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NSG 3023 CHAPTER 36 QUIZ
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NSG 3023 CHAPTER 36 QUIZChapter 36: Immobility
Potter: Essentials for Nursing Practice, 8th Edition
MULTIPLE CHOICE
1. An elderly patient was admitted to the hospital after falling in the nursing home. The patient
has a fractured right femur and is awaiting surgery. The surgeon orders bed rest. The patient
asks the nurse what this means. What is the nurse’s best explanation?
a. “You are to be immobile.”
b. “You cannot move.”
c. “You need restraints.”
d. “You have to remain in bed.”
ANS: D
A patient’s mobility can be restricted for therapeutic reasons, such as when bed rest is
ordered. Therapeutic reasons for bed rest include decreasing the body’s oxygen needs,
reducing cardiac workload, reducing pain, and allowing the debilitated or ill patient to rest.
The duration of bed rest depends on the type and nature of the illness or injury and the
patient’s prior state of health. Bed rest does not mean immobile, cannot move, or that
restraints are needed.
PTS: 1 DIF: Cognitive Level: Applying (Application)
REF: 1035 OBJ: Describe mobility and immobility.
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
2. The patient is recovering from a cerebrovascular accident (stroke). The patient is having
problems with balance and coordination. The patient asks the nurse what part of the brain
has been damaged. How should the nurse respond?
a. The hypothalamus has been damaged.
b. The cerebellum has been damaged.
c. The thalamus has been damaged.
d. The medulla oblongata has been damaged.
ANS: B
Damage to the cerebellum causes problems with balance, and motor impairment is directly
related to the amount of destruction of the motor strip. The hypothalamus controls
temperature. The thalamus controls the five senses: hearing, seeing, taste, smell, and touch.
The medulla oblongata is part of the brainstem and controls breathing, heart rate, and
digestion.
PTS: 1 DIF: Cognitive Level: Analyzing (Analysis)
REF: 1033
OBJ: Describe common physical and physiological changes associated with immobility.
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
, 3. A student nurse is caring for a young adult patient who is immobile with a back injury. On
auscultation, the student nurse hears rhonchi in the lower lobes. The student nurse reports
this symptom because the patient is developing which complication?
a. Increased lung expansion
b. Hypostatic pneumonia
c. Aspiration pneumonia
d. Increased diuresis
ANS: B
Decreased, not increased, lung expansion, generalized respiratory muscle weakness, and
dependent stasis of secretions occur with immobility. These conditions often contribute to
the development of atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation
of the lung from stasis or pooling of secretions). Aspiration pneumonia results from
aspiration, not from immobility. Diuresis is increased urine excretion.
PTS: 1 DIF: Cognitive Level: Analyzing (Analysis)
REF: 1035
OBJ: Describe common physical and physiological changes associated with immobility.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
4. A young adult patient was involved in a motorcycle accident. The patient was in the
intensive care unit of the hospital for 2 months with immobility and was just discharged to a
rehabilitation hospital. The patient asks the nurse, “Why am I so weak?” What is the best
response from the nurse?
a. “When you are in bed for a long time, your body begins to break down its own
protein.”
b. “When you don’t use it, you lose it.”
c. “You haven’t eaten much for the past couple of months.”
d. “Your body has spent energy trying to heal itself by increasing the metabolic rate.”
ANS: A
Immobility disrupts normal metabolic functioning, decreasing the metabolic rate and
altering the metabolism of carbohydrates, proteins, and fats. A patient’s basal metabolic rate
(BMR) decreases in response to reduced cellular energy because of the body’s decreased
ability to produce insulin and metabolize glucose. The body then begins to breakdown its
protein stores for energy resulting in a negative nitrogen balance and increased oxygen
demands. However, in the presence of an infection, immobilized patients have an increased
BMR. It is the immobility that has caused the weakness, not what was eaten. Not using it
leads to losing it is a cliché and should be avoided. The metabolic rate is decreased in
immobility not increased.
PTS: 1 DIF: Cognitive Level: Analyzing (Analysis)
REF: 1035 OBJ: Identify changes in metabolic rate associated with immobility.
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
5. Patients on prolonged bed rest are at risk for a deep vein thrombosis. Which information
indicates the nurse needs more teaching about the factors in Virchow’s triad?
a. One of the factors is loss of integrity of the vessel wall.
b. One of the factors is abnormalities of blood flow.
c. One of the factors is alterations in blood constituents.
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