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Questions and Answers
What is the average inflation pressure for the application of stockings?
What is the average inflation pressure for the application of stockings?
Which action should not be performed when using compression stockings?
Which action should not be performed when using compression stockings?
What is the primary condition exhibited by a patient with torticollis?
What is the primary condition exhibited by a patient with torticollis?
After total hip replacement surgery, which device is recommended to maintain leg abduction?
After total hip replacement surgery, which device is recommended to maintain leg abduction?
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Which of the following statements about stockings is false?
Which of the following statements about stockings is false?
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Which condition is characterized by an increased convexity of the thoracic spine?
Which condition is characterized by an increased convexity of the thoracic spine?
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What should be the primary concern when using sequential compression devices?
What should be the primary concern when using sequential compression devices?
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Which of the following is NOT a characteristic of kyphoscoliosis?
Which of the following is NOT a characteristic of kyphoscoliosis?
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What is the primary focus during auscultation in a respiratory assessment for patients with restricted activity?
What is the primary focus during auscultation in a respiratory assessment for patients with restricted activity?
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What is the appropriate action for measuring calf circumference in patients at risk of DVT?
What is the appropriate action for measuring calf circumference in patients at risk of DVT?
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Which of the following actions should be avoided when assessing for DVT in a patient suspected of having one?
Which of the following actions should be avoided when assessing for DVT in a patient suspected of having one?
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When performing range-of-motion (ROM) exercises, what principle is important for a nurse to teach the patient and family?
When performing range-of-motion (ROM) exercises, what principle is important for a nurse to teach the patient and family?
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What is a priority nursing intervention for a patient who is immobile to prevent complications related to DVT?
What is a priority nursing intervention for a patient who is immobile to prevent complications related to DVT?
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In the context of respiratory assessments, what is the nurse inspecting during the inspiratory-expiratory cycle?
In the context of respiratory assessments, what is the nurse inspecting during the inspiratory-expiratory cycle?
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Which assessment technique is considered least valid for diagnosing DVTs?
Which assessment technique is considered least valid for diagnosing DVTs?
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What should be the nurse's action regarding elastic stockings in patients at risk for DVT?
What should be the nurse's action regarding elastic stockings in patients at risk for DVT?
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What is the common misconception regarding calf pain with dorsiflexion in assessing DVT?
What is the common misconception regarding calf pain with dorsiflexion in assessing DVT?
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How should a nurse approach the mobility assessment of a patient with left-sided hemiparesis after a CVA?
How should a nurse approach the mobility assessment of a patient with left-sided hemiparesis after a CVA?
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What is a significant risk factor for the development of pressure ulcers in immobilized patients?
What is a significant risk factor for the development of pressure ulcers in immobilized patients?
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When planning care for a patient at risk for pressure ulcers, what position is recommended?
When planning care for a patient at risk for pressure ulcers, what position is recommended?
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Which statement correctly reflects the cost-effectiveness of preventing pressure ulcers compared to treating them?
Which statement correctly reflects the cost-effectiveness of preventing pressure ulcers compared to treating them?
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What misconception might a nurse have regarding breaks in skin integrity for immobilized patients?
What misconception might a nurse have regarding breaks in skin integrity for immobilized patients?
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In caring for a stroke patient, what is the most appropriate nursing action?
In caring for a stroke patient, what is the most appropriate nursing action?
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What outcome might result from placing a stroke patient on bed rest without sufficient ambulation?
What outcome might result from placing a stroke patient on bed rest without sufficient ambulation?
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What is a possible consequence of insufficient assistance with eating in the context of immobility?
What is a possible consequence of insufficient assistance with eating in the context of immobility?
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How does tissue metabolism change in the context of decreased mobility?
How does tissue metabolism change in the context of decreased mobility?
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Which statement about the prevention of pressure ulcers is most accurate?
Which statement about the prevention of pressure ulcers is most accurate?
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What error might be made regarding the nutritional needs of immobile patients?
What error might be made regarding the nutritional needs of immobile patients?
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What characterizes a stage 2 pressure injury?
What characterizes a stage 2 pressure injury?
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What is the first step in assessing a pressure injury in a patient with darkly pigmented skin?
What is the first step in assessing a pressure injury in a patient with darkly pigmented skin?
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Which of the following statements is true regarding stage 1 pressure injuries?
Which of the following statements is true regarding stage 1 pressure injuries?
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In a stage 3 pressure injury, which of the following is TRUE?
In a stage 3 pressure injury, which of the following is TRUE?
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Which item is LEAST important to use initially during the skin assessment of a pressure injury?
Which item is LEAST important to use initially during the skin assessment of a pressure injury?
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What complication can arise from inappropriate use of fluorescent lighting when assessing darkly pigmented skin?
What complication can arise from inappropriate use of fluorescent lighting when assessing darkly pigmented skin?
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What might indicate a stage 4 pressure injury?
What might indicate a stage 4 pressure injury?
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What is the primary reason for not ambulating the 16-year-old with a sprained ankle immediately after discharge?
