ATI Mobility Assessment Actual Exam | Complete
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Part I: Head to Toe – Systemic Consequences of Limited Mobility
Q1: Which of the following physiological changes is a direct result of immobility on the
musculoskeletal system?
A. Increased muscle tone and strength
B. Joint contractures and disuse atrophy [CORRECT]
C. Increased bone density
D. Enhanced coordination and balance
Correct Answer: B
Rationale: Immobility leads to disuse atrophy, where muscles waste away due to lack of
use, and contractures, which occur when joints become stiff and固定的 due to
shortening of the muscle-tendon unit.
Q2: A patient who has been on bed rest for 5 days suddenly complains of chest pain
and difficulty breathing. The nurse suspects a pulmonary embolism. Which assessment
finding is most consistent with this complication?
A. Hyperactive bowel sounds
B. Sudden onset of tachycardia and hypoxia [CORRECT]
C. Bilateral swelling of the lower extremities
D. Productive cough with pink frothy sputum
Correct Answer: B
Rationale: While DVT causes swelling, a pulmonary embolism (PE) is a life-threatening
emergency that often presents with sudden chest pain, tachycardia, and hypoxia due to
a blockage in the pulmonary arteries.
Q3: When teaching a patient about preventing thrombus formation while hospitalized,
the nurse explains the components of Virchow's Triad. Which of the following is NOT
one of the three components?
A. Venous stasis
B. Injury to the vessel wall
C. Increased blood flow velocity [CORRECT]
D. Hypercoagulability
,Correct Answer: C
Rationale: Virchow's Triad describes the three broad categories of factors that
contribute to thrombosis: stasis (slow flow), endothelial injury, and hypercoagulability.
Increased blood flow velocity would actually prevent clots, whereas venous stasis (slow
flow) is a risk.
Q4: A bedridden patient has a reddened area over the sacrum. When the nurse presses
on the area, it does not turn white (non-blanchable erythema). How should the nurse
stage this pressure injury?
A. Stage I [CORRECT]
B. Stage II
C. Stage III
D. Unstageable
Correct Answer: A
Rationale: A Stage I pressure injury is defined as intact skin with a localized area of
non-blanchable erythema (redness). It is the first visual sign that pressure is causing
tissue damage.
Q5: Scenario: A nurse finds an unconscious patient in bed with dried food around their
mouth and incontinent of urine. The patient has a reddened area on the sacrum that
does not blanch. What is the immediate nursing action?
A. Massage the reddened area vigorously to stimulate circulation.
B. Apply a thick protective barrier cream and keep the patient dry.
C. Relieve the pressure by repositioning the patient off the sacrum. [CORRECT]
D. Place a heating pad on the area to improve blood flow.
Correct Answer: C
Rationale: The priority is to stop the injury process by removing the source of pressure.
Massaging can damage deep tissue, and heating pads can burn insensate skin. Barrier
creams are secondary to the mechanical offloading of the area.
Q6: Which of the following respiratory complications is directly caused by the inability to
take deep breaths and cough effectively due to immobility?
A. Atelectasis [CORRECT]
B. Spontaneous pneumothorax
C. Pulmonary fibrosis
D. Asthma exacerbation
Correct Answer: A
, Rationale: Atelectasis is the collapse of alveoli caused by shallow breathing and
retained secretions, which is a common consequence of immobility because patients
cannot fully expand their lungs or clear mucus.
Q7: A patient is at risk for orthostatic hypotension. Which intervention is most important
for the nurse to implement before getting the patient out of bed?
A. Encourage the patient to drink a glass of water.
B. Have the patient dangle their legs at the bedside for a few minutes. [CORRECT]
C. Apply compression stockings to the upper extremities.
D. Administer prescribed analgesics 30 minutes prior.
Correct Answer: B
Rationale: Dangling allows the cardiovascular system to adjust to the change in
position, helping to prevent the dizziness and drop in blood pressure associated with
orthostatic hypotension.
Q8: Which of the following urinary complications is most likely to occur in a patient who
is immobile and has inadequate fluid intake?
A. Polycystic kidney disease
B. Renal calculi (kidney stones) [CORRECT]
C. Glomerulonephritis
D. Acute glomerular failure
Correct Answer: B
Rationale: Immobility leads to bone demineralization (releasing calcium) and urinary
stasis. Combined with dehydration, this creates an environment ripe for the formation of
renal calculi (stones).
Q9: An older adult patient who has been confined to bed for several weeks is exhibiting
signs of confusion and withdrawal. The nurse recognizes these changes may be related
to:
A. Sensory deprivation and social isolation [CORRECT]
B. Early onset of dementia
C. Improvement in their cognitive status
D. Side effects of bed rest pillows
Correct Answer: A
Rationale: Prolonged immobility reduces sensory stimulation and social interaction,
which can lead to confusion, depression, and sensory deprivation, often mistaken for
dementia in hospital settings.
