NCLEX Style Critical Thinking Questions On Mobility
(84).jpg "NCLEX Style Critical Thinking Questions On Mobility - Quiz")
From FUNDAMENTALS SUCCESS: A Course Review Applying Critical Thinking to Test Taking by Nugent and Vitale, pages 238-251
Questions and Answers
- 1.
Which nursing action is most dependent on the principle: "the wider the base of support the greater the stability"? ( p.238)
- A.
Carrying a heavy object
- B.
Raising the side rails on a bed
- C.
Repositioning a trochanter roll
- D.
Transferring a patient from a bed to a chair
Correct Answer
D. Transferring a patient from a bed to a chairExplanation
(a) Carrying a heavy object
This follows the principle "The closer an object is to the center of gravity, the greater the stability and the easier the object is to move"
(b) Raising the side rails on a bed
Side rails protect patients from falling out of bed and follow the principle "An object in motion stays in motion until it hits an opposing force"
(c) Repositioning a trochanter roll
Trochanter rolls placed lateral to the legs between the iliac crests and knees prevent external hip rotation when the patient is in the supine position. This follows the principle "An object in motion stays in motion until it hits an opposing force"
(d) Transferring a patient from a bed to a chair
When transferring a patient from bed to char both the nurse and the patient should have their feet spread the width of their shoulders and with one foot in front of the other. Appropriate body mechanics prevents falls.Rate this question:
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- 2.
What is a basic principle associated with transferring a patient from a bed to a chair using a mechanical lift? (p. 238)
- A.
Hook the longer chains on the end of the sling closest to the patient's feet
- B.
Ensure that there is a physician's order to use a mechanical lift
- C.
Place a sheepskin inside the sling so that it is under the patient
- D.
Lead with the patient's feet when existing the bed
Correct Answer
A. Hook the longer chains on the end of the sling closest to the patient's feetExplanation
(a) The longer chains go in the holes for the seat support, which keeps the legs and pelvis below the upper body. Appropriate placement of the upper and lower chains creates a bucket seat in which a patient is moved safely.
(b) Moving patients with a hydraulic life is within the scope of nursing practice and a practitioner's order is unnecessary.
(c) This could result in the patient's sliding down and out of the sling during the transfer. Nylon, net or canvas slings are available.
(d) it does not matter whether the feet or the head exits the bed first as long as functional alignment and safety are maintained.Rate this question:
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- 3.
Which position should be avoided for a patient at the greatest risk for the development of pressure ulcers?
- A.
Low Fowler's
- B.
Side-lying
- C.
Supine
- D.
Prone
Correct Answer
B. Side-lyingExplanation
(a) although in the low-Fowler's position the sacral area is at the greatest risk for pressure, the muscles and adipose tissues in the buttocks do provide some protection compared to other vulnerable areas of the body.
(b) In the side-lying position, the majority of the body weight is borne by the greater trochanter. the bone is close to the surface of the skin, with minimal overlying protective tissue.
(c) Although in the supine position, the occiput, scapulae, spine, elbows, sacrum, and heels are at risk for pressure, the body weight is distributed more evenly than in some other positions.
(d) Although in the prone position the ears, cheeks, acromion process, anterior superior spinous process, knees, toes, male genitalia, and female breasts are at risk for pressure, the body weight is distributed more evenly than in some other positions.Rate this question:
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- 4.
Reactive hyperemia over a bony prominence occurs in response to: (p. 128)
- A.
Applying a warm soak
- B.
Turning a patient off an affected site
- C.
Using an effleurage massage technique
- D.
Pulling a patient up in bed without a pull sheet
Correct Answer
B. Turning a patient off an affected siteExplanation
(a) heat causes vasodilation that increases circulation to the area and results in erythema, not reactive hyperemia.
(b) compressed skin appears pale because circulation to the area is impaired. When pressure is relieved, the skin takes on a bright red flush as extra blood flows to the area to compensate for the period of impeded blood flow.
(c) effleurage, light stroking of the skin, simulates the peripheral nerves and should not change skin coloration.
(d) The can cause a friction burn or a shearing force that can injure blood vessels and tissues.Rate this question:
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- 5.
Which motion occurs when the angle is reduced between the palm of the hand and forearm?
- A.
Hyperextension
- B.
Opposition
- C.
Abduction
- D.
Flexion
Correct Answer
D. FlexionExplanation
(a) hyperextension of the condyloid joint of the wrist is accomplished by bending the fingers and hand backwards as far as possible.
(b) Opposition of the thumb, which is a saddle joint, occurs when the thumb touches the top of each finger on the same hand.
(c) Abduction of the fingers (metacarpophalangeal joints - condyloid) occurs when the fingers of each hand spread apart.
(d) flexion of the wrist, a condyloid joint, occurs when the fingers of the hand move toward the inner aspect of the forearm.Rate this question:
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- 6.
Which is a local adaptation to immobility?
- A.
Renal calculi
- B.
Thrombophlebitis
- C.
Muscle contractures
- D.
