NR 443 CHAPTER 21: IMMOBILITY
Chapter 21: Immobility
Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. What negative effects does immobilization have on the musculoskeletal system?
a. Demineralization of bone
b. Increase in aerobic capacity
c. Increased muscle oxidation
d. Lengthening of muscle fibers
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?
a. Dietary supplements
b. Fluids
c. Adequate fiber
d. Exercise
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?
a. Apply a wet-to-dry dressing.
b. Massage the reddened area.
c. Reposition the patient.
d. Rub the area with alcohol.
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?
a. Use absorbent underpads.
b. Set up a toileting program.
c. Restrict fluid intake to 500 mL per 24 hours.
d. Restrict fluids after dinner and throughout the night.
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?
a. Extremely elevated blood pressure after ambulation
b. Nausea and vomiting after a meal
c. Lightheadedness and fainting during defecation
d. Inability to urinate
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
6. What is the most effective intervention to prevent constipation in a patient who recently sustained
a fractured femur and is currently in traction?
a. Get the patient up and to the bathroom at least twice each day.
b. Administer enemas each day until the patient has a bowel movement.
c. Administer pain medication to prevent pain during defecation.
d. Encourage a high-fiber diet and increased amounts of fluids.
ANS: D
Inactivity, decreased fluid intake, and a 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.
DIF: Cognitive Level: Application REF: p. 333 OBJ: 6
TOP: Constipation KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. A nurse caring for a patient who has been prescribed bed rest for 1 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. How should this area of pressure be classified?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: A
Chapter 21: Immobility
Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. What negative effects does immobilization have on the musculoskeletal system?
a. Demineralization of bone
b. Increase in aerobic capacity
c. Increased muscle oxidation
d. Lengthening of muscle fibers
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?
a. Dietary supplements
b. Fluids
c. Adequate fiber
d. Exercise
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?
a. Apply a wet-to-dry dressing.
b. Massage the reddened area.
c. Reposition the patient.
d. Rub the area with alcohol.
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?
a. Use absorbent underpads.
b. Set up a toileting program.
c. Restrict fluid intake to 500 mL per 24 hours.
d. Restrict fluids after dinner and throughout the night.
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?
a. Extremely elevated blood pressure after ambulation
b. Nausea and vomiting after a meal
c. Lightheadedness and fainting during defecation
d. Inability to urinate
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
6. What is the most effective intervention to prevent constipation in a patient who recently sustained
a fractured femur and is currently in traction?
a. Get the patient up and to the bathroom at least twice each day.
b. Administer enemas each day until the patient has a bowel movement.
c. Administer pain medication to prevent pain during defecation.
d. Encourage a high-fiber diet and increased amounts of fluids.
ANS: D
Inactivity, decreased fluid intake, and a 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.
DIF: Cognitive Level: Application REF: p. 333 OBJ: 6
TOP: Constipation KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. A nurse caring for a patient who has been prescribed bed rest for 1 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. How should this area of pressure be classified?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: A
