Chapter 21: Immobility

Chapter 21: Immobility

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. What negative effects does immobilization have on the musculoskeletal system?

ANS:  A

Immobilization has negative effects on the musculoskeletal system such as demineralization of bone, a decrease in aerobic capacity, a decrease in muscle oxidation, and shortening of muscle fibers.

DIF:    Cognitive Level: Comprehension     REF:   p. 326             OBJ:   1

TOP:   Effects of Immobility                      KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

2. What should the nurse be aware is the best prevention of immobility-related disorders?

ANS:  D

Exercise will help reduce the patient’s risk of immobility-related disorders.

DIF:    Cognitive Level: Knowledge            REF:   p. 326-327      OBJ:   2

TOP:   Preventing Complications of Immobility

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. A nurse’s assessment reveals an area of erythema on an immobilized patient’s sacrum. What is the initial nursing action?

ANS:  C

The first intervention is to reposition the patient with follow-up to ensure that the patient is repositioned often.

DIF:    Cognitive Level: Application           REF:   p. 331             OBJ:   5

TOP:   Treatment of Pressure Ulcers           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

4. A nurse is providing discharge instructions to the family of an older adult patient who is unable to get out of bed. What should the nurse instruct the family regarding the most effective way to prevent urinary incontinence associated with immobility?

ANS:  B

Patients should have scheduled toileting times with adjustments in the schedule based on the patient’s voiding patterns. Studies have been inconclusive regarding the effectiveness of limiting fluids.

DIF:    Cognitive Level: Application           REF:   p. 334             OBJ:   6

TOP:   Urinary Incontinence                       KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

5. The care plan of an older adult patient states that the patient should be monitored while in the bathroom because of a history of vasovagal reflex. What should the nurse assess with this patient?

ANS:  C

Constipated individuals may strain to defecate, causing an increase in intraabdominal pressure. This is called the Valsalva maneuver or vasovagal reflex, and it can lead to cardiovascular alterations.

DIF:    Cognitive Level: Comprehension     REF:   p. 333             OBJ:   6

TOP:   Vasovagal Reflex                            KEY:  Nursing Process Step: Assessment

MSC:   NCLEX: Physiological Integrity: Physiological Adaptation