NCLEX Style Critical Thinking Questions On Mobility

(a) Although turning a patient to a new position every 2 hours provides a variety and increased comfort, these are not the primary reasons for this intervention.

(b) Although turning frequently promotes elimination, the upright positions, such as high-Fowler's and sitting, have the greater influence on elimination.

(c) Compression of soft tissue greater than 32 mm Hg prevents capillary circulation and compromises tissue oxygenation in the compressed area. Turning the patient relieves the compression of tissue in dependent areas, particularly those tissues overlying bony prominences.

(d) Although turning and positioning promotes respiratory functioning, other interventions such as sitting, deep breathing, coughing, and incentive spirometry, have a greater influence on respiratory status.

(a) The nurse should face the direction the patient is to be moved to prevent twisting that will move the line of gravity outside the base of support. In addition, to prevent muscle strain the strong powerful gluteal and leg muscles should be used rather than the muscles of the arms and back,

(b) When moving a patient the nurse should widen the stance and flex the knees, hip and ankles. The wide base of support and the lowered center of gravity decrease strain on the nurse.

(c) Holding the breath (Valsalva maneuver) increases the cardiac workload and decreases coronary artery perfusion and should not be employed when moving patients. The nurse should be exhaling when moving patients. The tensing of the abdominal and gluteal muscles sets the internal girdle that protects the intervertebral disks from injury.

(d) The elbows and knees should be slightly flexed, not extended, when moving patients.

(a) Deep breathing prevents atelectasis and hypostatic pneumonia, not pressure ulcers.

(b) Although sheepskin reduces friction and limits pressure, its main purpose is to allow air to circulate under the patient in order to minimize moisture and maceration of skin.

(c) ROM exercises help prevent contractures, not pressure ulcers.

(d) Turning a patient relieves pressure on the capillary beds of the dependent areas of the body, particularly the skin overlying bony prominences, which re-establishes blood flow to the area.

(a) External rotation of the shoulder, a ball-and-socket joint, occurs when the upper arm is held parallel to the floor, the elbow is at a 90-degree angle, and the fingers are pointing toward the floor and the person moves the arm upward so that the fingers point toward the ceiling.

(b) Circumduction of the shoulder, a ball-and-socket joint, occurs when an extended arm moves forward, up, back and down in a full circle.

(c) Lateral flexion of the hand occurs with both abduction (radial flexion) and adduction (ulnar flexion). With the hand supinated, radial flexion occurs by bending the wrist laterally toward the fifth finger.

(d) Pronation of the hand occurs by rotating the hand and arm so that the palm of the hand is facing down toward the floor.

(a) This is a defining characteristic of the nursing diagnosis Activity Intolerance.

(b) This is a contributing factor for the nursing diagnosis Activity Intolerance

(c) Limited range of motion is a defining characteristic of the nursing diagnosis Impaired Physical Mobility

(d) An increased respiratory rate would be an adaptation to activity, not a defining characteristic of the nursing diagnosis Impaired Physical Mobility.

(a) Although the extent of weakness should be assessed, it is not the priority

(b) Although the presence of flaccidity should be assessed, it is not the priority

(c) Although the degree of atrophy should be assessed, it is not the priority

(d) If the patient is experiencing pain, there will be reluctance to move. An analgesic administered before beginning these exercises will promote acceptance and tolerance of the exercises

(a) Logrolling turns a patient while keeping the vertebral column, including the head and neck, in straight alignment to prevent twisting (rotation) that can injure the spinal cord

(b) Pressure of a pillow or the hands held against the abdomen supports an abdominal surgical incision, not log rolling.

(c) This patient does not need to be logrolled. The entire leg from hip to ankle should be supported when turning a patient with a long leg cast.

(d) This patient does not need to be logrollwed. The side of the body with hemiparesis or hemiplegia must be supported.

(a) Supination occurs when the hand and forearm rotate so that the palm of the hand is facing upward

(b) Adduction occurs when an arm or leg moves toward and/or beyond the midline of the body

(c) Dorsal flexion (dorsiflexion) of the joint of the ankle occurs when the toes of the foot point upward and backward toward the anterior portion of the lower leg.

