2
NUR 353 Exam 4 with verified detailed solutions
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The state or quality of being mobile or movable - ✔✔Mobility
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The state of not moving; motionless, not being able to move - ✔✔Immobility
|| || || || || || || || || || || ||
A term that encompasses similar concepts and includes nursing diagnoses related to
|| || || || || || || || || || || ||
inactivity. Risks for this include impaired skin integrity, constipation, altered respiratory
|| || || || || || || || || || ||
function, altered peripheral tissue perfusion, activity intolerance, impaired physical
|| || || || || || || || ||
mobility, injury, altered sensory perception, powerlessness, and body image disturbance. -
|| || || || || || || || || || ||
✔✔Disuse syndrome ||
A general downslide of overall physical strength and endurance. Although most patients
|| || || || || || || || || || || ||
might have a tweak of this after a big surgery or major illness, this term is usually applied
|| || || || || || || || || || || || || || || || || ||
when a formerly independent, or mostly independent, person is now not able to perform
|| || || || || || || || || || || || || ||
routine activities, like their ADLs, and IADLs, and their progress continues to decline. -
|| || || || || || || || || || || || || ||
✔✔Deconditioned
List two screening tools to detect mobility/immobility. - ✔✔1. Osteoporosis
|| || || || || || || || ||
2. Fall risk assessment
|| || ||
When should fall assessment screening tools be used? - ✔✔Look in Giddens
|| || || || || || || || || || ||
List some general care guidelines for a patient who is immobilized. - ✔✔1. Frequent
|| || || || || || || || || || || || || ||
turning and changing positions every 2 hours in bed or 30 minutes in a chair.
|| || || || || || || || || || || || || ||
2. Frequent skin assessment and skin care.
|| || || || || ||
3. Range of motion exercises
|| || || ||
4. Deep breathing exercises
|| || ||
,2
5. Weight bearing exercises if possible
|| || || || ||
5. Measures to optimize elimination, such as high fluids, high fiber, and laxatives or stool
|| || || || || || || || || || || || || || ||
softeners.
6. Ambulation, stretches, balance
|| || ||
What should you give to a patient before moving around to decrease pain when moving
|| || || || || || || || || || || || || || ||
their joints? - ✔✔Anti-inflammatory and pain medications
|| || || || || ||
A disruption or break in the continuity of bone - ✔✔Fracture
|| || || || || || || || || ||
The break goes completely through the bone - ✔✔Complete fracture
|| || || || || || || || ||
Occurs partly across a bone shaft but the bone is still intact - ✔✔Incomplete fracture
|| || || || || || || || || || || || || ||
Describe the metabolic changes that occur with immobility. - ✔✔1. Decreases metabolic
|| || || || || || || || || || || ||
rate, altering the metabolism of carbs, fats, and proteins
|| || || || || || || ||
2. Fluid, electrolyte and calcium imbalances
|| || || || ||
3. Decreased appetite
|| ||
4. Slowed peristalsis
|| ||
5. Endocrine system is altered
|| || || || ||
6. Hypercalcemia, calcium is released from the bones in immobile patients, which can cause
|| || || || || || || || || || || || ||
pathologic fractures because there is not enough calcium in the bones!
|| || || || || || || || || || ||
You are caring for a patient who is immobile. Which of the following electrolyte imbalances
|| || || || || || || || || || || || || || ||
would you expect in a patient who has been immobile?
|| || || || || || || || ||
a. Hypercalcemia
||
,2
b. Hypokalemia
||
c. Hyponatremia
||
d. Hypermagnesemia - ✔✔A (In immobile people, calcium is released from their bones into
|| || || || || || || || || || || || ||
their blood stream. Normally, your kidneys will excrete this calcium but if they are unable
|| || || || || || || || || || || || || || || ||
to respond appropriately, hypercalcemia results.)
|| || || ||
List some gastrointestinal impairments caused by decreased mobility. - ✔✔1. Constipation
|| || || || || || || || || ||
2. Fluid intake decreases, risk for dehydration
|| || || || || ||
3. Anorexia
||
List two respiratory changes that occur with immobility. - ✔✔1. Atelectasis (Collapse of
|| || || || || || || || || || || || ||
alveoli)
2. Hypostatic pneumonia (Inflammation of the lung from stasis or pooling of secretions)
|| || || || || || || || || || || ||
List three cardiovascular changes that occur with immobility. - ✔✔1. Orthostatic
|| || || || || || || || || || ||
hypotension
2. Thrombus formation
|| ||
3. Decreased cardiac output, resulting in increased workload
|| || || || || || ||
List some musculoskeletal changes associated with immobility. (6) - ✔✔1. Loss of
|| || || || || || || || || || || ||
endurance, strength and muscle mass and decreased stability and balance
|| || || || || || || || ||
2. Decreased muscle mass
|| || || ||
3. Joint abnormalities (contractures--From muscle disuse, atrophy and shortening of the
|| || || || || || || || || || ||
muscle fibers) ||
4. Disuse osteoporosis (Osteoporosis from immobility)
|| || || || ||
5. Pathological fractures from disuse osteoporosis
|| || || || ||
6. Impaired calcium metabolism
|| || ||
, 2
List 3 urinary complications associated with immobility. - ✔✔1. Urinary stasis from lack of
|| || || || || || || || || || || || || ||
gravity pulling the urine from the renal pelvis into the ureters to the bladder.
