Chapter 28: ImmobilityPotter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE

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2. A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take? a. Moves patient’s arm in a full circle b. Moves patient’s arm cros... s the body as far as possible c. Moves patient’s arm behind body, keeping elbow straight d. Moves patient’s arm until thumb is upward and lateral to head with elbow flexed ANS: D 4. A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse’s action? a. Prevention of atelectasis b. Prevention of renal calculi c. Prevention of pressure ulcers d. Prevention of joint contractures ANS: D 8. A nurse reviews an immobilized patient’s laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient? a. Hypostatic pneumonia b. Renal calculi c. Pressure ulcers d. Thrombus formation ANS: B 9. A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient? a. Increased appetite b. Increased diarrhea c. Increased metabolic rate d. Altered nutrient metabolism ANS: D 14. A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal? a. When observed laterally, the spinal curves align in a reversed “S” pattern. b. When observed posteriorly, the hips and shoulders form an “S” pattern. c. The arms should be crossed over the chest or in the lap. d. The feet should be close together with toes pointed out. ANS: A 15. The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding? a. The edge of the seat is in contact with the popliteal space. b. Both feet are supported on the floor with ankles flexed. c. The body weight is directly on the buttocks only. d. The arms hang comfortably at the sides. ANS: B 16. The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use? a. Supine position b. Lateral position c. Lateral position with positioning supports d. Supine position with no pillow under the patient’s head ANS: B 19. A nurse is assessing the skin of an immobilized patient. What will the nurse do? a. Assess the skin every 4 hours. b. Limit the amount of fluid intake. c. Use a standardized tool such as the Braden Scale. d. Have special times for inspection so as to not interrupt routine care. ANS: C 21. A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess? a. Imbalance b. Hemiplegia c. Muscle sprain d. Lower extremity paralysis ANS: A 22. Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan? a. A patient who is completely immobile b. A patient who is not completely immobile c. A patient at risk for single-system involvement d. A patient who is at risk for multisystem problems ANS: B [Show More]

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