Pathological fracture
Correct Answer
C. Muscle contracturesExplanation
(a) Demineralization of bone is a systemic response to immobility. Without the stress of weight-bearing activity, the bones begin to demineralize and the urine becomes more alkaline. Calcium salts precipitate out as crystals to form calculi.
(b) Thrombophlebitis results from the systemic responses of impaired venous return and hypercoagulability in conjunction with injury to a vessel wall.
(c) A contracture is a localized response to immobility. When muscle fibers are not able to shorten or lengthen, eventually a permanent shortening of the muscles and subsequently of the tendons and ligaments occurs.
(d) Immobility can cause the systemic response of demineralization of bone (disuse osteoporosis) that eventually can result in bone fractures.Rate this question:
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- 7.
What is the greatest potential problem associated with Low Fowler's position?
- A.
Dorsiflexion contractures of the feet
- B.
Pressure on the ischial tuberosities
- C.
External rotation of the hips
- D.
Adduction of the legs
Correct Answer
B. Pressure on the ischial tuberositiesExplanation
(a) Plantar flexion contractures (foot drop), not dorsiflexion contractures, can occur in the low-Fowler's position.
(b) In the low-Fowler's position, the majority of the body's weight is borne by portions of the pelvis: bony protuberances of the lower portion of the ischium (ischial tuberosities) and the triangular bone at the dorsal part of the pelvis (sacrum)
(c) This is more likely to occur in the spine, rather than the low-Folwer's position.
(d) Abduction, rather than adduction, of the legs is more likely to occur in the low-Fowler's position.Rate this question:
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- 8.
What is the best thing a nurse can do to prevent plantar flexion when making the bed?
- A.
Tuck in the top linens on just the sides of the bed
- B.
Place a toe pleat in the top linens over the feet
- C.
Let the top linens hang off the end of the bed
- D.
Use trochanter rolls to position the feet
Correct Answer
B. Place a toe pleat in the top linens over the feetExplanation
(a) Top sheets tucked in along the sides of the bed would still exert pressure on the upper surface of the feet, which may promote plantar flexion. The sides of top sheets, mitered at the foot of the bed, hang freely off the side of the bed
(b) Making a vertical or horizontal toe pleat at the foot of the bed over the patient's feet laves room for the feet to move freely and avoids exerting pressure on the upper surface of the feet, thus preventing plantar flexion.
(c) The weight of the top sheets would still exert pressure on the upper surface of the feet, promoting plantar flexion.
(d) Trochanter rolls prevent external hip rotation, not plantar flexion.Rate this question:
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- 9.
Which is a systemic adaptation to immobility?
- A.
Plantar flexion contracture
- B.
Hypostatic pneumonia
- C.
Dependent edema
- D.
Pressure ulcer
Correct Answer
C. Dependent edemaExplanation
(a) Plantar flexion contracture (foot drop) is a localized response to prolonged extension of the ankle
(b) Static respiratory secretions provide an excellent media for bacterial growth that can result in hypostatic pneumonia, which is a localized response to immobility
(c) Decreased calf muscle activity and pressure of the bed on the legs allow blood to accumulate in the distal veins. The resulting increased hydrostatic pressure moves fluid out of the intravascular compartment into the interstitial compartment, causing edema.
(d) Prolonged pressure on the skin over a bony prominence interferes with capillary blood flow to the skin, which ultimately can result in the localized response of a pressure ulcer.Rate this question:
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- 10.
Which stage pressure ulcer would just have partial thickness skin loss involving epidermis and dermis?
- A.
Stage I
- B.
Stage II
- C.
Stage III
- D.
Stage IV
Correct Answer
B. Stage IIExplanation
(a) In Stage I pressure ulcer, the skin is still intact and presents clinically as reactive hyperemia.
(b) In Stage II pressure ulcer the partial-thickness skin loss presents clinically as an abrasion, blister; or shallow crater
(c) In Stage III pressure ulcer, there is full-thickness skin loss involving the subcutaneous tissue that may extent to the underlying fascia. The ulcer presents clinically as a deep crater with or without undermining.
(d) In Stage IV pressure ulcer there is full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscles, bone or supporting structures.Rate this question:
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- 11.
The most important action when assisting a patient to move from the bed to a wheelchair
- A.
Applying pressure under the patient's axillae when standing up
- B.
Letting the patient help as much as possible when permitted
- C.
Keeping the patient's feet next to each other 1 foot apart
- D.
Lowering the bed to below the height of the wheel chair
Correct Answer
B. Letting the patient help as much as possible when permittedExplanation
(a) This should be avoided because it can injure nerves and blood vessels
(b) Encouraging the patient to be as self-sufficient as possible ensures that the transfer is conducted at their pace, promotes self-esteem and decreases the physical effort expended by the nurse.
(c) This will provide a narrow base of support and is unsafe
(d) The bed should be higher, not lower, than the wheelchair so that gravity can facilitate transferRate this question:
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- 12.
The orthopneic position is used primarily to
- A.
Facilitate respirations
- B.
Support hip extension
- C.
Prevent pressure ulcers
- D.