What is the primary reason for not ambulating the 16-year-old with a sprained ankle immediately after discharge?
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Which strategy is essential for the nurse to follow when repositioning a 136.1 kg (300-pound) patient?
Which strategy is essential for the nurse to follow when repositioning a 136.1 kg (300-pound) patient?
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In managing a patient post-stroke with total paralysis, when is it most appropriate to begin passive range-of-motion exercises?
In managing a patient post-stroke with total paralysis, when is it most appropriate to begin passive range-of-motion exercises?
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Which condition is least likely to prioritize the need for ambulation in a patient?
Which condition is least likely to prioritize the need for ambulation in a patient?
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What should a nurse prioritize to prevent personal injury while moving a heavy patient?
What should a nurse prioritize to prevent personal injury while moving a heavy patient?
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What fundamental technique should nurses employ during passive range-of-motion exercises to avoid injury?
What fundamental technique should nurses employ during passive range-of-motion exercises to avoid injury?
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When is it appropriate for a nurse to place a patient in the Trendelenburg position?
When is it appropriate for a nurse to place a patient in the Trendelenburg position?
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What is NOT a recommended approach to assisting a patient who has sustained impaired mobility?
What is NOT a recommended approach to assisting a patient who has sustained impaired mobility?
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To ensure safety while moving a heavy patient, which posture should a nurse avoid?
To ensure safety while moving a heavy patient, which posture should a nurse avoid?
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Which factor is most critical in developing an individualized care plan for a patient with impaired mobility?
Which factor is most critical in developing an individualized care plan for a patient with impaired mobility?
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Study Notes
Mobility and Immobility
- Prolonged bed rest can lead to decreased appetite, slowed digestion, reduced fluid volume pooling in the lower body, decreased cardiac output (lower blood pressure), increased heart rate, and decreased urine output.
- Immobilized patients have a higher risk for dehydration and concentrated urine.
- Cerebrovascular accident (CVA) or stroke patients with left-sided paralysis should use assistive devices like walkers or canes instead of crutches.
- Assessment of immobilized patients should include checking for unilateral swelling and muscle atrophy in the affected limbs.
- Sequential compression stockings are used to prevent blood clots and should be measured around the thigh, then wrapped from ankle to mid-thigh, maintaining the opening over the kneecap.
- Maintaining a 30-degree lateral position is recommended for patients in the recumbent position to reduce pressure on the sacrum and lower the risk of skin breakdown.
- Immobility can lead to several issues, including hypercalcemia, which increases the risk for renal calculi.
- Immobility disrupts normal metabolic functioning, leading to reduced metabolic rate, altered metabolism of carbohydrates, fats, and proteins, and often gastrointestinal problems.
- Immobility increases risk of pressure ulcers.
- Preventing pressure ulcers is less expensive than treatment.
- Immobilized patients should be repositioned frequently and assisted to perform as many self-care activities as possible to maintain mobility and function.
- Patients resuming activity after bed rest should have baseline blood pressure taken before getting up.
- Passive range-of-motion (ROM) exercises should be started as soon as the patient loses the ability to move a joint or extremity.
- Assistance from several people is needed for the safe repositioning of immobilized patients.
- Foot cradles are an option for patients with poor lower extremity circulation to reduce pressure on toes.
Skin Integrity and Wound Care
- Pressure injuries are caused by pressure intensity, duration, and tissue tolerance.
- Impaired sensory perception, impaired mobility, shear, friction, and moisture are risk factors for pressure injuries.
- Unconscious or disoriented patients are very high risk for pressure injuries as they are unable to self-care or communicate discomfort.
- Stage 1 is nonblanchable redness over a bony prominence.
- Stage 2 is partial-thickness skin loss.
- Stage 3 is full-thickness skin loss with damage to subcutaneous tissue.
- Stage 4 is full-thickness skin loss with exposed bone, tendon, or muscle.
- Irrigating pressure injuries with normal saline is recommended, not hydrogen peroxide.
- Wound healing is influenced by factors such as nutrition, tissue perfusion, infection, and age.
- Primary intention healing is for wounds with minimal tissue loss.
- Secondary intention healing is for wounds with significant tissue loss.
- Tertiary intention healing occurs when a wound is left open until it can be closed surgically.
- A stage 1 pressure injury does not require a dressing.
- Monitoring for signs of infection, such as increased redness or drainage, is essential for any wound.
- Laboratory test for nutritional status (serum albumin) is essential when supporting a wound-healing plan.
- Addressing psychological issues in patients with impaired mobility or skin integrity will improve overall well-being and healing.
- A consult with the dietician is necessary for wound healing plan.
- Pain management is a priority in patients with wounds.
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Description
This quiz covers important aspects of mobility and immobility in patient management. It addresses the effects of prolonged bed rest, aids for stroke patients, assessment techniques for immobilized patients, and prevention strategies like using sequential compression stockings. Understanding these elements is essential for ensuring patient safety and promoting effective care.
