Immobility

MULTIPLE CHOICE

1. In assessing a patient’s risk for complications of immobility, the nurse should be aware that
there are several reasons for a person becoming immobile. A therapeutic reason may be:
1. to reduce the workload of the heart.
2. lack of motivation.
3. bereavement resulting from the loss of a loved one.
4. to decrease flexibility and strength.

ANS: 1
A therapeutic reason is for the treatment of a disease or disorder. A cardiac or renal condition
may require a patient to be immobile to reduce the workload of the heart.

2. The nurse is teaching a patient how to prevent complications of being immobile. The nurse
knows that the best medicine for immobility is:
1. dietary supplements.
2. fluids.
3. adequate fiber.
4. exercise.

ANS: 4
Some effort must be made to prevent the adverse effects of immobility. Exercise will help
reduce the patient’s risk.

3. When the nurse’s assessment reveals an area of erythema on a patient’s sacrum, the first step
should be to:
1. apply a wet-to-dry dressing.
2. massage the reddened area.
3. position the patient so that there is no pressure on the sacrum.
4. rub the area with alcohol.

ANS: 3
The first step in treating pressure ulcers is to continue all preventive measures.

4. The greatest impact of immobilization on a patient depends on the duration, degree, and
type of:
1. physical therapy.
 2. mobility limitation.
3. nursing care.
4. family support.

ANS: 2
Duration, degree, and type of mobility limitation have the greatest impact. The other choices
may affect the impact once the mobility limitation becomes an issue.

5. The nurse is providing discharge instructions to the family of an older adult patient who is
unable to get out of bed. The nurse should instruct the family that the most effective way to
prevent urinary incontinence associated with immobility is to:
1. use absorbent underpads.
2. set up a toileting program.
3. restrict fluid intake to 500 mL/24 hours.
4. restrict fluids after dinner and throughout the night.

ANS: 2
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.

6. 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. The nurse knows that she should
assess for:
1. extremely elevated blood pressure after ambulation.
2. nausea and vomiting after a meal.
3. lightheadedness and fainting during defecation.
4. inability to urinate.

ANS: 1
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.

7. The patient who recently suffered a fractured femur and is currently in traction is at high
risk for developing constipation. The most appropriate nursing intervention would be to:
1. get the patient up to the bathroom at least twice each day.
2. administer enemas each day until the patient has a bowel movement.
3. administer pain medication to prevent pain during defecation.
 4. encourage a high-fiber diet and increased amounts of fluids.

ANS: 4
Inactivity, decreased fluid intake, and lack of adequate fiber in the diet can combine to cause
constipation. Activity is not an option for this patient, but encouraging a high-fiber diet and
increased fluids can help prevent or relieve constipation.

8. A nurse caring for a patient who has been on bed rest for a week notices a reddened area on
the patient’s left hip. The skin is intact but, when the nurse presses on the area, the redness
does not fade. The nurse recognizes this pressure ulcer as a:
1. stage I ulcer.
2. stage II ulcer.
3. stage III ulcer.
4. stage IV ulcer.

ANS: 1
The major characteristic of a stage I ulcer is erythema (redness) that does not blanch when
pressed.

9. When positioning an immobile patient, the nurse should:

1. be sure that the patient’s knees and hips are flexed.
2. picture how people look while standing and try to have the patient achieve that
position while he or she is lying down.
3. reposition no more than every 4 hours.
4. always position the patient on his or her back with the head raised to prevent
aspiration.

ANS: 2
Positioning should be done to maintain joints in their functional positions so that they are
not abnormally flexed or extended.

10. To prevent respiratory complications resulting from immobility, the best nursing
interventions would be to:
1. suction every 4 to 6 hours.
2. administer pain medications as frequently as possible.
3. teach the patient the technique of pursed lip breathing.
4. reposition the patient and encourage him or her to cough and deep-breathe at least
every 2 hours.

ANS: 4
 When a person remains immobile or does not take deep breaths, thick secretions can
accumulate and pool in the lower respiratory structures.

11. A discharge order for the patient with left-sided weakness after having a stroke is to teach
the patient to perform range-of-motion exercises on the affected extremities. The patient
asks why she needs to do range-of-motion exercises. The nurse’s best response would be:
1. “Because the physician has ordered it.”
2. “You will regain full use of your arm and leg if you will do them correctly.”
3. “They prevent the muscles and tendons from shortening and becoming
unmovable.”
4. “It will give you something to do since you can’t work anymore.”

ANS: 3
Muscular activity maintains range of motion by allowing the joint to remain flexible and
functional. When there is little or no movement of a joint, the muscles shorten and lose their
elasticity.

12. The nurse evaluates a patient’s risk for developing a pressure ulcer using the Norton scale.
The patient’s score is 18. The nurse should:
1. call the physician immediately.
2. implement a pressure ulcer prevention program.
3. document the score.
4. order an alternating air mattress.

ANS: 3
If the total score on the Norton scale is greater than 14, there is little risk of pressure ulcer
development; if it is less than 14, there is a significant risk.

13. A patient in traction because of a fractured hip from falling is diagnosed with a stage I
pressure ulcer. She asks the nurse how she got a pressure ulcer when she had been confined
to bed for only 2 days. The nurse’s response is based on her knowledge that:
1. erythema can occur in an hour or two, even in a person with healthy skin and
adequate circulation.
2. it takes several days for a pressure ulcer to form.
3. the pressure ulcer probably occurred when she fell.
4. the cause of pressure ulcers isn’t really known.