Promote urinary elimination
Correct Answer
A. Facilitate respirationsExplanation
(a) Sitting in the high-Fowler's position and leaning forward allows the abdominal organs to drop by gravity, which will promote contraction of the diaphragm. The arms resting on an over-bed table increases thoracic excursion.
(b) the hips will be in extreme flexion, not extension.
(c) Pressure ulcers can still occur on the ischial tuberosities
(d) Ambulation is superior to any bed position for promoting urinary elimination.Rate this question:
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- 13.
When doing ROM exercises, moving the thumb so it touches each finger is called...
- A.
Flexion
- B.
Inversion
- C.
Abduction
- D.
Opposition
Correct Answer
D. OppositionExplanation
(a) Flexion of the metacarpophalangeal joints (condyloid joints) and the interphalangeal joints (hinge joints) occurs by making a fist, which decreases the angles of the joints.
(b) Inversion is turning the sole of a foot medially, which is not a range-of-motion of the hand.
(c) Abduction is moving an arm or a leg away from the midline of the body.
(d) Opposition occurs when the thumb touches the top of each finger of the same hand.Rate this question:
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- 14.
An immobilized bedridden patient is placed on a 2-hour turning and positioning program primarily to:
- A.
Support comfort
- B.
Promote elimination
- C.
Maintain skin integrity
- D.
Facilitate respiratory function
Correct Answer
C. Maintain skin integrityExplanation
(a) Although turning a patient to a new position every 2 hours provides a variety and increased comfort, these are not the primary reasons for this intervention.
(b) Although turning frequently promotes elimination, the upright positions, such as high-Fowler's and sitting, have the greater influence on elimination.
(c) Compression of soft tissue greater than 32 mm Hg prevents capillary circulation and compromises tissue oxygenation in the compressed area. Turning the patient relieves the compression of tissue in dependent areas, particularly those tissues overlying bony prominences.
(d) Although turning and positioning promotes respiratory functioning, other interventions such as sitting, deep breathing, coughing, and incentive spirometry, have a greater influence on respiratory status.Rate this question:
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- 15.
Which is the most important action related to the use of antiembolism hose?
- A.
Put them on after the patient's legs have been dependent for several minutes
- B.
Monitor the heels for blanchable erythema every eight hours
- C.
Apply body lotion before putting them on
- D.
Remove and reapply them once a day
Correct Answer
B. Monitor the heels for blanchable erythema every eight hoursExplanation
(a) this is unsafe because pressure injures fluid-filled tissue. They should be applied before, not after, the legs are dependent.
(b) Elastic stockings provide external pressure on the patient's legs to prevent pooling of blood in the veins while not interfering with arterial circulation. Inspecting the skin 3 times a day is adequate.
(c) when applying elastic stockings, lotion increases friction that can injure tissue. Baby powders can be applied to facilitate application.
(d) this is unsafe. Elastic stockings should be removed for 30 minutes 3 times a day.Rate this question:
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- 16.
A major reason injuries occur to nurses when moving patients is because nurses:
- A.
Use the longer, rather than the shorter, muscles when moving patients
- B.
Place their feet close together when transferring patients
- C.
Pull rather than push when turning patients
- D.
Misalign their backs when moving patients
Correct Answer
D. Misalign their backs when moving patientsExplanation
(a) Nurses should use the longer, stronger muscles of the thighs and buttocks when moving patients to protect their weaker back and arm muscles.
(b) Nurses should have a wide base of support when moving patients to provide better stability.
(c) Nurses should use a pulling motion to turn patients because the muscles that flex, rather than extend, the arm are stronger and pulling, rather than pushing, creates less friction and therefore less effort.
(d) misaligning the back when moving patients occurs most often when not facing the direction of the move. Twisting (rotation) of the thoracolumbar spine and flexion of the back place the line of gravity outside the base of support, which can cause muscle strain and disabling injuries.Rate this question:
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- 17.
When positioning a patient on the left side, the nurse should position the:
- A.
Right leg resting on top of the left leg
- B.
Knees in 90 degrees of flexion
- C.
Ankles in plantar flexion
- D.
Left shoulder protracted
Correct Answer
D. Left shoulder protractedExplanation
(a) the right leg should be supported on a pillow in front of the left leg.
(b) this excessive flexion can result in flexion contractures of the hip and knee if left in this position extensively.
(c) The ankles should be maintained at 90 degrees
(d) In the left lateral (side-lying) position, the left arm is positioned in front of the body with shoulder protracted. this reduces the pressure on the joint in the shoulder and the acromial process.Rate this question:
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- 18.
Which motion occurs when the ankle is turned so that the sole of the foot moves medially toward the midline?
- A.
Inversion
- B.
Adduction
- C.
Plantar Flexion
- D.
Internal Rotation
Correct Answer
A. InversionExplanation
(a) Inversion, a gliding movement of the foot, occurs by turning the sole of the foot medially toward the mid line of the body
(b) Adduction occurs when an arm or leg moves toward and beyond the midline of the body
(c) Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg.
(d) Internal rotation of a leg occurs by turning the foot and leg inward so that the toes point toward the other leg.Rate this question:
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- 19.