(d) There is no range of motion called plantar extension. Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg.

(a) This should be avoided because it can injure nerves and blood vessels

(b) Encouraging the patient to be as self-sufficient as possible ensures that the transfer is conducted at their pace, promotes self-esteem and decreases the physical effort expended by the nurse.

(c) This will provide a narrow base of support and is unsafe

(d) The bed should be higher, not lower, than the wheelchair so that gravity can facilitate transfer

(a) The unaffected leg should be advanced first because the weight of the body is lifted to the next step on the leg with the greatest strength.

(b) With the tip of the cane placed 6 inches lateral to the foot, the handle should be at the level of the patient's greater trochanter to ensure that the elbow will be flexed 15 to 30 degrees when using the cane

(c) A cane is a hand-gripped assistive device; therefore, the hand opposite to the hemiparesis should hold the cane. Exercises can strengthen the flexor and extensor muscles of the arms and the muscles that dorsiflex the wrist.

(d) This will cause flexion of the neck, hips, or waist that will move the center of gravity outside the line of gravity. Proper body alignment (posture) is essential for balance, stability, and safe ambulation.

(a) Muscle strain is reduced when moving patients with gravity, not with added effort needed to move patients against gravity.

(b) The gluteal and leg muscles should be used rather than the sacrospinal muscles of the back to exert an upward lift. These larger muscles fatigue less quickly, and their use protects the intervertebral disks.

(c) the muscles of the legs are used inefficiently when the knees are kept locked. This increases the strain on the other muscles being used.

(d) Bending from the waist increases the strain on the sacrospinal muscles and intervertebral disks.

(a) When in a sitting position the hips and knees are flexed at 90 degrees and the body's weight is borne by the pelvis, particularly the ischial tuberosities, which are bony protuberances of the lower portion of the ischium. Using a wheel chair results in prolonged sitting unless interventions are used to promote local circulation.

(b) Pressure to the scapulae occurs in all back-lying positions, such as the supine and Fowler's positions.

(c) Pressure to a trochanter occurs in a side-lying, not the sitting, position.

(d) Pressure to the malleolus (medial and lateral) of the ankle occurs in a side-lying, not a sitting, position

(a) Vest restraints are needed only when a patient's safety is at risk and if there is a physician's order.

(b) The knees do not have to be at 90 degrees. Depending on the needs of the patient, the knees may be supported in the extended position on the wheelchair leg rests,

(c) After transfer, it is most important that the patient be supported in functional alignment to avoid any strain on neuromusculoskeletal structures of the body.

(d) This may be necessary only if the patient is confused and needs to be monitored for safety

(a) the knees are extended, not flexed, when in a supine position,

(b) the supine position is a back-lying position that results in pressure in the heels (calcaneus), which have minimal tissue between the bone and skin, making them vulnerable to the development of pressure ulcers.

(c) There is no pressure on either greater trochanter when in the supine position. Pressure on the greater trochanter occurs when the patient is in a lateral (side-lying) position.

(d) External rotation, not internal rotation, of the hips tends to occur when a patient is in the supine position.

(a) Heat lamp treatments should not be used because they can cause burns

(b) Topical antibiotics are used only when the ulcer is infected, not to treat eschar

(c) Cleansing irrigations are ineffective in removing the thick fibrin-containing cells of eschar covering the surface of the wound

(d) Thick, leather-like necrotic devitalized tissue (eschar) must be removed surigally or enzymatically before wound healing can occur.

(a) In Stage I pressure ulcer, the skin is still intact and presents clinically as reactive hyperemia.

(b) In Stage II pressure ulcer the partial-thickness skin loss presents clinically as an abrasion, blister; or shallow crater

(c) In Stage III pressure ulcer, there is full-thickness skin loss involving the subcutaneous tissue that may extent to the underlying fascia. The ulcer presents clinically as a deep crater with or without undermining.

