CCBC Nursing 153: Exam with Questions and Correct Answers
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Course
CCBC Nursing
Institution
CCBC Nursing
What are 5 nursing interventions that can be used in regards to oxygenation problems
as a result of immobility? - Answer 1. Increase activity
2. Incentive spriometer EVERY HOUR
3. Coughing and deep breathing exercises
4. Elevate HOB
5. Keep well hydrated
CCBC Nursing 153: Exam with Questions and
Correct Answers
What are 5 nursing interventions that can be used in regards to oxygenation problems
as a result of immobility? - Answer 1. Increase activity
2. Incentive spriometer EVERY HOUR
3. Coughing and deep breathing exercises
4. Elevate HOB
5. Keep well hydrated
What are 4 effects that immobility has on Perfusion? - Answer 1. Increased cardiac
workload
2. Edema and pressure ulcers
3. Venous stasis and thrombus formation (DVT)
4. Orthostatic hypotension
What are 7 nursing interventions that can be used in regards to perfusion problems as a
result of immobility? - Answer 1. Increase activity!!
2. Check vitals: HR
3. Assess peripheral circulation: pulses, edema
4. Monitor for signs of DVT
5. Turn every 2 hours, ROM
6. TEDs and SCDs
,7. Dangle, move gradually when getting patient OOB
What are 4 effects of immobility on Nutrition and Metabolism? - Answer 1. Loss of
appetite
2. Increased risk of dehydration
3. Increased risk of electrolyte imbalance
4. Altered carb, fat, and protein metabolism
What are 5 nursing interventions that can be used in regards to nutrition and
metabolism problems as a result of immobility? - Answer 1. Work with dietary: provide
patient with adequate needs for total protein, calories, fiber, fluids and other nutrients
2. Provide smaller meals or supplements
3. Ask family to bring food from home
4. Assess patient's likes and dislikes
5. Appropriate environment to eat
What are the 2 most common effects of immobility on Skin Integrity? - Answer 1.
PRESSURE ULCERS!
2. Prolonged tissue ischemia can lead to necrosis.
What are 5 nursing interventions that can be used in regards to skin integrity problems
as a result of immobility? - Answer 1. Assess skin every shift
2. Turn every 2 hours, pad bony prominences
3. Hand Hygiene!
4. Maintain clean dry skin and a wrinkle free bed
5. Nutritional status
,What are 3 commons effects of immobility on Psychosocial Integrity? - Answer 1.
Feelings of depression, anxiety, hostility, loss of control, fear, isolation.
2. Inappropriate behaviors and mood changes
3. Sensory alterations
What are 6 nursing interventions that can be used in regards to psychosocial problems
as a result of immobility? - Answer 1. Orient patient to person, place and time
2. Provide stimulation and diversions
3. Increase daytime activity
4. Encourage family and friends to visit
5. Get patient out of room if possible
6. Allow patient to make decisions
What are 8 common nursing diagnoses related to immobility? - Answer 1. Risk for falls
2. Activity Intolerance
3. Risk for injury
4. Risk for loneliness
5. Impaired physical mobility
6. Risk for impaired skin integrity
7. Impaired transfer ability
8. Impaired walking
What are the 4 components that make up a great nursing outcome? - Answer Outcomes
are:
1. Patient-Centered
, 2. Measurable
3. Realistic
4. Have a target date
What are 4 nursing responsibilities in regards to mobility? - Answer 1. Assess patient's
mobility status and needs
2. Utilize good body mechanics
3. Work with other disciplines
4. Interventions
What part of the body acts as the center of gravity for proper body alignment? - Answer
The hips.
What is the term used to describe an increased lumbar curvature? What population is
this most commonly found in? - Answer Lordosis, most commonly found with pregnant
women.
What is the term used to describe an exaggeration of posterior curvature of thoracic
spine? What population is this most commonly found in? - Answer Kyphosis
(hunchback), most commonly found with older adults.
What is the term used to describe a lateral spinal curvature? What population is this
most commonly found in? - Answer Scoliosis, most commonly found with teenage girls.
What are 4 common effects of immobility? - Answer 1. Atony: loss of muscle tone
2. Loss of muscle strength (weakness)
3. Contractures: permanent shortening of the muscles because of the flexor muscles
overpowering the weaker extendor muscles
4. Osteoporosis: decalcification of the bone
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