What should the nurse do to quickly assess a patient's tolerance to a change in position when transferring the patient from a bed to a wheelchair?
- A.
Take the patient's blood pressure
- B.
Monitor the patient for bradycardia
- C.
Establish whether or not the patient feels dizzy
- D.
Allow the patient time to adjust to the change in position
Correct Answer
C. Establish whether or not the patient feels dizzyExplanation
(a) Although a blood pressure reading may indicate the presence of hypotension, the blood pressure should be obtained before and after a transfer to allow a comparison to conclude that the hypotension is orthostatic hypotension.
(b) If the patient is experiencing orthostatic hypotension, the heart rate will increase, not decrease
(c) Feeling dizzy is a subjective adaptation to orthostatic hypotension. Obtaining feedback from the patient provides a quick evaluation of the patient's response to the transfer.
(d) This is not an assessment. This is a safe intervention for a patient who is experiencing orthostatic hypotensionRate this question:
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- 20.
To best prevent pressure ulcers when a patient is on bed rest, the nurse should:
- A.
Place an air mattress on the bed
- B.
Massage bony prominences every shift
- C.
Apply a moisture barrier to the sacral area
- D.
Raise the head of the bed to the low-Fowler's position
Correct Answer
A. Place an air mattress on the bedExplanation
(a) Air mattresses automatically and rhythmically inflate and deflate, which applies and relieves pressure on various body areas. Capillary beds close at between 12-32 mm Hg (capillary closing pressure). Any device that reduces pressure below capillary closing pressure is considered a pressure relief device. Any device that does not consistently reduce pressure below capillary closing pressure is considered a pressure reducing device.
(b) A bedridden patient is at risk for skin breakdown, and therefore 3 back rubs a day are inadequate
(c) Moisture barriers prevent skin breakdown when a patient is incontinent of urine or feces, they do not prevent pressure on the skin
(d) This increases the risk of the patient's sliding down in bed, which may cause shearing force that can injure tissue. In addition, this position increases pressure on the vulnerable sacral area.Rate this question:
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- 21.
A basic principle associated with transferring a patient using a mechanical lift
- A.
Lock the base lever in open position when moving the mechanical lift
- B.
Keep the wheels of the mechanical lift locked throughout the transfer
- C.
Ensure that the patient's feet are protected during the transfer
- D.
Raise the lift so that the patient is 6 inches off the mattress
Correct Answer
C. Ensure that the patient's feet are protected during the transferExplanation
(a) The width of these depends on the configuration of the bed, objects in the room, and the ultimate destination. The base usually is locked open when lifting or lowering the patient and locked closed when moving the lift.
(b) The wheels must be unlocked to move the lift from under the bed to its ultimate destination
(c) The legs dangle from the sling and therefore may drag across the linens or hit other objects if not protected.
(d) This is unsafe. The life should raise the patient high enough to clear the surface of the bed.Rate this question:
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- 22.
Which complication of immobility would be of most concern?
- A.
Dehydration
- B.
Incontinence
- C.
Contractures
- D.
Hypertension
Correct Answer
C. ContracturesExplanation
(a) Dehydration is not an adaptation to immobility
(b) The decreased tone of the urinary bladder and the inability to assume the normal voiding position in bed promotes urinary retention, rather than urinary incontinence.
(c) Contractures result from permanent shortening of muscles, tendons, and ligaments. Contractures are irreversible without surgical intervention.
(d) With immobility, the increased heart rate reduces the diastolic pressure. In addition, there is a decrease in blood pressure related to postural changes from lying to sitting or standing (orthostatic hypotension). This situation is manageable with a priority on maintaining patient safety.Rate this question:
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- 23.
Which stage pressure ulcer would require the nurse to measure the extent of undermining?
- A.
Stage 0
- B.
Stage I
- C.
Stage II
- D.
Stage III
Correct Answer
D. Stage IIIExplanation
(a) There is no Stage 0 in the classification system for staging pressure ulcers.
(b) The skin is still intact and there is no undermining in a Stage I pressure ulcer.
(c) Tissue damage is superficial and there is no undermining in a Stage II pressure ulcer.
(d) IN a Stage III pressure ulcer there is full thickness skin loss involving damage to subcutaneous tissue that may not be undermining, which is tissue destruction underneath intact skin along wound margins.Rate this question:
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- 24.
Which intervention is unnecessary when assisting the patient with active range of motion exercises?
- A.
Supporting above and below the joint being moved
- B.
Positioning the patient in the supine position in bed
- C.
Providing on-going encouragement and supervision
- D.
Moving the joint through its full range at least three times
Correct Answer
B. Positioning the patient in the supine position in bedExplanation
(a) Stabilization of body parts ensures that only the joint moves through its full range of motion.
(b) The supine position is more appropriate for performing passive range-of-motion exercises. Active range-of-motion exercises can be performed in any comfortable position.
(c) This promotes motivation and correct completion of the procedure.
(d) Subsequent contraction of muscles tends to be more extensive and efficient, facilitating fuller range of motion.Rate this question:
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- 25.
Which word is most closely associated with nursing care strategies to maintain functional alignment when patients are bedridden?