(d) In Stage IV pressure ulcer there is full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscles, bone or supporting structures.

(a) Assessing posture will identify whether the patient's center of gravity is in the midline from the middle of the forehead to a midpoint between the feet and therefore balanced within the patient's base of support.

(b) Strength has more to do with the exertion of power, not balance.

(c) energy has more to do with endurance, not balance

(d) Assessing respiratory rate establishes a baseline against which to compare respiratory rate after activity to determine tolerance, not balance.

(a) Endurance relates to aerobic exercise that improves the body's capacity to consume oxygen for producing energy at the cellular level.

(b) Strength relates to isometric and isotonic exercises, which contract muscles and promote their development.

(c) The line of gravity passes through the center of gravity when the body is correctly aligned; this results in the least amount of stress on the muscles, joints, and soft tissues. Bedridden patients often need assistive devices such as pillows, sandbags, bed cradles, wedges, rolls, and splints to support and maintain the vertebral column and extremities in functional alignment.

(d) Balance relates to body mechanics, and is achieved through a wide base of support and a lowered center of gravity.

(a) hyperextension of the condyloid joint of the wrist is accomplished by bending the fingers and hand backwards as far as possible.

(b) Opposition of the thumb, which is a saddle joint, occurs when the thumb touches the top of each finger on the same hand.

(c) Abduction of the fingers (metacarpophalangeal joints - condyloid) occurs when the fingers of each hand spread apart.

(d) flexion of the wrist, a condyloid joint, occurs when the fingers of the hand move toward the inner aspect of the forearm.

(a) There is no Stage 0 in the classification system for staging pressure ulcers.

(b) The skin is still intact and there is no undermining in a Stage I pressure ulcer.

(c) Tissue damage is superficial and there is no undermining in a Stage II pressure ulcer.

(d) IN a Stage III pressure ulcer there is full thickness skin loss involving damage to subcutaneous tissue that may not be undermining, which is tissue destruction underneath intact skin along wound margins.

(a) Dehydration is not an adaptation to immobility

(b) The decreased tone of the urinary bladder and the inability to assume the normal voiding position in bed promotes urinary retention, rather than urinary incontinence.

(c) Contractures result from permanent shortening of muscles, tendons, and ligaments. Contractures are irreversible without surgical intervention.

(d) With immobility, the increased heart rate reduces the diastolic pressure. In addition, there is a decrease in blood pressure related to postural changes from lying to sitting or standing (orthostatic hypotension). This situation is manageable with a priority on maintaining patient safety.

(a) Plantar flexion contractures (foot drop), not dorsiflexion contractures, can occur in the low-Fowler's position.

(b) In the low-Fowler's position, the majority of the body's weight is borne by portions of the pelvis: bony protuberances of the lower portion of the ischium (ischial tuberosities) and the triangular bone at the dorsal part of the pelvis (sacrum)

(c) This is more likely to occur in the spine, rather than the low-Folwer's position.

(d) Abduction, rather than adduction, of the legs is more likely to occur in the low-Fowler's position.

(a) Sitting in the high-Fowler's position and leaning forward allows the abdominal organs to drop by gravity, which will promote contraction of the diaphragm. The arms resting on an over-bed table increases thoracic excursion.

(b) the hips will be in extreme flexion, not extension.

(c) Pressure ulcers can still occur on the ischial tuberosities

(d) Ambulation is superior to any bed position for promoting urinary elimination.

(a) A person who chooses not to ambulate still has the ability to assume many different sitting or lying down positions.

(b) Anxiety and ultimately panic that is precipitated by a situation can be prevented by avoiding the situation.

(c) A person who chooses not to ambulate still can socialize

(d) Most falls occur when ambulating. Fear of falling results in the conscious choice not to place oneself in a position where a fall can occur. Disuse and muscle wasting cause a reduction of muscle strength at the rate of 5 to 10 percent per week so that within 2 months of immobility over 50 percent of a muscle's strength can be lost. In addition, there is a decreased cardiac reserve. These adaptations result in decreased physical conditioning.

