments is essential for identifying early signs of pressure ulcers and implementing appropriate preventive measures in patients with limited mobility.
b. Applying petroleum jelly to vulnerable areas may create a barrier but does not address the underlying issue of pressure and does not substitute for regular skin assessments and preventive measures.
c. Placing the patient on an air mattress can provide pressure redistribution, but it should be used based on individualized assessment and healthcare provider recommendations. Skin assessments remain essential.
d. Encouraging the patient to sit for prolonged periods increases the risk of pressure ulcers. Adequate repositioning and regular mobilization should be prioritized to prevent skin breakdown.
Which intervention should the nurse implement to maintain adequate hydration in an immobile patient?
Offering fluids at room temperature can enhance the patient's comfort and promote adequate hydration in immobile patients.
b. Limiting fluid intake to prevent incontinence is not appropriate as it can lead to dehydration. Adequate hydration should be maintained, and measures to manage incontinence should be implemented separately.
c. Providing a straw for easier drinking can facilitate fluid intake, but it may not be suitable for all patients or situations. Individualized assessment and patient preference should be considered.
d. Continuous intravenous fluids may not be necessary for all immobile patients and should be based on specific indications determined by the healthcare provider. Oral intake should be encouraged unless contraindicated.
Which intervention is important for preventing venous thromboembolism (VTE) in an immobile patient?
Encouraging frequent ambulation and leg exercises helps prevent venous stasis and promotes blood flow, reducing the risk of venous thromboembolism (VTE) in immobile patients.
b. Administering sedatives can increase the risk of VTE by promoting immobility and reducing leg movement. It is not an appropriate preventive measure.
c. Applying cold compresses to the lower extremities does not directly prevent VTE. Warm compresses may be used to promote circulation, but prevention strategies primarily focus on mobilization and blood flow promotion.
d. Limiting fluid intake does not directly prevent VTE. Adequate hydration should be maintained to promote circulation and prevent complications such as dehydration and urinary tract infections.
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