1. A nurse is preparing to assess a patient for orthostatic hypotension. Which piece
of equipment will the nurse obtain to assess for this condition?
a.
... [Show More] Thermometer
b. Elastic stockings
c. Blood pressure cuff
d. Sequential compression devices
ANS: C
A blood pressure cuff is needed. Orthostatic hypotension is a drop of blood pressure
greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolicpressure and
symptoms of dizziness, light-headedness, nausea, tachycardia, pallor, or fainting when
the patient changes from the supine to standing position. A thermometer is used to
assess for fever. Elastic stockings and sequential compression devices are used to
prevent thrombus.
2. The patient has been in bed for several days and needs to be
ambulated. Which action will the nurse take first?
a. Maintain a narrow base of support.
b. Dangle the patient at the bedside.
c. Encourage isometric exercises.
d. Suggest a high-calcium diet.
ANS: B
To prevent injury, nurses implement interventions that reduce or eliminate the effects
of orthostatic hypotension. Mobilize the patient as soon as the physical condition allows,
even if this only involves dangling at the bedside or moving toa chair. A wide base of
support increases balance. Isometric exercises (i.e., activities that involve muscle tension
without muscle shortening) have no beneficial effect on preventing orthostatic
hypotension, but they improve activity tolerance. A high-calcium diet can help with
osteoporosis but can be detrimental in an immobile patient.
3. A nurse reviews an immobilized patient’s laboratory results and
discovers hypercalcemia. Which condition will the nurse monitor for most
closely in this patient? 1
a. Hypostatic pneumonia
b. Renal calculi
c. Pressure ulcers
d. Thrombus formation
ANS: B
Renal calculi are calcium stones that lodge in the renal pelvis or pass through theureters.
Immobilized patients are at risk for calculi because they frequently have hypercalcemia.
Hypercalcemia does not lead to hypostatic pneumonia, pressure ulcers, or thrombus
formation. Immobility is one cause of hypostatic pneumonia,which is inflammation of the
lung from stasis or pooling of secretions. A pressureulcer is an impairment of the skin that
results from prolonged ischemia (decreased blood supply) within tissues. A thrombus is an
accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood
attached to the interior wall of a vein or artery, which sometimes occludes the lumen of
the vessel.
4. A nurse is caring for an immobile patient. Which metabolic
alteration will the nurse monitor for in this patient?
a. Increased appetite
b. Increased diarrhea
c. Increased metabolic rate
d. Altered nutrient metabolism
ANS: D
Immobility disrupts normal metabolic functioning: decreasing the metabolic rate,
altering the metabolism of carbohydrates, fats, and proteins; causing fluid,electrolyte,
and calcium imbalances; and causing gastrointestinal disturbances such as decreased
appetite and slowing of peristalsis, leading to constipation.
5. A nurse is preparing a care plan for a patient who is immobile. Which
psychosocial aspect will the nurse consider?
a. Loss of bone mass
b. Loss of strength
c. Loss of weight
d. Loss of hope
ANS: D 2
Loss of hope is a psychosocial aspect. Patients with restricted mobility may havesome
depression. Depression is an affective disorder characterized by [Show Less]