(a) Carrying a heavy object
This follows the principle "The closer an object is to the center of gravity, the greater the stability and the easier the object is to move"

(b) Raising the side rails on a bed
Side rails protect patients from falling out of bed and follow the principle "An object in motion stays in motion until it hits an opposing force"

(c) Repositioning a trochanter roll
Trochanter rolls placed lateral to the legs between the iliac crests and knees prevent external hip rotation when the patient is in the supine position. This follows the principle "An object in motion stays in motion until it hits an opposing force"

(d) Transferring a patient from a bed to a chair
When transferring a patient from bed to char both the nurse and the patient should have their feet spread the width of their shoulders and with one foot in front of the other. Appropriate body mechanics prevents falls.

(a) the patient would feel discomfort por pain, not tingling, with thrombophlebitis

(b) A slowed blood flow and increased viscosity of the blood allow platelets and calcium to settle out against the intimal lining of a vein, which can result in thrombus formation. The inflammatory process causes calf edema, pain, heat, and erythema

(c) The skin would appear taut and shiny, not dry with thrombophlebitis

(d) The area would feel warm, not cool, to the touch with thrombophlebitis

(a Quadriplegia, the paralysis of all four extremities, places the patient at greatest risk for pressure ulcers because the patient has no ability to shift the body weight off of bony prominences or change position without total assistance

(b) Bladder and bowel retraining, incontinence devices, and meticulous skin care limit the potential for skin breakdown when patients are incontinent

(c) Hemiparesis, muscle weakness on one side of the body, does not prevent a person from shifting or changing position to relieve pressure on the skin

(d) Confused patients can move independently when uncomfortable or when encouraged and assisted to move by the nurse.

(a) Nurses should use the longer, stronger muscles of the thighs and buttocks when moving patients to protect their weaker back and arm muscles.

(b) Nurses should have a wide base of support when moving patients to provide better stability.

(c) Nurses should use a pulling motion to turn patients because the muscles that flex, rather than extend, the arm are stronger and pulling, rather than pushing, creates less friction and therefore less effort.

(d) misaligning the back when moving patients occurs most often when not facing the direction of the move. Twisting (rotation) of the thoracolumbar spine and flexion of the back place the line of gravity outside the base of support, which can cause muscle strain and disabling injuries.

(a) This is unsafe. A trochanter roll placed in the small back would be uncomfortable and produce an excessive lumbar curvature.

(b) This is contraindicated because it places unnecessary pressure on the popliteal area.

(c) A trochanter roll is a rolled wedge, pillow, or sandbag placed by the lateral aspect of the leg between the iliac crest and knees to prevent external hip rotation.

(d) The diameter of a trochanter roll would be too wide to maintain the hand in functional alignment.

(a) Demineralization of bone is a systemic response to immobility. Without the stress of weight-bearing activity, the bones begin to demineralize and the urine becomes more alkaline. Calcium salts precipitate out as crystals to form calculi.

(b) Thrombophlebitis results from the systemic responses of impaired venous return and hypercoagulability in conjunction with injury to a vessel wall.

(c) A contracture is a localized response to immobility. When muscle fibers are not able to shorten or lengthen, eventually a permanent shortening of the muscles and subsequently of the tendons and ligaments occurs.

(d) Immobility can cause the systemic response of demineralization of bone (disuse osteoporosis) that eventually can result in bone fractures.

(a) In the left Sim's position the patient's right arm and leg are supported on pillows to prevent internal rotation of the shoulder and the hip.

(b) The right arm is positioned in front of, not behind, the back

(c) The right hand is positioned in pronation, not supination

(d) The right arm is positioned to maintain the shoulder in external, not internal rotation.

(a) Although a blood pressure reading may indicate the presence of hypotension, the blood pressure should be obtained before and after a transfer to allow a comparison to conclude that the hypotension is orthostatic hypotension.

(b) If the patient is experiencing orthostatic hypotension, the heart rate will increase, not decrease

(c) Feeling dizzy is a subjective adaptation to orthostatic hypotension. Obtaining feedback from the patient provides a quick evaluation of the patient's response to the transfer.