- A.
Endurance
- B.
Strength
- C.
Support
- D.
Balance
Correct Answer
C. SupportExplanation
(a) Endurance relates to aerobic exercise that improves the body's capacity to consume oxygen for producing energy at the cellular level.
(b) Strength relates to isometric and isotonic exercises, which contract muscles and promote their development.
(c) The line of gravity passes through the center of gravity when the body is correctly aligned; this results in the least amount of stress on the muscles, joints, and soft tissues. Bedridden patients often need assistive devices such as pillows, sandbags, bed cradles, wedges, rolls, and splints to support and maintain the vertebral column and extremities in functional alignment.
(d) Balance relates to body mechanics, and is achieved through a wide base of support and a lowered center of gravity.Rate this question:
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- 26.
Which is a localized adaptation to immobility?
- A.
Orthostatic Hypotension
- B.
Muscle Atrophy
- C.
Osteoporosis
- D.
Atelectasis
Correct Answer
D. AtelectasisExplanation
(a) A systematic response to immobility is a decrease in blood pressure related to postural changes from lying to sitting or standing (orthostatic hypotension).
(b) After 24 to 36 hours of inactivity, all the muscles begin to lose their contractile strength, the initial process of atrophy, which is a systemic response to mobility.
(c) Osteoporosis, a systemic response to immobility, is demineralization of bone because of the lack of weight-bearing activity.
(d) The pooling of respiratory secretions that block the bronchioles and the decreased production of surfactant associated with immobility cause the localized effect of ATELECTASIS (Collapse of all or part of a lung)Rate this question:
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- 27.
How is the right arm positioned when using the left Sims' position?
- A.
On a pillow
- B.
Behind the back
- C.
With the palm up
- D.
In internal rotation
Correct Answer
A. On a pillowExplanation
(a) In the left Sim's position the patient's right arm and leg are supported on pillows to prevent internal rotation of the shoulder and the hip.
(b) The right arm is positioned in front of, not behind, the back
(c) The right hand is positioned in pronation, not supination
(d) The right arm is positioned to maintain the shoulder in external, not internal rotation.Rate this question:
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- 28.
Which would be the best example of a discharge goal for a patient with a nursing diagnosis of Impaired Physical mobility? The patient will:
- A.
Understand range of motion exercises
- B.
Transfer independently to a chair
- C.
Be taught ROM exercises
- D.
Be kept clean and dry
Correct Answer
B. Transfer independently to a chairExplanation
(a) This goal is not measurable as stated. Understanding is not measurable unless parameters are identified.
(b) This goal is patient-centered and measurable.
(c) This is a nursing intervention, not a patient goal.
(d) This is a nursing goal, not a patient goal.Rate this question:
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- 29.
Which assessment reflects a defining characteristic that would support the nursing diagnosis Impaired Physical Mobility?
- A.
Exertional fatigue
- B.
Sedentary lifestyle
- C.
Limited Range of Motion
- D.
Increase Respiratory Rate
Correct Answer
C. Limited Range of MotionExplanation
(a) This is a defining characteristic of the nursing diagnosis Activity Intolerance.
(b) This is a contributing factor for the nursing diagnosis Activity Intolerance
(c) Limited range of motion is a defining characteristic of the nursing diagnosis Impaired Physical Mobility
(d) An increased respiratory rate would be an adaptation to activity, not a defining characteristic of the nursing diagnosis Impaired Physical Mobility.Rate this question:
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- 30.
Which action is specifically related to the principle, "the greater the base of support, the more stable the body?"
- A.
Keeping the back straight when lifting an object
- B.
Holding objects close to the body when walking
- C.
Locking the wheels of a wheelchair
- D.
Using a walker when ambulating
Correct Answer
D. Using a walker when ambulatingExplanation
(a) This follows the principle: Balance is maintained and muscle strain is limited as long as the line of gravity passes through the base of support.
(b) This follows the principle: The closer an object is held to the center of gravity the greater the stability and the easier the object is to move.
(c) This follows the principle An object with wheels that are locked will remain stationery.
(d) Walkers surround a person on three sides and provide 4 points of contact with the floor. This wide base provides the best support available for assisted ambulation.Rate this question:
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- 31.
Which motion occurs when in the supine position the ankle is bent so that the toes are pointed towards the ceiling?
- A.
Supination
- B.
Adduction
- C.
Dorsal flexion
- D.
Plantar extension
Correct Answer
C. Dorsal flexionExplanation
(a) Supination occurs when the hand and forearm rotate so that the palm of the hand is facing upward
(b) Adduction occurs when an arm or leg moves toward and/or beyond the midline of the body
(c) Dorsal flexion (dorsiflexion) of the joint of the ankle occurs when the toes of the foot point upward and backward toward the anterior portion of the lower leg.
(d) There is no range of motion called plantar extension. Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg.Rate this question:
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- 32.
Which position would contribute most to the formation of a hip flexion contracture?
- A.
Semi-fowler's
- B.
Orthopneic
- C.
Supine
- D.
