CHAPTER 28: Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford

Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford Chapter 28: Activity, Immobility, and Safe Movement Multiple Choice Questions 1. What response would the nurse give the patient when questioned about the effect of rheumatoid arthritis on the musculoskeletal system? A. Muscle weakness B. Muscle wasting C. Joint inflammation D. Joint spasticity Answer: C Explanation: Rheumatoid arthritis primarily causes joint inflammation, leading to pain and limited mobility, rather than affecting muscles directly. This distinguishes it from conditions like muscular dystrophy (muscle wasting) or cerebral palsy (spasticity). Why Other Options Are Wrong: A and B describe muscle-related conditions, not rheumatoid arthritis. D refers to neurological disorders causing abnormal muscle tone. 2. The nurse is implementing generalized falls precautions for patients who are at risk for falls. Which intervention indicates a lack of understanding of these precautions? A. The bed is placed in the low position. B. The patient is wearing socks. C. The patient's cell phone is by the bedside. D. The patient's call light is within reach. Answer: B Explanation: Socks without grips increase slip risk; nonskid footwear is required for ambulatory patients. Other options align with falls precautions (e.g., accessible call light, low bed). Why Other Options Are Wrong: A, C, and D are correct interventions for fall prevention. 3. The nurse is educating the family of a patient on falls risk precautions. Which statement by the family indicates a need for further education? A. "I should keep the wheelchair locked unless using it to move Mom." B. "I should leave the bathroom light on as she does at her home." C. "I should leave her slippers by the wheelchair." D. "I should keep her cell phone close to her bed." Answer: C Explanation: Slippers without nonskid soles are a fall hazard; nonskid footwear is essential. Locking wheels and keeping items accessible (A, D) are correct. Lighting (B) depends on patient preference. Why Other Options Are Wrong: A, B, and D demonstrate appropriate understanding of fall precautions. 4. The nurse is performing passive range-of-motion exercises on a patient when the patient begins to complain of pain. What is the first thing the nurse should do? A. Notify the health care provider. B. Hyperextend the joint. C. Stop the range of motion. D. Switch to active range of motion. Answer: C Explanation: Pain during passive ROM indicates potential injury or overextension; stopping prevents harm. Hyperextension (B) is contraindicated, and active ROM (D) is inappropriate if pain persists. Why Other Options Are Wrong: A delays immediate action. B risks joint damage. D is unsuitable if pain is present. 5. The nurse recognizes which goal to be appropriate for the patient who is postoperative day one from a hip fracture with the nursing diagnosis Impaired mobility? A. Patient will interact with others. B. Patient will ambulate to the bathroom with assistance. C. Patient will have no skin breakdown. D. Patient will have a physical therapy consult. Answer: B Explanation: Ambulation with assistance directly addresses impaired mobility. Skin breakdown (C) relates to immobility but is not the primary goal. A and D are interventions or secondary outcomes. Why Other Options Are Wrong: A addresses social isolation, not mobility. C is a risk but not a mobility goal. D is an intervention, not a goal. 6. The nurse identifies which goal to be appropriate for the patient who is postoperative day one from abdominal surgery and on bed rest with the nursing diagnosis Impaired skin integrity? A. Patient will ambulate twice a day. B. Patient will eat 50% of meals. C. Patient will have no further skin breakdown. D. Patient will interact with others. Answer: C Explanation: Preventing further skin breakdown is the priority for impaired skin integrity. Ambulation (A) and nutrition (B) support healing but are not primary goals for this diagnosis. Why Other Options Are Wrong: A and D address mobility and socialization, not skin integrity. B is nutrition-related. 7. The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicates a good understanding of these exercises? A. "An example of this type of exercise is walking." B. "An example of this type of exercise is running." C. "An example of this type of exercise is Kegels." D. "An example of this type of exercise is weight lifting." Answer: C Explanation: Isometric exercises involve muscle tension without joint movement (e.g., Kegels). Walking (A) and running (B) are isotonic; weight lifting (D) is anaerobic. Why Other Options Are Wrong: A and B describe isotonic exercises. D refers to anaerobic activity. 8. The nurse is preparing to assist the patient to walk to the bathroom after medicating the patient with a narcotic for pain management. What possible adverse effect should the nurse be immediately aware of? A. Constipation B. Depression C. Dizziness D. Pain relief Answer: C Explanation: Dizziness from narcotics increases fall risk during ambulation. Pain relief (D) is expected; constipation (A) and depression (B) are not immediate safety concerns. Why Other Options Are Wrong: A and B are side effects but not urgent. D is the intended effect. 9. The nurse correctly selects which intervention to avoid causing shear or friction when moving a patient in bed? A. Using an airflow bed B. Using a slide board C. Using a trochanter roll D. Using a gel mattress Answer: B Explanation: Slide boards reduce friction during transfers. Airflow (A) and gel mattresses (D) address pressure ulcers. Trochanter rolls (C) prevent hip rotation. Why Other Options Are Wrong: A and D manage pressure, not shear. C stabilizes hips. 10. Which explanation by the nurse best describes active assistive range of motion? A. The patient independently moves all joints. B. The patient partially moves all joints. C. The caregiver must move the patient's joints. D. The patient performs isotonic exercises. Answer: B Explanation: Active assistive ROM involves partial patient effort with caregiver assistance. A describes active ROM; C describes passive ROM. D refers to isotonic exercises. Why Other Options Are Wrong: A is active ROM. C is passive ROM. D is unrelated to assistive ROM. Multiple Response Questions 1. The nurse is teaching a patient about ways to decrease risk of bone fractures. Which statements by the patient indicate a good understanding of decreasing this risk? A. "I should do weight-bearing exercises." B. "I should get adequate intake of calcium and vitamin D." C. "I should exercise regularly." D. "I need to do yoga exercises." E. "I wish I could reduce my risk but can't do anything." Answer: A, B, C Explanation: Weight-bearing exercise, calcium/vitamin D, and regular activity strengthen bones. Yoga (D) is optional, and E reflects a misunderstanding of preventive measures. Why Other Options Are Wrong: D is not essential for bone strength. E is incorrect because risk reduction is possible. 