Questions and Answers, 100% Verified – Pass
Guaranteed - A+ Graded
Part I: Head to Toe – Systemic Consequences of Limited Mobility
Q1: Which of the following physiological changes is a direct result of immobility on the
musculoskeletal system?
A. Increased muscle tone and strength
B. Joint contractures and disuse atrophy [CORRECT]
C. Increased bone density
D. Enhanced coordination and balance
Correct Answer: B
Rationale: Immobility leads to disuse atrophy, where muscles waste away due to lack of
use, and contractures, which occur when joints become stiff and固定的 due to
shortening of the muscle-tendon unit.
Q2: A patient who has been on bed rest for 5 days suddenly complains of chest pain
and difficulty breathing. The nurse suspects a pulmonary embolism. Which assessment
finding is most consistent with this complication?
A. Hyperactive bowel sounds
B. Sudden onset of tachycardia and hypoxia [CORRECT]
C. Bilateral swelling of the lower extremities
D. Productive cough with pink frothy sputum
Correct Answer: B
Rationale: While DVT causes swelling, a pulmonary embolism (PE) is a life-threatening
emergency that often presents with sudden chest pain, tachycardia, and hypoxia due to
a blockage in the pulmonary arteries.
Q3: When teaching a patient about preventing thrombus formation while hospitalized,
the nurse explains the components of Virchow's Triad. Which of the following is NOT
one of the three components?
A. Venous stasis
B. Injury to the vessel wall
C. Increased blood flow velocity [CORRECT]
D. Hypercoagulability
,Correct Answer: C
Rationale: Virchow's Triad describes the three broad categories of factors that
contribute to thrombosis: stasis (slow flow), endothelial injury, and hypercoagulability.
Increased blood flow velocity would actually prevent clots, whereas venous stasis (slow
flow) is a risk.
Q4: A bedridden patient has a reddened area over the sacrum. When the nurse presses
on the area, it does not turn white (non-blanchable erythema). How should the nurse
stage this pressure injury?
A. Stage I [CORRECT]
B. Stage II
C. Stage III
D. Unstageable
Correct Answer: A
Rationale: A Stage I pressure injury is defined as intact skin with a localized area of
non-blanchable erythema (redness). It is the first visual sign that pressure is causing
tissue damage.
Q5: Scenario: A nurse finds an unconscious patient in bed with dried food around their
mouth and incontinent of urine. The patient has a reddened area on the sacrum that
does not blanch. What is the immediate nursing action?
A. Massage the reddened area vigorously to stimulate circulation.
B. Apply a thick protective barrier cream and keep the patient dry.
C. Relieve the pressure by repositioning the patient off the sacrum. [CORRECT]
D. Place a heating pad on the area to improve blood flow.
Correct Answer: C
Rationale: The priority is to stop the injury process by removing the source of pressure.
Massaging can damage deep tissue, and heating pads can burn insensate skin. Barrier
creams are secondary to the mechanical offloading of the area.
Q6: Which of the following respiratory complications is directly caused by the inability to
take deep breaths and cough effectively due to immobility?
A. Atelectasis [CORRECT]
B. Spontaneous pneumothorax
C. Pulmonary fibrosis
D. Asthma exacerbation
Correct Answer: A
, Rationale: Atelectasis is the collapse of alveoli caused by shallow breathing and
retained secretions, which is a common consequence of immobility because patients
cannot fully expand their lungs or clear mucus.
Q7: A patient is at risk for orthostatic hypotension. Which intervention is most important
for the nurse to implement before getting the patient out of bed?
A. Encourage the patient to drink a glass of water.
B. Have the patient dangle their legs at the bedside for a few minutes. [CORRECT]
C. Apply compression stockings to the upper extremities.
D. Administer prescribed analgesics 30 minutes prior.
Correct Answer: B
Rationale: Dangling allows the cardiovascular system to adjust to the change in
position, helping to prevent the dizziness and drop in blood pressure associated with
orthostatic hypotension.
Q8: Which of the following urinary complications is most likely to occur in a patient who
is immobile and has inadequate fluid intake?
A. Polycystic kidney disease
B. Renal calculi (kidney stones) [CORRECT]
C. Glomerulonephritis
D. Acute glomerular failure
Correct Answer: B
Rationale: Immobility leads to bone demineralization (releasing calcium) and urinary
stasis. Combined with dehydration, this creates an environment ripe for the formation of
renal calculi (stones).
Q9: An older adult patient who has been confined to bed for several weeks is exhibiting
signs of confusion and withdrawal. The nurse recognizes these changes may be related
to:
A. Sensory deprivation and social isolation [CORRECT]
B. Early onset of dementia
C. Improvement in their cognitive status
D. Side effects of bed rest pillows
Correct Answer: A
Rationale: Prolonged immobility reduces sensory stimulation and social interaction,
which can lead to confusion, depression, and sensory deprivation, often mistaken for
dementia in hospital settings.