Sim's
Correct Answer
B. OrthopneicExplanation
(a) In the semi-Fowler's position the hips are slightly flexed (135-165 degrees)
(b) While in the high-Fowler's position the patient is then positioned leaning forward with arms resting on an over-bed table. In the orthopneic position, the hips are extensively flexed at the hips creating an angle less than 90 degrees.
(c) In the supine position, the hips are extended (180 degrees) and not flexed.
(d) In the Sims' position, the him and knee of the upper leg are just slightly flexedRate this question:
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- 33.
The presence of which adaptation is most important to assess before administering passive ROM exercises?
- A.
Weakness
- B.
Flaccidity
- C.
Atrophy
- D.
Pain
Correct Answer
D. PainExplanation
(a) Although the extent of weakness should be assessed, it is not the priority
(b) Although the presence of flaccidity should be assessed, it is not the priority
(c) Although the degree of atrophy should be assessed, it is not the priority
(d) If the patient is experiencing pain, there will be reluctance to move. An analgesic administered before beginning these exercises will promote acceptance and tolerance of the exercisesRate this question:
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- 34.
Which medical treatment is specific for a patient with a stage IV pressure ulcer with eschar?
- A.
Heat lamp treatment three times a day
- B.
Application of a topical antibiotic
- C.
Cleansing irrigations every shift
- D.
Debridement of the wound
Correct Answer
D. Debridement of the woundExplanation
(a) Heat lamp treatments should not be used because they can cause burns
(b) Topical antibiotics are used only when the ulcer is infected, not to treat eschar
(c) Cleansing irrigations are ineffective in removing the thick fibrin-containing cells of eschar covering the surface of the wound
(d) Thick, leather-like necrotic devitalized tissue (eschar) must be removed surigally or enzymatically before wound healing can occur.Rate this question:
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- 35.
Which statement by the patient would indicate immobility-induced thrombophlebitis. "My lower left leg..."
- A.
Is tingling
- B.
Looks swollen
- C.
Has very dry skin
- D.
Feels cold when touched.
Correct Answer
B. Looks swollenExplanation
(a) the patient would feel discomfort por pain, not tingling, with thrombophlebitis
(b) A slowed blood flow and increased viscosity of the blood allow platelets and calcium to settle out against the intimal lining of a vein, which can result in thrombus formation. The inflammatory process causes calf edema, pain, heat, and erythema
(c) The skin would appear taut and shiny, not dry with thrombophlebitis
(d) The area would feel warm, not cool, to the touch with thrombophlebitisRate this question:
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- 36.
Raising the arm of over the head during range-of-motions exercise is called
- A.
Flexion
- B.
Abduction
- C.
Supination
- D.
Hyperextension
Correct Answer
A. FlexionExplanation
(a) The shoulder, a ball and socket joint, flexes by raising the arm from a position by the side of the body forward and upward to a position beside the head
(b) Abduction of the should occurs by moving the arm laterally from a resting position at the side of the body to a side position above the head, with the palm of the hand held facing away from the head.
(c) Supination occurs when the hand and forearm rotate so that the palm of the hand is facing upward
(d) Hyperextension of the arms occurs by moving an arm from a resting position at the side of the body to a position behind the body.Rate this question:
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- 37.
Which position places a patient at the greatest risk for pressure on the popliteal space?
- A.
Prone
- B.
Supine
- C.
Contour
- D.
Trendelenburg
Correct Answer
C. ContourExplanation
(a) In the prone position, there is pressure in front of, not behind, the knees.
(b) In the supine position, the hips and legs are extended, which does not exert pressure on the popliteal space.
(c) In the contour position, the head of the bed and the knee gatch are slightly elevated. The elevated knee gatch puts pressure on the popliteal spaces.
(d) In the Trendelenburg position, the hips and knees are extended, which does not exert pressure on the popliteal space.Rate this question:
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- 38.
Which new strategy has been demonstrated to reduce the incidence of fractured hips among institutionalized older adults?
- A.
Placing bolsters on the sides of a patient's bed
- B.
Dressing a patient with a hip protector undergarment
- C.
Putting an alarm under a patient's wheelchair cushion
- D.
Positioning mats on the floor alongside a patient's bed
Correct Answer
B. Dressing a patient with a hip protector undergarmentExplanation
(a) Bolsters prevent arms and legs from becoming entangled in bed rails
(b) If a padded undergarment is worn when a fall occurs, the padding provides protection for the bony prominences of the pelvis and femurs.
(c) Although this has reduced accidents, not all patients at risk for falls need wheelchairs. The majority of patients who fracture their hips are ambulatory.
(d) Rugs or mats on the floor increase the risk of falls and injury.Rate this question:
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- 39.
When a patient with hemiparesis uses a cane, the nurse needs to teach the patient to:
- A.
Advance up a step with the weak leg first followed by the strong leg and cane
- B.
Adjust the can height 12 inches lower than the waist
- C.
Hold the cane in the strong hand when walking
- D.
Look at the feet when walkng
Correct Answer
C. Hold the cane in the strong hand when walkingExplanation
(a) The unaffected leg should be advanced first because the weight of the body is lifted to the next step on the leg with the greatest strength.
