A patient has damage to the cerebellum. Which disorder is most important for the
nurse to assess?
a. Imbalance
b. Hemiplegia
c. Muscle sprain
d.
... [Show More] Lower extremity paralysis
ANS: A
Damage to the cerebellum causes problems with balance, and motor impairment is
directly related to the amount of destruction of the motor strip. A stroke can lead to
hemiplegia. Direct trauma to the musculoskeletal system results in bruises,
contusions, sprains, and fractures. A complete transection of the spinal cord can
lead to lower extremity paralysis.
2. Which patient will cause the nurse to select a nursing diagnosis of Impaired
physical mobility for a care plan?
a. A patient who is completely immobile
b. A patient who is not completely immobile
c. A patient at risk for single-system involvement
d. A patient who is at risk for multisystem problems
ANS: B
The diagnosis of Impaired physical mobility applies to the patient who has some
limitation but is not completely immobile. The diagnosis of Risk for disuse
syndrome applies to the patient who is immobile and at risk for multisystem
problems because of inactivity. Beyond these diagnoses, the list of potential
diagnoses is extensive because immobility affects multiple body systems.
3. The patient has the nursing diagnosis of Impaired physical mobility related
to pain in the left shoulder. Which priority action will the nurse take?
a. Encourage the patient to do self-care.
b. Keep the patient as mobile as possible.
c. Encourage the patient to perform ROM.
d. Assist the patient with comfort measures.
1
ANS: D
The diagnosis related to pain requires the nurse to assist the patient with comfort
measures so that the patient is then willing and more able to move. Pain must be
controlled so the patient will not be reluctant to initiate movement. The diagnosis
related to reluctance to initiate movement requires interventions aimed at keeping
the patient as mobile as possible and encouraging the patient to perform self-care
and ROM.
4. A nurse is developing an individualized plan of care for a patient. Which
action is important for the nurse to take?
a. Establish goals that are measurable and realistic.
b. Set goals that are a little beyond the capabilities of the patient.
c. Use the nurse’s own judgment and not be swayed by family desires.
d. Explain that without taking alignment risks, there can be no progress.
ANS: A
The nurse must develop an individualized plan of care for each nursing diagnosis
and must set goals that are individualized, realistic, and measurable. The nurse
should set realistic expectations for care and should include the patient and
family when possible. The goals focus on preventing problems or risks to body
alignment and mobility.
5. Which behavior indicates the nurse is using a team approach when caring for a
patient who is experiencing alterations in mobility?
a. Delegates assessment of lung sounds to nursing assistive personnel
b. Becomes solely responsible for modifying
activities of daily living Consults physical
therapy for strengthening exercises in the [Show Less]