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Chapter 047

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 47: Mobility and Immobility MULTIPLE CHOICE 1. A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the client, the nurse is alert to a(n): 1. Increased blood pressure 2. Decreased heart rate 3. Increased urinary output 4. Decreased peristalsis ANS: 4 Immobility causes gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. In t
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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 47: o!ility and mmo!ility#$T P$E C% CE 1.A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the client, the nurse is alert to a(n):1.Increased blood pressure2.ecreased heart rate!.Increased urinary output .ecreased peristalsisA#$:  Immobility causes gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. In the immobili%ed client, decreased circulating fluid volume, pooling of  blood in the lower e&tremities, and decreased autonomic response occur. 'hese factors result in decreased venous return, followed by a decrease in cardiac output, which is reflected by a decline in blood pressure. ecumbency increases cardiac worload and results in an increased pulse rate. *luid intae can diminish with immobility, and this combined with other causes, such as fever, increases the ris for dehydration. +rinary output may decline on or about the fifth or si&th day after immobili%ation, and the urine isoften highly concentrated.'$:1I*:A-*:122/0:omprehension'/:#ursing rocess: Assessment3$:#4-56 test plan designation: hysiological Integrity70asic are and omfort73obility7Immobility2.A 819year9old client recently suffered left9sided paralysis from a cerebrovascular accident(stroe). In planning care for this client, the nurse implements which one of the followingas an appropriate intervention1.-ncourage an even gait when waling in place.2.Assess the e&tremities for unilateral swelling and muscle atrophy.!.-ncourage holding the breath fre;uently to hyperinflate the client<s lungs. .'each the use of a two9point crutch techni;ue for ambulation.A#$:2 3osby items and derived items = 2>>?, 2>> by 3osby, Inc., an affiliate of -lsevier Inc.  'est 0an 0ecause edema moves to dependent body regions, assessment of the immobili%ed client should include the sacrum, legs, and feet. +nilateral increases in calf diameter can be an early indication of thrombosis. 'he client who has suffered a cerebrovascular accident with left9sided paralysis may not be capable of an even gait. 'o prevent stasis of  pulmonary secretions, the client@s position should be changed every 2 hours, and fluids should be increased to 2>>> m4, if not contraindicated. 'he client should deep breathe and cough every 1 to 2 hours to promote chest e&pansion. 'he client would most liely ambulate safely with a waler, or a cane. If crutches are used, the client should use a three9point support.'$:1I*:A-*:12!/0:omprehension'/:#ursing rocess: lanning3$:#4-56 test plan designation: hysiological Integrity70asic are and omfort73obility7Immobility!.'wo nurses are standing on opposite sides of the bed to move the client up in bed with a drawsheet. Bhere should the nurses be standing in relation to the client@s body as they  prepare for the move1.-ven with the thora&2.-ven with the shoulders!.-ven with the hips .-ven with the neesA#$:2'he nurses should be standing even with the client@s shoulders when they prepare to move the client up in bed.'$:1I*:A-*:12!/0:omprehension'/:#ursing rocess: Implementation3$:#4-56 test plan designation: hysiological Integrity70asic are and omfort73obility7Immobility .A client is leaving for surgery and because of preoperative sedation needs complete assistance to transfer from the bed to the stretcher. Bhich of the following should the nurse do first1.-levate the head of the bed.2.-&plain the procedure to the client.!.lace the client in the prone position. .Assess the situation for any potentially unsafe complications.A#$: 3osby items and derived items = 2>>?, 2>> by 3osby, Inc., an affiliate of -lsevier Inc. C92  'est 0an 0efore transferring the client from the bed to the stretcher, the nurse should assess the situation for any potentially unsafe complications. 'he sedated client is transferred most easily in the supine position, unless contraindicated. 'he head of the bed should be at the same level as the head of the stretcher. 