(d) This is not an assessment. This is a safe intervention for a patient who is experiencing orthostatic hypotension

(a) In the lateral (side-lying) position, the majority of the body's weight is on the greater trochanter of the femur as well as the lateral aspect of the lower scapula and the lateral aspect of the ilium.

(b) The ischial tuberosity, a rounded protuberance of the lower part of the ischium, is at the greatest risk for skin breakdown when the patient is sitting on a chair or lying in a high Fowler's position.

(c) The occipital area of the head is at the greatest risk for skin breakdown when the patient is lying in the supine position.

(d) The scapulae are at the greatest risk for skin breakdown when patient is lying in the supine position.

(a) Flexion of the metacarpophalangeal joints (condyloid joints) and the interphalangeal joints (hinge joints) occurs by making a fist, which decreases the angles of the joints.

(b) Inversion is turning the sole of a foot medially, which is not a range-of-motion of the hand.

(c) Abduction is moving an arm or a leg away from the midline of the body.

(d) Opposition occurs when the thumb touches the top of each finger of the same hand.

(a) Inversion, a gliding movement of the foot, occurs by turning the sole of the foot medially toward the mid line of the body

(b) Adduction occurs when an arm or leg moves toward and beyond the midline of the body

(c) Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg.

(d) Internal rotation of a leg occurs by turning the foot and leg inward so that the toes point toward the other leg.

(a) Nonblanchable erythema refers to erythema of intact skin that persists when finger pressure is applied. This is the heralding lesion of a Stage I pressure ulcer.

(b) Circumoral cyanosis is associated with hypoxia, not pressure ulcers.

(c) With necrosis, death of cells has occurred. This is a Stage IV, not Stage I, pressure ulcer

(d) With an abrasion, the superficial layers of the skin are scraped away. This STAGE II, not Stage I, pressure ulcer appears reddened and there may be localized serous weeping or bleeding.

(a) This is associated with cardiovascular problems

(b) This is associated with bowel and/or urinary incontinence

(c) this is associated with the older adult and people with peripheral neuropathy or neurologic disease.

(d) Cachexia involves weight loss, muscle atrophy, and decreased subcutaneous tissue, which results in a reduction in the padding between skin and bones, thus increasing the risk of pressure ulcer development

(a) Air mattresses automatically and rhythmically inflate and deflate, which applies and relieves pressure on various body areas. Capillary beds close at between 12-32 mm Hg (capillary closing pressure). Any device that reduces pressure below capillary closing pressure is considered a pressure relief device. Any device that does not consistently reduce pressure below capillary closing pressure is considered a pressure reducing device.

(b) A bedridden patient is at risk for skin breakdown, and therefore 3 back rubs a day are inadequate

(c) Moisture barriers prevent skin breakdown when a patient is incontinent of urine or feces, they do not prevent pressure on the skin

(d) This increases the risk of the patient's sliding down in bed, which may cause shearing force that can injure tissue. In addition, this position increases pressure on the vulnerable sacral area.

(a) This goal is not measurable as stated. Understanding is not measurable unless parameters are identified.

(b) This goal is patient-centered and measurable.

(c) This is a nursing intervention, not a patient goal.

(d) This is a nursing goal, not a patient goal.

(a) Top sheets tucked in along the sides of the bed would still exert pressure on the upper surface of the feet, which may promote plantar flexion. The sides of top sheets, mitered at the foot of the bed, hang freely off the side of the bed

(b) Making a vertical or horizontal toe pleat at the foot of the bed over the patient's feet laves room for the feet to move freely and avoids exerting pressure on the upper surface of the feet, thus preventing plantar flexion.

(c) The weight of the top sheets would still exert pressure on the upper surface of the feet, promoting plantar flexion.

(d) Trochanter rolls prevent external hip rotation, not plantar flexion.

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(a) Pressure on the popliteal areas can cause damage to nerves and interfere with circulation and must be avoided.

(b) Transfer belts should be removed once the patient is transferred.

