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NUR 353 Exam 4 Questions And 100% Correct Answers
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NUR 353 Exam 4 Questions And 100% CorrectAnswers 2024-2025
State or condition of being mobile or movable ANSWER Mobility
Condition of not moving; motionless, unable to move ANSWER Immobility
A term similar in meaning and encompassing nursing diagnoses related to inactivity.
Risks include impaired skin integrity, constipation, altered respiratory function, altered
peripheral tissue perfusion, activity intolerance, impaired physical mobility, injury,
altered sensory perception, powerlessness, and body image disturbance. - ANSWER
Disuse syndrome
A generalized decline in overall physical strength and endurance. While most patients
may experience a tweak of this after a big surgery or major illness, this term is generally
applied when a previously independent, or mostly independent person is now no longer
able to perform routine activities such as their ADLs and IADLs and their course
continues to decline. - ANSWER Deconditioned
List two screening tools to detect mobility/immobility. - ANSWER 1. Osteoporosis
2. Fall risk assessment
When should fall assessment screening tools be used? - ANSWER Look in Giddens
List some general care guidelines for a patient who is immobilized. - ANSWER 1.
Frequent turning and changing positions every 2 hours in bed or 30 minutes in a chair.
2. Frequent skin assessment and skin care.
3. Range of motion exercises
4. Deep breathing exercises
,5. Resistive exercises if able
5. Interventions to facilitate elimination include high fluids, high fiber and laxatives or
stool softeners.
6. Ambulation, stretches, balance
What do you administer to a client before mobilizing to minimize pain with joint
movement? - ANSWER Anti-inflammatory and pain medications
A break or disruption in the continuity of bone- ANSWER Fracture
The break completely traverses the bone - ANSWER Complete fracture
Puna- Partially across the shaft of a bone yet the bone remains intact - ANSWER
Incomplete fracture
Explain the metabolic changes that occur with immobilization. - ANSWER 1. Slows
metabolic rate, which alters carbohydrate, fat, and protein metabolism
2. Fluid, electrolyte and calcium imbalances
3. Loss of appetite
4. Slowed peristalsis
5. Endocrine system is altered
6. Hypercalcemia, calcium is mobilized from bones in patients who are immobile. The
problem with this is it can lead to pathologic fractures since there is not as much
calcium within the bones!
You are caring for a patient who is immobile. What electrolyte imbalance would you
expect concerning an immobile patient?
a. Hypercalcemia
b. Hypokalemia
,c. Hyponatremia
d. Hypermagnesemia - ANSWER A (In immobile people, calcium is released from their
bones into their blood stream. Normally, your kidneys will excrete this calcium but if
they are unable to respond appropriately, hypercalcemia results.)
List some gastrointestinal impairments caused by decreased mobility. - ANSWER 1.
Constipation
2. Fluid intake decreases, risk for dehydration
3. Anorexia
List two respiratory changes that occur with immobility. - ANSWER 1. Atelectasis
(Collapse of alveoli)
2. Hypostatic pneumonia (Inflammation of the lung from stasis or pooling of secretions)
List three cardiovascular changes that occur with immobility. - ANSWER 1. Orthostatic
hypotension
2. Thrombus formation
3. Decreased cardiac output, resulting in increased workload
List some musculoskeletal changes associated with immobility. (6) - ANSWER 1. Loss of
endurance, strength and muscle mass and decreased stability and balance
2. Decreased muscle mass
3. Joint abnormalities (contractures--From muscle disuse, atrophy and shortening of the
muscle fibers)
4. Disuse osteoporosis (Osteoporosis from immobility)
5. Pathological fractures from disuse osteoporosis
6. Impaired calcium metabolism
List 3 urinary complications associated with immobility. - ANSWER 1. Urinary stasis
from lack of gravity pulling the urine from the renal pelvis into the ureters to the bladder.
, 2. UTIs from urinary stasis
3. Renal calculi from hypercalcemia
List one integumentary complication associated with immobility. - ANWER Pressure
ulcers
List some psychosocial effects seen with immobility. - ANWER 1. Social isolation
2. Helplessness
3. Loneliness
4. Depression
The nurse is caring for an older-adult patient who has been bedridden for 2 weeks. The
patient makes the following statements. Which complaint by the patient indicates to the
nurse that he or she is developing a complication of immobility?
a. Loss of appetite
b. Gum soreness
c. Difficulty swallowing
d. Left-ankle joint stiffness - ANWER D Patients who are immobile require ROM
exercises daily to reduce the risks of immobility. Temporary immobilization, even for as
short a period as two weeks results in some degree of muscle atrophy, loss of muscle
tone, and joint stiffness. Two weeks of joint immobilization without ROM can result
rapidly in the development of contractures.
The client is a geriatric patient who has been relatively immobile since surgery on a total
knee replacement. During your assessment, you note that the patient becomes dyspnic
with position changes to supine. Which of the following assessment findings would be
supportive of a potential pulmonary complication associated with this immobility
problem?
Deselect all that apply.
a. B/P = 128/84
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