'his client has had preoperative sedation, which may impair his or her cognition. 'he nurse should simplify instructions when e&plaining the procedure to the client, but this should be done immediately before transferring the client.'$:1I*:-*:128/0:Analysis'/:#ursing rocess: lanning3$:#4-56 test plan designation: hysiological Integrity70asic are and omfort73obility7Immobility.A client has se;uential compression stocings in place. 'he nurse evaluates that they are implemented appropriately by the new staff nurse when the:1.Initial measurement is made around the client@s calves2.Intermittent pressure is set at > mm Dg!.$tocings are wrapped directly over the leg from anle to nee .$tocings are removed every hour during applicationA#$:2Inflation pressures average > mm Dg. Initial measurement is made around the largest  part of the client@s thigh. A protective stocinette is placed over the client@s legE then the stocing is wrapped around the leg, starting at the anle, with the opening over the  patella. *or optimal results, se;uential compression devices ($s) or intermittent  pneumatic compression (I) are used as soon as possible and maintained until the client  becomes fully ambulatory. $tocings are not removed every hour but should be removed  periodically to assess the condition of the client@s sin.'$:1I*:A-*:12!/0:omprehension'/:#ursing rocess: -valuation3$:#4-56 test plan designation: hysiological Integrity70asic are and omfort73obility7Immobility8.'he nurse assesses that the client has torticollis and that this may adversely influence the client@s mobility. 'his individual has a(n):1.-&aggeration of the lumbar spine curvature2.Increased conve&ity of the thoracic spine!.Abnormal anteroposterior and lateral curvature of the spine .ontracture of the sternocleidomastoid muscle with a head inclineA#$: 'orticollis is inclining of the head to the affected side, in which the sternocleidomastoid muscle is contracted. 4ordosis is an e&aggeration of the lumbar spine curvature. Fyphosisis an increased conve&ity in the curvature of the thoracic spine. Fyphoscoliosis is an abnormal anteroposterior and lateral curvature of the spine. 3osby items and derived items = 2>>?, 2>> by 3osby, Inc., an affiliate of -lsevier Inc. C9!  'est 0an '$:1I*:A-*:122 /0:omprehension'/:#ursing rocess: Assessment3$:#4-56 test plan designation: hysiological Integrity70asic are and omfort73obility7ImmobilityC.An immobili%ed client is suspected of having atelectasis. 'his is assessed by the nurse upon auscultation as:1.Darsh cracles2.Bhee%ing on inspiration!.iminished breath sounds .0ronchovesicular whooshingA#$:!Atelectasis is the collapse of alveoli. In atelectasis, secretions bloc a bronchiole or a  bronchus, and the distal lung tissue (alveoli) collapses as the e&isting air is absorbed,  producing hypoventilation. If the client were suspected of having atelectasis, the nurse would e&pect diminished breath sounds in the area of hypoventilation. Darsh cracles indicate e&cessive airway secretion. Bhee%ing on inspiration indicates narrowing of the lumen of a respiratory passageway. 0ronchovesicular sounds are a mi&ture of bronchial and vesicular sounds. 0ronchovesicular whooshing would not be an e&pected sound indicating atelectasis.'$:1I*:A-*:1228/0:omprehension'/:#ursing rocess: Assessment3$:#4-56 test plan designation: hysiological Integrity70asic are and omfort73obility7Immobility.'he best approach for the nurse to use to assess the presence of thrombosis in an immobili%ed client is to:1.3easure the calf and thigh circumferences2.Attempt to elicit Domans@ sign!.alpate the temperature of the feet ./bserve for a loss of hair and sin turgor in the lower legsA#$:1alf and thigh circumferences should be measured daily. +nilateral increases in calf or thigh circumference can be an early indication of thrombosis. Domans@ sign is not always positive in the presence of thrombosis. Assessing the temperature of the feet is not the  best approach to determine the presence of thrombosis. /bserving for hair loss and sin turgor of the lower legs is not the best approach to determine the presence of thrombosis. A lac of hair may indicate a chronic lac of o&ygen. $in turgor is a measure of hydration.'$:1I*:A-*:12!/0: 3osby items and derived items = 2>>?, 2>> by 3osby, Inc., an affiliate of -lsevier Inc. C9

Chapter 038

Jul 23, 2017

Chapter 039

Jul 23, 2017
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