(b) With the tip of the cane placed 6 inches lateral to the foot, the handle should be at the level of the patient's greater trochanter to ensure that the elbow will be flexed 15 to 30 degrees when using the cane
(c) A cane is a hand-gripped assistive device; therefore, the hand opposite to the hemiparesis should hold the cane. Exercises can strengthen the flexor and extensor muscles of the arms and the muscles that dorsiflex the wrist.
(d) This will cause flexion of the neck, hips, or waist that will move the center of gravity outside the line of gravity. Proper body alignment (posture) is essential for balance, stability, and safe ambulation.Rate this question:
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- 40.
Logrolling when positioning a patient is most important when the patient has had:
- A.
Spinal cord trauma
- B.
Abdominal surgery
- C.
A long leg cast applied
- D.
Cerebral vascular accident
Correct Answer
A. Spinal cord traumaExplanation
(a) Logrolling turns a patient while keeping the vertebral column, including the head and neck, in straight alignment to prevent twisting (rotation) that can injure the spinal cord
(b) Pressure of a pillow or the hands held against the abdomen supports an abdominal surgical incision, not log rolling.
(c) This patient does not need to be logrolled. The entire leg from hip to ankle should be supported when turning a patient with a long leg cast.
(d) This patient does not need to be logrollwed. The side of the body with hemiparesis or hemiplegia must be supported.Rate this question:
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- 41.
Which causes the MOST concern when a person is in the supine position?
- A.
Increased cardiac workload
- B.
Urinary tract infection
- C.
Venous pooling
- D.
Sacral pressure
Correct Answer
A. Increased cardiac workloadExplanation
(a) The supine position increases venous return because the blood does not flow against gravity to return to the heart. An increased venous return increases the workload on the heart by 30 percent, which places the patient at risk for heart failure.
(b) Although prolonged immobility in the supine position can cause urinary stasis that increases the risk for urinary tract infections, it is not the greatest concern.
(c) Venous pooling occurs when the legs are dependent, not when they are level with the heart as they are in the supine position.
(d) Although the supine position causes sacral pressure, is is not the greatest cocnern.Rate this question:
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- 42.
Which health problem would place a patient at the greatest risk for complications associated with immobility?
- A.
Quadriplegia
- B.
Incontinence
- C.
Hemiparesis
- D.
Confusion
Correct Answer
A. QuadriplegiaExplanation
(a Quadriplegia, the paralysis of all four extremities, places the patient at greatest risk for pressure ulcers because the patient has no ability to shift the body weight off of bony prominences or change position without total assistance
(b) Bladder and bowel retraining, incontinence devices, and meticulous skin care limit the potential for skin breakdown when patients are incontinent
(c) Hemiparesis, muscle weakness on one side of the body, does not prevent a person from shifting or changing position to relieve pressure on the skin
(d) Confused patients can move independently when uncomfortable or when encouraged and assisted to move by the nurse.Rate this question:
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- 43.
When an older adult is afraid of falling, the most common consequence is:
- A.
Impaired skin integrity
- B.
Occurrence of panic attacks
- C.
Self-imposed social isolation
- D.
Decreased physical conditioning
Correct Answer
D. Decreased pHysical conditioningExplanation
(a) A person who chooses not to ambulate still has the ability to assume many different sitting or lying down positions.
(b) Anxiety and ultimately panic that is precipitated by a situation can be prevented by avoiding the situation.
(c) A person who chooses not to ambulate still can socialize
(d) Most falls occur when ambulating. Fear of falling results in the conscious choice not to place oneself in a position where a fall can occur. Disuse and muscle wasting cause a reduction of muscle strength at the rate of 5 to 10 percent per week so that within 2 months of immobility over 50 percent of a muscle's strength can be lost. In addition, there is a decreased cardiac reserve. These adaptations result in decreased physical conditioning.Rate this question:
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- 44.
To best evaluate an ambulating patient's balance, the nurse should assess the patient's:
- A.
Posture
- B.
Strength
- C.
Energy level
- D.
Respiratory Care
Correct Answer
A. PostureExplanation
(a) Assessing posture will identify whether the patient's center of gravity is in the midline from the middle of the forehead to a midpoint between the feet and therefore balanced within the patient's base of support.
(b) Strength has more to do with the exertion of power, not balance.
(c) energy has more to do with endurance, not balance
(d) Assessing respiratory rate establishes a baseline against which to compare respiratory rate after activity to determine tolerance, not balance.Rate this question:
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- 45.
Which safety measure is most important when using a mechanical lift to move a patient from a bed to a wheelchair?
- A.
Hook the shorter chains on the sling closest to the patient's feet
- B.
Cross the patient's arms across the chest throughout the transfer
- C.
Center the sling under the patient from the shoulders to just above the knees
- D.
Release the hydraulic valve on the lift swiftly while lowering the patient on the chair.
Correct Answer
C. Center the sling under the patient from the shoulders to just above the kneesExplanation
(a) This will place the lower part of the body level to or above the lower body, which is an unsafe, unstable position because the body is not balanced with the center of gravity in the "seat" of the sling. The shorter chains go in the holes closes to the head, not the feet.