2. The nurse knows that a patient with a compromised cardiopulmonary system has a diminished capacity for exercise because of which conditions? A. Decreased tissue perfusion B. Loss of sensation C. Hemiparesis D. Diminished respiratory capacity E. Muscle weakness Answer: A, D Explanation: Cardiopulmonary compromise reduces perfusion and respiratory efficiency, limiting exercise capacity. B and C are neurological, and E is nonspecific. Why Other Options Are Wrong: B and C relate to nervous system disorders. E can result from multiple causes. 3. The nurse is educating the patient about the effects of immobility on the body. Which statements by the patient indicate a need for further education? A. "I can become very weak." B. "I will gain weight." C. "I will lose muscle tone." D. "I can get bed sores." E. "I won't have any lung problems." Answer: B, E Explanation: Immobility often causes anorexia (not weight gain) and increases lung complication risks (e.g., atelectasis). A, C, and D are accurate effects. Why Other Options Are Wrong: A, C, and D correctly describe immobility consequences. 4. The nurse knows which items are included in the documentation for a patient on fall precautions? A. History of any falls B. Falls risk assessment scores C. Patient and family education D. Use of assist devices E. Any fall or reported fall Answer: A, B, C, D, E Explanation: Fall documentation includes risk assessments, education, device use, and incident reports to ensure comprehensive safety monitoring. Why Other Options Are Wrong: All options are correct and required for thorough documentation. 5. The nurse knows which findings indicate orthostatic hypotension? A. A decrease in systolic blood pressure by 30 mm Hg B. A decrease in diastolic blood pressure by 10 mm Hg C. An increase in heart rate by 30 beats/min D. An increase in systolic blood pressure by 20 mm Hg E. A decrease in heart rate by 20 beats/min Answer: B, D Explanation: Orthostatic hypotension is defined by a diastolic drop ≥10 mm Hg or systolic drop ≥20 mm Hg with standing. A and C exceed typical thresholds. Why Other Options Are Wrong: A and C exceed diagnostic criteria. E describes bradycardia, not orthostasis. 6. The nurse appropriately delegates care of the unit's patients to the properly trained UAP when that UAP is assigned which tasks? A. UAP assigned to reposition the patient. B. UAP assigned to complete the MORSE falls risk scale. C. UAP assigned to provide range-of-motion exercises. D. UAP assigned to ambulate the patient in the hallway. E. UAP assigned to time the patient on a TUG test. Answer: A, C, D Explanation: UAPs can reposition, perform ROM, and assist with ambulation but cannot conduct assessments (B, E). Why Other Options Are Wrong: B and E involve assessment, which is outside UAP scope. 7. The nurse is correctly demonstrating the use of a transfer belt when engaging in which actions? A. The belt is placed around the patient's hips. B. The belt is secure, leaving only enough room for the nurse to grasp the belt. C. The nurse stands on the weaker side. D. The nurse holds the belt on the side of the patient. E. The nurse stands behind the patient while ambulating. Answer: B, C Explanation: The belt should be snug with room for grip, and the nurse stands on the weaker side for support. A is incorrect (waist placement); D and E are unsafe positions. Why Other Options Are Wrong: A risks improper placement. D and E compromise stability. 8. The nurse is correctly assisting the patient in using a cane when the patient demonstrates which activities? A. The top of the cane is level with the patient's bent elbow. B. The patient holds the cane on his/her weaker side. C. The patient moves the cane forward first. D. The patient's arm is comfortably bent when walking. E. The patient moves the strong leg forward first. Answer: C, D Explanation: Proper cane use involves moving the cane first, with the arm slightly bent. The cane should be on the stronger side (B), and height should align with the hip (A). Why Other Options Are Wrong: A and B describe incorrect placement. E contradicts proper gait sequence. 9. The nurse is providing discharge education for the patient who is going home with a walker. Which statements by the patient indicate a good level of understanding of safety in the home? A. "I need to remove the throw rugs." B. "I should make sure I only take a bath." C. "I cannot use the stairs." D. "I need to place a nonskid mat in front of the kitchen sink." E. "I wish I had two ways of leaving the house." Answer: A, D Explanation: Removing rugs and using nonskid mats prevent falls. Bathing (B) can be safe with a shower chair, and stairs (C) may be used with proper training. Why Other Options Are Wrong: B and C reflect misconceptions. E is unnecessary for walker safety. 10. The nurse identifies that knee-high SCD sleeves are correctly placed on the patient when which conditions are met? A. Both sleeves are connected to the SCD device. B. Two fingers fit inside when the SCDs are inflated. C. There are no kinks in the tubing. D. The ankle pressure is 55 to 65 mm Hg. E. The cooling control is on. Answer: A, C, E Explanation: Proper SCD placement requires connected sleeves, unobstructed tubing, and activated cooling. Fit (B) is checked when deflated; pressure (D) is irrelevant. Why Other Options Are Wrong: B is assessed deflated. D refers to pressure settings, not placement.