CH 28 Immobility NCLEX questions and answers latest
2024
A 61-year-old client recently suffered left sided paralysis from a cerebrovascular
accident (stroke). Which of the following is the best intervention for this client?
A. Encourage an even gait when walking in place.
B. Assess the extremities for unilateral swelling and muscle atrophy.
C. Encourage holding the breath frequently to hyperinflate his lungs.
D. Teach the use of a two-point crutch technique for ambulation.
B. Assess the extremities for unilateral swelling and muscle atrophy.
Which of the following is indicated when the client is to have passive range-of-
motion exercises performed by the nurse?
A. Exercise the joint beyond the point of slight resistance.
B. Perform movements quickly.
C. Perform each movement one time during the session.
D. Institute exercises as soon as the client's ability to move the extremity is lost.
D. Institute exercises as soon as the client's ability to move the extremity is lost.
An immobilized client is suspected of having atelectasis. This is assessed by the
nurse upon auscultation as:
A. Harsh crackles
B. Wheezing on inspiration
C. Diminished breath sounds
D. Bronchovesicular whooshing
C. Diminished breath sounds
A client is getting up for the first time after a period of bedrest. The nurse should
first:
A. Obtain a baseline blood pressure
B. Assist the client to sit at the edge of the bed
C. Assess the respiratory function
D. Ask the client if he/she feels lightheaded
A. Obtain a baseline blood pressure
Which of the following factors may contribute to an increased risk for thrombus
formation, impaired skin integrity, respiratory infection, and constipation in the
immobilized client?
A. Insufficient passive range of motion
B. Emotional depression
C. Inadequate fluid intake
D. Use of hypnotic medication
C. Inadequate fluid intake
Which of the following are physiological outcomes of immobility?
A. Increased metabolism
B. Reduced cardiac workload
C. Decreased lung expansion
D. Decreased oxygen demand
C. Decreased lung expansion
2024
A 61-year-old client recently suffered left sided paralysis from a cerebrovascular
accident (stroke). Which of the following is the best intervention for this client?
A. Encourage an even gait when walking in place.
B. Assess the extremities for unilateral swelling and muscle atrophy.
C. Encourage holding the breath frequently to hyperinflate his lungs.
D. Teach the use of a two-point crutch technique for ambulation.
B. Assess the extremities for unilateral swelling and muscle atrophy.
Which of the following is indicated when the client is to have passive range-of-
motion exercises performed by the nurse?
A. Exercise the joint beyond the point of slight resistance.
B. Perform movements quickly.
C. Perform each movement one time during the session.
D. Institute exercises as soon as the client's ability to move the extremity is lost.
D. Institute exercises as soon as the client's ability to move the extremity is lost.
An immobilized client is suspected of having atelectasis. This is assessed by the
nurse upon auscultation as:
A. Harsh crackles
B. Wheezing on inspiration
C. Diminished breath sounds
D. Bronchovesicular whooshing
C. Diminished breath sounds
A client is getting up for the first time after a period of bedrest. The nurse should
first:
A. Obtain a baseline blood pressure
B. Assist the client to sit at the edge of the bed
C. Assess the respiratory function
D. Ask the client if he/she feels lightheaded
A. Obtain a baseline blood pressure
Which of the following factors may contribute to an increased risk for thrombus
formation, impaired skin integrity, respiratory infection, and constipation in the
immobilized client?
A. Insufficient passive range of motion
B. Emotional depression
C. Inadequate fluid intake
D. Use of hypnotic medication
C. Inadequate fluid intake
Which of the following are physiological outcomes of immobility?
A. Increased metabolism
B. Reduced cardiac workload
C. Decreased lung expansion
D. Decreased oxygen demand
C. Decreased lung expansion