(b) The patient can either cross the arms on the chest or grasp the shorter chains during the transfer
(c) Centering the sling ensures full support between the shoulders and the knees and with the correct placement of the chains places the center of gravity in the "seat" if the sling. Centering the sling just above the knees prevents pressure on the popliteal space and prevents extension of the lower legs, which would alter the center of gravity and be unsafe.
(d) The hydraulic valve should be opened slowly, not swiftly because sling movement can be frightening and sudden movement can unbalance the lift.Rate this question:
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- 46.
Which is a potential problem associated with the supine position?
- A.
Flexion on the knees
- B.
Pressure on the heels
- C.
Pressure on the trochanters
- D.
Internal rotation of the hips
Correct Answer
B. Pressure on the heelsExplanation
(a) the knees are extended, not flexed, when in a supine position,
(b) the supine position is a back-lying position that results in pressure in the heels (calcaneus), which have minimal tissue between the bone and skin, making them vulnerable to the development of pressure ulcers.
(c) There is no pressure on either greater trochanter when in the supine position. Pressure on the greater trochanter occurs when the patient is in a lateral (side-lying) position.
(d) External rotation, not internal rotation, of the hips tends to occur when a patient is in the supine position.Rate this question:
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- 47.
When lifting a patient, strain to the nurse can be reduced when the nurse:
- A.
Moves the patient up against gravity
- B.
Uses the large muscles of the legs
- C.
Keeps the knees locked
- D.
Bends from the waist
Correct Answer
B. Uses the large muscles of the legsExplanation
(a) Muscle strain is reduced when moving patients with gravity, not with added effort needed to move patients against gravity.
(b) The gluteal and leg muscles should be used rather than the sacrospinal muscles of the back to exert an upward lift. These larger muscles fatigue less quickly, and their use protects the intervertebral disks.
(c) the muscles of the legs are used inefficiently when the knees are kept locked. This increases the strain on the other muscles being used.
(d) Bending from the waist increases the strain on the sacrospinal muscles and intervertebral disks.Rate this question:
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- 48.
What should the nurse use to best limit perspiration on dependent skin surfaces of a patient on bed rest?
- A.
Ventilated heel protectors
- B.
Air-filled rings
- C.
Air mattress
- D.
Sheepskin
Correct Answer
D. SheepskinExplanation
(a) these protect only the heels, not the other dependent areas of the body.
(b) Air-filled rings usually are made of plastic that tends to promote sweating. Air rings are rarely used because they are designed for just the sacral area and often they increase , not decrease, pressure.
(c) Air mattresses usually are made of plastic which tends to promote sweating
(d) The soft tuffs of sheepskin allow air to circulate, thereby promoting the evaporation of moisture that can precipitate skin breakdownRate this question:
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- 49.
Which is the primary reason why immobilized people develop contractures?
- A.
Muscles that flex, adduct, and internally rotate are stronger than weaker opposing muscles
- B.
Muscle mass and strength decline at a rate of 5 to 10 percent per week
- C.
Muscular contractures occur because of excessive muscle flaccidity
- D.
Muscle catabolism exceeds muscle anabolism
Correct Answer
A. Muscles that flex, adduct, and internally rotate are stronger than weaker opposing musclesExplanation
(a) The state of balance between muscles that serve to contract in opposite directions is impaired with immobility. The fibers of the stronger muscles contract for longer periods that do those of the weaker, opposing muscles. This results in a change in the loose connective tissue to a more dense connective tissue and to fibrotic changes that limit range of motion.
(b) Disuse and muscle wasting cause a reduction in muscle strength at the rate of 5 tp 10 percent a week so that within 2 months over 50 percent of a muscle's strength can be lost.
(c) Contractures occur because of muscle spasticity and shortening, not muscle flaccidity.
(d) This is unrelated to contractures. In unused muscles, catabolism exceeds anabolism, and the muscles decrease in size (disuse atrophy)Rate this question:
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- 50.
Which action occurs when you turn the palm of the hand downward?
- A.
External rotation
- B.
Circumduction
- C.
Lateral flexion
- D.
Pronation
Correct Answer
D. PronationExplanation
(a) External rotation of the shoulder, a ball-and-socket joint, occurs when the upper arm is held parallel to the floor, the elbow is at a 90-degree angle, and the fingers are pointing toward the floor and the person moves the arm upward so that the fingers point toward the ceiling.
(b) Circumduction of the shoulder, a ball-and-socket joint, occurs when an extended arm moves forward, up, back and down in a full circle.
(c) Lateral flexion of the hand occurs with both abduction (radial flexion) and adduction (ulnar flexion). With the hand supinated, radial flexion occurs by bending the wrist laterally toward the fifth finger.
(d) Pronation of the hand occurs by rotating the hand and arm so that the palm of the hand is facing down toward the floor.Rate this question:
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Quiz Review Timeline +
Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.
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Current Version
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Aug 22, 2024Quiz Edited by
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May 07, 2013Quiz Created by
Arnoldjr2
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