Question 1 of 8
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Within which time frame will contractures begin to develop after immobilization of a body part?
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- 3 to 7 daysWhen skeletal muscles are not regularly stretched and contracted to their normal limits, they attempt to adapt themselves to this limited use by becoming shorter and less elastic. An “adaptive shortening,” or contracture, begins to form within 3 to 7 days after immobilization of a body part, and the process usually is complete in 6 to 8 weeks.
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- 1 to 2 weeksContractures begin to develop earlier than 1 to 2 weeks.
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- 2 to 6 weeksContractures begin to develop earlier than 2 to 6 weeks.
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- 6 to 8 weeksThe process usually is complete in 6 to 8 weeks but begins earlier.
Question 2 of 8
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Which action would the nurse perform for a patient who has a continuous passive motion (CPM) machine after knee replacement surgery?
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- Conduct regular assessments of adequacy of pain relief.The nurse would frequently assess pain.
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- Refresh ice applications frequently to reduce pain and swelling.Pain is relieved by ongoing circulation of ice water through the pad of the device, so the nurse does not have to reapply fresh ice applications.
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- Ensure that device is always in place and functional.It is used intermittently throughout the day, so the device can be removed as needed for care and comfort.
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- Perform passive range-of-motion exercises on affected knee.The CPM is motor driven and set to automatically provide passive range-of-motion; the nurse and the patient do not need to perform exercise.
Question 3 of 8
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Which patient action indicates a need for further teaching for a patient who must use a cane after a right knee injury?
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- Holds the cane in the right hand.The cane would be held on the unaffected side unless the health care provider prescribes otherwise.
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- Looks straight ahead when walking.The patient would be correct to look straight ahead when walking.
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- Holds cane with elbow bent at a 30-degree angle.The patient would be correct to have the elbow bent at a 30-degree angle when the cane is placed on the ground.
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- Moves cane forward when the right leg moves forward.The patient would be correct to move the cane forward when the affected leg moves forward.
Question 4 of 8
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Which action by the unlicensed assistive personnel (UAP) would prompt the nurse to immediately intervene for a patient who is experiencing spastic paralysis after a spinal cord injury?
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- Ensuring appropriate joint flexion after turning the patientThe UAP would be appropriate in ensuring appropriate joint flexion after turning.
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- Ensuring that the patient’s sheets are smooth and free of creasesThe UAP would be appropriate in ensuring that the sheets are smooth and free of creases.
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- Turning the patient every 2 hours and padding pressure pointsThe UAP would be appropriate in turning the patient every 2 hours, and padding pressure points.
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- Placing footboards in contact with the patient’s feet after bathingFootboards are used to prevent footdrop in patients with flaccid paralysis. The patient in spastic paralysis could experience worsened spasticity from the pressure.
Question 5 of 8
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The nurse is caring for a patient who has been immobile for several weeks after surgery. Which physiologic consequence is the patient at risk for?
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- PneumoniaPneumonia may result as a consequence of immobility because of reduced lung expansion.
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- HypocalcemiaHypercalcemia, not hypocalcemia, may result as a consequence of bone breakdown.
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- Increased peristalsisPeristalsis decreases with limited physical activity.
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- Increased cardiac outputCardiac output decreases with immobility.
Question 6 of 8
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Which complications would the nurse monitor for in an immobile patient? Select all that apply. One, some, or all responses may be correct.
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- HeadachesHeadaches are not a complication from immobility.
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- DepressionDepression is a common clinical manifestation of immobility, so the nurse should monitor for signs and symptoms.
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- Muscle atrophyMuscle atrophy occurs as a complication of immobility because the muscles are not being used effectively.
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- Skin breakdownSkin breakdown occurs as a result of immobility, especially if the patient is not turned frequently.
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- Deep venous thrombosis (DVT)DVT and clotting is common with immobility because of venous stasis and blood pooling.
Question 7 of 8
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For which patient condition would the nurse question the use of isometric exercises?
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- Migraine headacheMigraine headaches are not contraindications for use of isometric exercises.
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- Prostate cancerProstate cancer is not a contraindication for use of isometric exercises.
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- Blood pressure 190/98 mmHgHypertension, increased intracranial pressure, and congestive heart failure are contraindications for use of isometric exercises because they can result in a significant increase in blood pressure and heart rate.
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- Chronic obstructive pulmonary disease (COPD)COPD is not a contraindication for isometric exercises.
Question 8 of 8
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Which nursing intervention is appropriate for a patient prescribed crutches for ambulation?
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- Remove rubber tip from the bottom of the crutches.Canes and crutches should always have an intact rubber tip in place on the bottom for safety.
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- Have the patient use the crutch on the affected side only.The patient should use the can on the good side unless the provider orders otherwise.
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- Instruct the patient to straighten the elbows during weight bearing with crutches.The patient should be instructed to straighten the elbow and wrist during weight bearing when walking with crutches.
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- Ensure that the patient’s hand grip is bent at a 90-degree angle when weight is placed on the crutch.This relates to cane use, rather than gripping of crutches. The patient’s hand grip should be bent at a 30-degree angle when weight is placed on the cane.