|| || || || || || || || || || || || || ||
2. UTIs from urinary stasis
|| || || ||
3. Renal calculi from hypercalcemia
|| || || ||
List one integumentary complication associated with immobility. - ✔✔Pressure ulcers
|| || || || || || || || ||
List some psychosocial effects seen with immobility. - ✔✔1. Social isolation
|| || || || || || || || || ||
2. Helplessness
||
3. Loneliness
||
4. Depression
||
An older-adult patient has been bedridden for 2 weeks. Which of the following complaints
|| || || || || || || || || || || || || ||
by the patient indicates to the nurse that he or she is developing a complication of
|| || || || || || || || || || || || || || || ||
immobility?
||
a. Loss of appetite
|| || ||
b. Gum soreness
|| ||
c. Difficulty swallowing
|| ||
d. Left-ankle joint stiffness - ✔✔D (Patients whose mobility is restricted require range-of-
|| || || || || || || || || || || ||
motion (ROM) exercises daily to reduce the hazards of immobility. Temporary
|| || || || || || || || || || ||
immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Two || || || || || || || || || || || || || ||
weeks of joint immobilization without ROM can quickly result in contractures.)
|| || || || || || || || || ||
An older adult has limited mobility as a result of a total knee replacement. During
|| || || || || || || || || || || || || || ||
assessment you note that the patient has difficulty breathing while lying flat. Which of the
|| || || || || || || || || || || || || || ||
following assessment data support a possible pulmonary problem related to impaired
|| || || || || || || || || || ||
mobility?
NUR 353 Exam 4 with verified detailed solutions
|| || || || || || ||
The state or quality of being mobile or movable - ✔✔Mobility
|| || || || || || || || || ||
The state of not moving; motionless, not being able to move - ✔✔Immobility
|| || || || || || || || || || || ||
A term that encompasses similar concepts and includes nursing diagnoses related to
|| || || || || || || || || || || ||
inactivity. Risks for this include impaired skin integrity, constipation, altered respiratory
|| || || || || || || || || || ||
function, altered peripheral tissue perfusion, activity intolerance, impaired physical
|| || || || || || || || ||
mobility, injury, altered sensory perception, powerlessness, and body image disturbance. -
|| || || || || || || || || || ||
✔✔Disuse syndrome ||
A general downslide of overall physical strength and endurance. Although most patients
|| || || || || || || || || || || ||
might have a tweak of this after a big surgery or major illness, this term is usually applied
|| || || || || || || || || || || || || || || || || ||
when a formerly independent, or mostly independent, person is now not able to perform
|| || || || || || || || || || || || || ||
routine activities, like their ADLs, and IADLs, and their progress continues to decline. -
|| || || || || || || || || || || || || ||
✔✔Deconditioned
List two screening tools to detect mobility/immobility. - ✔✔1. Osteoporosis
|| || || || || || || || ||
2. Fall risk assessment
|| || ||
When should fall assessment screening tools be used? - ✔✔Look in Giddens
|| || || || || || || || || || ||
List some general care guidelines for a patient who is immobilized. - ✔✔1. Frequent
|| || || || || || || || || || || || || ||
turning and changing positions every 2 hours in bed or 30 minutes in a chair.
|| || || || || || || || || || || || || ||
2. Frequent skin assessment and skin care.
|| || || || || ||
3. Range of motion exercises
|| || || ||
4. Deep breathing exercises
|| || ||
,2
5. Weight bearing exercises if possible
|| || || || ||
5. Measures to optimize elimination, such as high fluids, high fiber, and laxatives or stool
|| || || || || || || || || || || || || || ||
softeners.
