NUR 155 Unit 7 CH 28 Immobility

Multiple Choice

Which of the following is NOT a potential effect of immobility on the musculoskeletal system?

• Bone fragility

• Muscle atrophy

• Contracture

• Increased muscle tone

Multiple Select

Which of the following are cardiopulmonary alterations caused by immobility

• Pooling of secretions

• Cardiac workload increased

• lung expansion increased

• Circulatory stasis occurs

Multiple Select

Select all the effects of immobility on nutrition and elimination.

• Basal metabolic rate is reduced

• Urinary stasis may develop

• Muscle atrophy

• Catabolism of protein leads to negative nitrogen balance

Multiple Choice

Which of the following are psychosocial impacts that may result from immobility.

• self-concept may be altered

• sleep/rest patterns may be altered

• isolation-sensory deprivation may occur

• all of the above

Multiple Choice

Which supporting data would most likely be associated with a nursing diagnosis of 'Risk for Fall'?

• Left-sided weakness, impaired visual special perception

• Altered mobility, CVA

• Deconditioning effects of bed rest, shortness of breath

• Pressure injuries

Multiple Choice

Which of the following is NOT a musculoskeletal and nervous system intervention listed in the slides?

• Early ambulation

• Isotonic exercise

• Pain assessment and treatment

• Medication administration

Open Ended

Explain the importance of positioning devices such as pillows, splints, braces, and handrolls in musculoskeletal and nervous systems in the immobile client

Multiple Choice

Which of the following are used for fall prevention and safe ambulation in musculoskeletal and nervous system interventions?

• Trochanter rolls

• Logrolling

• Ambulation aids

• Splints and braces

Multiple Select

How does the use of lift equipment maximize client assistance and reduce injuries to nurses during safe client movement?

• reduces nurse injury

• maanceximizes client assist

• Makes transfer easier on the nurse

• Is the patient preference

Multiple Select

Which of the following interventions help prevent deep vein thrombosis in cardiopulmonary system care?

• Teach client to perform leg, ankle, and foot exercises

• Apply antiembolism hose

• Raise the head of the bed

• Avoid placing pressure on lower extremities

Multiple Choice

Which of the following is NOT a recommended nutrition intervention for clients according to the slide?

• Offer clients meals that include lean protein

• Offer larger, less frequent meals

• Involve clients in dietary choices

• Encourage adequate fluid intake

Multiple Select

Which interventions are recommended for elimination according to the slide?

• Adequate fluid intake

• Position changes

• Toileting program

• Bedside commode

Open Ended

Why is it important to turn immobile clients at least every 2 hours and using pressure-relieving mattresses in skin interventions

Multiple Choice

Which of the following is a psychosocial intervention that helps orient the client to reality?

• Encourage contact with family and friends

• Explain all procedures

• Orient client to reality

• Refer to community resources