A nurse is assessing body alignment. What is the nurse monitoring?
a. The relationship of one body part to another while in different positions
b. The coordinated efforts of the musculoskeletal and nervous systems
c. The force that occurs in a direction to oppose movement
d. The inability t...
A nurse is assessing body alignment. What is the nurse monitoring?
a. The relationship of one body part to another while in different positions
b. The coordinated efforts of the musculoskeletal and nervous systems
c. The force that occurs in a direction to oppose movement
d. The inability to move about freely - ANS A
A nurse is providing range of motion to the shoulder and must perform external rotation. Which
action will the nurse take?
a. Moves patient's arm in a full circle.
b. Moves patient's arm cross the body as far as possible.
c. Moves patient's arm behind body, keeping elbow straight.
d. Moves patient's arm until thumb is upward and lateral to head with elbow flexed. - ANS
D
. A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. The
absence of which finding will indicate goal achievement for the nurse's action?
a. Atelectasis
b. Renal calculi
c. Pressure ulcers
d. Joint contractures - ANS D
The patient has been in bed for several days and needs to be ambulated. Which action will the
nurse take first?
a. Maintain a narrow base of support.
b. Dangle the patient at the bedside.
c. Encourage isometric exercises.
d. Suggest a high-calcium diet. - ANS B
A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which
condition will the nurse monitor for most closely in this patient?
a. Hypostatic pneumonia
b. Renal stones
c. Pressure ulcers
, d. Thrombus formation - ANS B
A nurse is caring for an older, immobile patient whose condition requires a supine position.
Which metabolic alteration will the nurse monitor for in this patient?
a. Increased appetite
b. Increased diarrhea
c. Increased metabolic rate
d. Increased pulse rate - ANS D
The nurse is preparing to lift and reposition a patient. Which action will the nurse take first?
a. Position a drawsheet under the patient.
b. Assess weight to determine assistance needs.
c. Delegate the task to a nursing assistive personnel.
d. Attempt to manually lift the patient alone before asking for assistance. - ANS B
The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which
intervention will the nurse add to the care plan?
a. Encourage the patient to perform as many self-care activities as possible.
b. Provide a complete bed bath to promote patient comfort.
c. Coordinate with occupational therapy for gait training.
d. Place the patient on bed rest to prevent fatigue. - ANS A
A nurse is assessing the body alignment of a standing patient. Which finding will the nurse
report as normal?
a. When observed laterally, the spinal curves align in a reversed ―S‖ pattern. b. When
observed posteriorly, the hips and shoulders form an ―S‖ pattern.
c. The arms should be crossed over the chest or in the lap.
d. The feet should be close together with toes pointed out. - ANS A
The nurse is assessing the patient for respiratory complications of immobility. Which action will
the nurse take when assessing the respiratory system?
a. Inspect chest wall movements primarily during the expiratory cycle.
b. Auscultate the entire lung region to assess lung sounds.
c. Focus auscultation on the upper lung fields.
d. Assess the patient at least every 4 hours. - ANS B
The nurse is assessing an immobile patient for deep vein thromboses (DVTs). Which action will
the nurse take?
a. Remove elastic stockings every 4 hours.
b. Measure the calf circumference of both legs.
c. Lightly rub the lower leg for redness and tenderness.
d. Dorsiflex the foot while assessing for patient discomfort. - ANS B
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