6. Ambulation, stretches, balance
|| || ||
What should you give to a patient before moving around to decrease pain when moving
|| || || || || || || || || || || || || || ||
their joints? - ✔✔Anti-inflammatory and pain medications
|| || || || || ||
A disruption or break in the continuity of bone - ✔✔Fracture
|| || || || || || || || || ||
The break goes completely through the bone - ✔✔Complete fracture
|| || || || || || || || ||
Occurs partly across a bone shaft but the bone is still intact - ✔✔Incomplete fracture
|| || || || || || || || || || || || || ||
Describe the metabolic changes that occur with immobility. - ✔✔1. Decreases metabolic
|| || || || || || || || || || || ||
rate, altering the metabolism of carbs, fats, and proteins
|| || || || || || || ||
2. Fluid, electrolyte and calcium imbalances
|| || || || ||
3. Decreased appetite
|| ||
4. Slowed peristalsis
|| ||
5. Endocrine system is altered
|| || || || ||
6. Hypercalcemia, calcium is released from the bones in immobile patients, which can cause
|| || || || || || || || || || || || ||
pathologic fractures because there is not enough calcium in the bones!
|| || || || || || || || || || ||
You are caring for a patient who is immobile. Which of the following electrolyte imbalances
|| || || || || || || || || || || || || || ||
would you expect in a patient who has been immobile?
|| || || || || || || || ||
a. Hypercalcemia
||
,2
b. Hypokalemia
||
c. Hyponatremia
||
d. Hypermagnesemia - ✔✔A (In immobile people, calcium is released from their bones into
|| || || || || || || || || || || || ||
their blood stream. Normally, your kidneys will excrete this calcium but if they are unable
|| || || || || || || || || || || || || || || ||
to respond appropriately, hypercalcemia results.)
|| || || ||
List some gastrointestinal impairments caused by decreased mobility. - ✔✔1. Constipation
|| || || || || || || || || ||
2. Fluid intake decreases, risk for dehydration
|| || || || || ||
3. Anorexia
||
List two respiratory changes that occur with immobility. - ✔✔1. Atelectasis (Collapse of
|| || || || || || || || || || || || ||
alveoli)
2. Hypostatic pneumonia (Inflammation of the lung from stasis or pooling of secretions)
|| || || || || || || || || || || ||
List three cardiovascular changes that occur with immobility. - ✔✔1. Orthostatic
|| || || || || || || || || || ||
hypotension
2. Thrombus formation
|| ||
3. Decreased cardiac output, resulting in increased workload
|| || || || || || ||
List some musculoskeletal changes associated with immobility. (6) - ✔✔1. Loss of
|| || || || || || || || || || || ||
endurance, strength and muscle mass and decreased stability and balance
|| || || || || || || || ||
2. Decreased muscle mass
|| || || ||
3. Joint abnormalities (contractures--From muscle disuse, atrophy and shortening of the
|| || || || || || || || || || ||
muscle fibers) ||
4. Disuse osteoporosis (Osteoporosis from immobility)
|| || || || ||
5. Pathological fractures from disuse osteoporosis
|| || || || ||
6. Impaired calcium metabolism
|| || ||
, 2
List 3 urinary complications associated with immobility. - ✔✔1. Urinary stasis from lack of
|| || || || || || || || || || || || || ||
gravity pulling the urine from the renal pelvis into the ureters to the bladder.
|| || || || || || || || || || || || || ||
2. UTIs from urinary stasis
|| || || ||
3. Renal calculi from hypercalcemia
|| || || ||
List one integumentary complication associated with immobility. - ✔✔Pressure ulcers
|| || || || || || || || ||
List some psychosocial effects seen with immobility. - ✔✔1. Social isolation
|| || || || || || || || || ||
2. Helplessness
||
3. Loneliness
||
4. Depression
||
An older-adult patient has been bedridden for 2 weeks. Which of the following complaints
|| || || || || || || || || || || || || ||
by the patient indicates to the nurse that he or she is developing a complication of
|| || || || || || || || || || || || || || || ||
immobility?
||
a. Loss of appetite
|| || ||
b. Gum soreness
|| ||
c. Difficulty swallowing
|| ||
d. Left-ankle joint stiffness - ✔✔D (Patients whose mobility is restricted require range-of-
|| || || || || || || || || || || ||
motion (ROM) exercises daily to reduce the hazards of immobility. Temporary
|| || || || || || || || || || ||
immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Two || || || || || || || || || || || || || ||
weeks of joint immobilization without ROM can quickly result in contractures.)
|| || || || || || || || || ||
An older adult has limited mobility as a result of a total knee replacement. During
|| || || || || || || || || || || || || || ||
assessment you note that the patient has difficulty breathing while lying flat. Which of the
|| || || || || || || || || || || || || || ||
following assessment data support a possible pulmonary problem related to impaired
|| || || || || || || || || || ||
mobility?