(c) This would move the patient too lose to the front of the seat and would be unsafe.

(d) The patient's feet should be positioned flat on the foot rest of the wheelchair, not the floor, to protect the feet if the wheelchair is moved.

(a) The knees can be flexed, but the back should be held in straight alignment to prevent twisting of the spine or straining in the muscles in the lower back.

(b) Placing the patient in functional alignment before being turned limits stress or strain on the musculoskeletal system.

(c) moving an object along a level surface requires less energy than moving an object up an inclined surface against the force of gravity.

(d) This follows the principle TASKS PERFORMED CLOSE TO THE CENTER OF GRAVITY REQUIRE LESS EFFORT

(a) this is unsafe because pressure injures fluid-filled tissue. They should be applied before, not after, the legs are dependent.

(b) Elastic stockings provide external pressure on the patient's legs to prevent pooling of blood in the veins while not interfering with arterial circulation. Inspecting the skin 3 times a day is adequate.

(c) when applying elastic stockings, lotion increases friction that can injure tissue. Baby powders can be applied to facilitate application.

(d) this is unsafe. Elastic stockings should be removed for 30 minutes 3 times a day.

(a) Stabilization of body parts ensures that only the joint moves through its full range of motion.

(b) The supine position is more appropriate for performing passive range-of-motion exercises. Active range-of-motion exercises can be performed in any comfortable position.

(c) This promotes motivation and correct completion of the procedure.

(d) Subsequent contraction of muscles tends to be more extensive and efficient, facilitating fuller range of motion.

(a) The longer chains go in the holes for the seat support, which keeps the legs and pelvis below the upper body. Appropriate placement of the upper and lower chains creates a bucket seat in which a patient is moved safely.

(b) Moving patients with a hydraulic life is within the scope of nursing practice and a practitioner's order is unnecessary.

(c) This could result in the patient's sliding down and out of the sling during the transfer. Nylon, net or canvas slings are available.

(d) it does not matter whether the feet or the head exits the bed first as long as functional alignment and safety are maintained.

(a) heat causes vasodilation that increases circulation to the area and results in erythema, not reactive hyperemia.

(b) compressed skin appears pale because circulation to the area is impaired. When pressure is relieved, the skin takes on a bright red flush as extra blood flows to the area to compensate for the period of impeded blood flow.

(c) effleurage, light stroking of the skin, simulates the peripheral nerves and should not change skin coloration.

(d) The can cause a friction burn or a shearing force that can injure blood vessels and tissues.

(a) The width of these depends on the configuration of the bed, objects in the room, and the ultimate destination. The base usually is locked open when lifting or lowering the patient and locked closed when moving the lift.

(b) The wheels must be unlocked to move the lift from under the bed to its ultimate destination

(c) The legs dangle from the sling and therefore may drag across the linens or hit other objects if not protected.

(d) This is unsafe. The life should raise the patient high enough to clear the surface of the bed.

(a) This will place the lower part of the body level to or above the lower body, which is an unsafe, unstable position because the body is not balanced with the center of gravity in the "seat" of the sling. The shorter chains go in the holes closes to the head, not the feet.

(b) The patient can either cross the arms on the chest or grasp the shorter chains during the transfer

(c) Centering the sling ensures full support between the shoulders and the knees and with the correct placement of the chains places the center of gravity in the "seat" if the sling. Centering the sling just above the knees prevents pressure on the popliteal space and prevents extension of the lower legs, which would alter the center of gravity and be unsafe.

(d) The hydraulic valve should be opened slowly, not swiftly because sling movement can be frightening and sudden movement can unbalance the lift.

(a) Bolsters prevent arms and legs from becoming entangled in bed rails

(b) If a padded undergarment is worn when a fall occurs, the padding provides protection for the bony prominences of the pelvis and femurs.

(c) Although this has reduced accidents, not all patients at risk for falls need wheelchairs. The majority of patients who fracture their hips are ambulatory.

(d) Rugs or mats on the floor increase the risk of falls and injury.