ANS: 1
Because of impaired blood flow, capillaries in the area of pressure can become congested
and erythema can occur in an hour or two.
14. The patient is complaining to the nurse that he feels the need to have a bowel movement but
has not been able to defecate. He states that he has had cramping and even a small amount
of brown watery stool. The nurse recognizes these symptoms as:
1. diarrhea.
2. fecal incontinence.
3. fecal impaction.
4. flatulence.

ANS: 3
Symptoms of a fecal impaction include painful defecation, a feeling of fullness in the
rectum, abdominal distention, and sometimes cramps and watery stool.

15. During shift report, the nurse is told that the patient she will be caring for has a stage II
pressure ulcer. During the dressing change, the nurse would expect to see:
1. an ulcer that appears black with possible signs of infection.
2. a shallow ulcer that appears blistered, cracked, or abraded.
3. a crater-like sore with a distinct outer margin formed as the epidermis thickens and
rolls over the edge toward the ulcer base.
4. redness of skin with no ulceration.

ANS: 2
In a stage II pressure ulcer, there is some skin loss in the epidermis and dermis.

16. When preparing a plan of care for an older adult patient, the nurse should consider the
common problems associated with immobility. These problems may be classified as:
1. environmental and intellectual.
2. internal and external.
3. mental and medical.
4. physical and psychosocial.

ANS: 4
Immobility can have a profound impact on both the mind and body. Psychosocial problems
include depression, fear, anxiety, social withdrawal, and apathy. Physically, immobility can
have an adverse effect on every body system.

17. The nurse points out that the National Pressure Ulcer Advisory Panel prefers to refer to skin
breakdown as:
1. bed sores.
2. pressure ulcers.
 3. decubitus ulcers.
4. decubiti.

ANS: 2
Decubitus means “lying down”; therefore, decubitus ulcers and bed sores are associated
with lying in bed. Skin breakdown can also develop from sitting.

18. The patient complains of his “bottom” being sore. The nurse assesses the area and finds an
open area on the sacrum that appears blistered. The nurse should:
1. document the cause of the burn.
2. clean with alcohol, apply moisturizer, and cover with a set dressing.
3. massage the area to promote circulation.
4. clean with mild soap, dry, and apply a light dressing.

ANS: 4
If pressure ulcers develop despite all preventive measures, proper and early treatment
improves the chance for reversal. A stage II ulcer should be cleaned with mild soap and
water or with sterile normal saline, patted dry, and covered with a dressing that allows air
flow.

19. The nurse is performing a wet-to-dry dressing change on a stage IV pressure ulcer. The
nurse understands that the purpose of this type of dressing is to:
1. keep the wound moist.
2. prevent infection.
3. débride necrotic tissue.
4. increase circulation to the tissue.

ANS: 3
Wet-to-dry dressings and a whirlpool are used for small amounts of débridement of necrotic
tissue. Débridement is necessary to promote granulation of new, healthy tissue.

20. The nursing assistant is bathing a patient who has a stage I pressure ulcer on the right
shoulder. The nurse should remind the nursing assistant that the tissue could become more
damaged if she:
1. positions the patient on the left side.
2. massages the reddened area.
3. cleans the area with mild soap and water.
4. positions the patient in a prone position.
 ANS: 2
Any type of massage around or on a reddened area of skin can damage fragile capillaries.

21. When planning the care of a patient who is immobile, the nurse should remember that the
patient will be at risk for urinary tract infection because:
1. the urine will pool in the bladder when the patient remains in a supine position.
2. the patient is likely to have urinary incontinence.
3. the patient’s appetite may be decreased.
4. the patient may not be able to move quickly enough to get to the bathroom.

ANS: 1
If the body remains in a supine position for even a few days, the flow becomes sluggish and
the urine pools in the bladder, which will increase the risk of a urinary tract infection.

22. The nurse instructs a patient in a wheelchair that the risk for pressure ulcers can be
diminished if the patient will:
1. use a ring pillow on the seat of the chair
2. lift the weight of the body using the arms of the wheelchair every 15 minutes.
3. “scoot” forward and back in the seat to stimulate circulation.
4. wear underwear that holds moisture close to skin.

ANS: 2
Using the arms of the wheelchair to left the weight off the buttocks and coccyx is beneficial
for reducing the risk of pressure ulcers in the patient in a wheelchair.

23. The physician asks the nurse to instruct a patient on doing isometric exercises. The nurse
should instruct the patient to:
1. contract the muscle for several seconds, then relax the muscle for a few seconds,
and contract it again.
2. perform full range-of-motion exercises of each joint.
3. have a family member perform full range-of-motion exercises on each of the
patient’s joints.
4. stand in front of a wall and push with the arms without bending the elbow.

ANS: 1
Isometric exercises maintain muscle tone without moving the joint. This type of exercise is
helpful in maintaining muscle strength after a fracture.
24. The nurse is talking with a patient who recently became paraplegic as a result of a cervical
spinal cord injury. When discussing some of the equipment that will be needed at home, the
patient becomes angry and says, “I don’t need to worry about pressure ulcers.” The best
response by the nurse would be:
1. “I know you will be walking soon, but you may need some equipment until then.”
2. “There is very little chance that you will ever walk.”
3. “Tell me what it is about this equipment that bothers you.”
4. “Let me call the physician to come explain your injuries to you.”

ANS: 3
The nurse should use therapeutic communication techniques to explore the patient’s
feelings.

25. The nurse is performing an assessment of a newly admitted patient. During the skin integrity
assessment, the nurse notices an area on the right heel that is black and draining purulent,
foul-smelling exudates. The nurse should document this as a pressure ulcer in:
1. stage I.
2. stage II.
3. stage III.
4. stage IV.

ANS: 4
In a stage IV pressure ulcer, there is full-thickness skin loss with extensive destruction of the
deeper underlying muscle and possibly the bone tissue.