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NUR 215 Module 13-15 Exam Questions with Correct Answers
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NUR 215 Module 13-15 Exam Questions with Correct Answers
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NUR 215 Module 13-15 Exam Questionswith Correct Answers
What is mobility? - Answer-Is freedom and independence in purposeful movement.
Refers to adapting to and having self-awareness of the environment. Functional
musculoskeletal and nervous systems are essential for mobility.
What is immobility ? - Answer-Is the inability to move freely and independently at will.
The risk of complications increases with the degree of immobility and the length of time
of immobilization. Periods of immobility or prolonged bed rest can cause major
physiological and psychosocial effects.
-Can be temporary due to a knee replacement or post op
-May be permanent: Paralized
-Acute: Broken leg
Factors affecting Mobility - Answer--Alterations in muscles (muscle atrophy)
-Injury to the musculoskeletal system
-Poor posture
-Impaired central nervous system
-Health status and age
Effects of immobility - Answer--Integumentary
-Musculoskeletal
-Cardiovascular
-Respiratory
-Gastrointestinal
Interventions to promote mobility and to prevent complications associated with
immobility - Answer--Integumentary(specifically pressure ulcers)
-Musculoskeletal
-Cardiovascular
-Respiratory
Interventions immobility: Musculoskeletal - Answer-Make sure clients change position in
bed at least every 2 hr and perform weight shifts in the wheelchair every 15 min
Encourage active or provide passive ROM two or three times/day
A continuous passive motion(CPM) device might be prescribed. Develop an
individualized program for each client. Older adult clients can require a program that
addresses the aging process.
Cluster care to promote a proper sleep-wake cycle
Request physical therapy for clients who have decreased mobility.
Assist client with ambulation. Use assistive devices(gait belts, walkers, canes or
crutches) as needed
,-Patient education
Perform ROM while bathing, eating, grooming and dressing
Cane Instructions - Answer--Maintain two points of support on the ground at all times
-Keep the cane on the stronger side of the body
-Support body weight on both legs
-Move the cane forward 15-25cm (6-10in)
-Next, move the weaker leg forward toward the cane
-Finally, advance the stronger leg past the cane
Thrombophlebitis, DVT - Answer-Are inflammation of a vein (usually in the lower ext)
that results in clot formation
Manifestations: Pain edema, warmth, and erythema at the site
Assessment: Measure bilateral calf and thigh circumferences daily. Unilateral increase
is early indication of thrombosis
Nursing action:
-Notify the provider immediately
-Position the client in bed with the leg elevated
-Avoid any pressure at the site of the inflammation
-Acticipate giving anticoagulants
Pulmonary embolism - Answer-Is a potentially life-threatening occlusion of blood flow to
one or more of the pulmonary arteries by a clot. The clot or embolus often originates in
the venous system of the LE
Manifestations: SOB, chest pain, hemoptysis (coughing up blood), decreased blood
pressure, and rapid pulse
Nursing actions:
-Prepare to give throbolytics or anticoagulants
-Position client in a high fowlers position
-Obtain pulse ox
-Administer oxygen
-Prepare to obtain blood gas analysis
-Monitor vital signs frequently
Interventions Immobility: Cardiovascular - Answer-Increase activity as soon as possible
by dangling feet on side of bed or transferring to a chair
Change position as often as possible
Move the client gradually during position changes
Instruct clients to avoid the Valsalva maneuver
Give a stool softner to prevent straining
, Teach ROM and antiembolic exercises(ankle pumps, foot circles, knee flexion).
Use elastic stockings
Use sequential compression devices(SCD) or intermittent pneumatic compression(IPC)
Increase fluid intake if no restrictions
Administer low-dose heparin or enoxaparin subcutaneously prophylactically
Contact the provider immediately if there is absence of a peripheral pulse in the lower
extremities or assessment data that indicates venous thrombosis
Patient education
-Perform isometric exercises to increase activity tolerance
-Avoid placing pillows under the knees or lower ext, crossing the legs, wearing tight
clothes around the waist or on the legs, sitting for long periods of time, and massaging
the legs
Interventions immobility: Respiratory - Answer-Maintain airway patency, achieve optimal
lung expansion and gas exchange, and mobilize airway secretions.
Reposition every 1 to 2 hr
Remove abdominal binders every 2 hr and replace correctly
Use chest physiotherapy
Auscultate the lungs to determine the effectiveness of chest physiotherapy or other
respiratory therapy
Monitor the ability to expectorate secretions
Use suction if unable to expectorate secretion
Patient education
-Turn, cough, and breathe deeply every 1 to 2 hr while awake
-Yawn every hour while awake
-Use an incentive spirometer while awake
-Consume at least 2000ml fluid per day, unless intake is restricted
Metabolic Interventions - Answer-Reduce skin injury and maintain metabolism
-Record anthropometric measurements of height, weight and skin folds
-Assess I&O
-Assess food intake
-Review urinary and bowel elimination status
-Assess wound healing
-Ausculatate bowel sounds
-Check skin turgor
-Review lab values for electrolytes, blood total protein, and BUN
Actions
-Provide a high calorie, high protein diet with vitamin B and C supplements
-Monitor and evaluate oral intake, For clients who cannot eat or drink, provide enteral or
parenteral nutritional therapy
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