1. A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility.

In assessment of the client, the nurse is alert to a(n): Decreased peristalsis 2. A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident (stroke). In planning care for this client, the nurse implements which one of the following as an appropriate intervention? Assess the extremities for unilateral swelling and muscle atrophy. 3. Two nurses are standing on opposite sides of the bed to move the client up in bed with a drawsheet. Where should the nurses be standing in relation to the client's body as they prepare for the move? Even with the shoulders 4. A client is leaving for surgery and because of preoperative sedation needs complete assistance to transfer from the bed to the stretcher. Which of the following should the nurse do first? Assess the situation for any potentially unsafe complications. 5. A client has sequential compression stockings in place. The nurse evaluates that they are implemented appropriately by the new staff nurse when the: Intermittent pressure is set at 40 mm Hg 6. The nurse assesses that the client has torticollis and that this may adversely influence the client's mobility. This individual has a(n): Contracture of the sternocleidomastoid muscle with a head incline 7. An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as: Diminished breath sounds 8. The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to: Measure the calf and thigh circumferences 9. A client is getting up for the first time after a period of bed rest. The nurse should first: Obtain a baseline blood pressure 10. To promote respiratory function in the immobilized client, the nurse should: Encourage deep breathing and coughing every hour 11. Antiembolic stockings (thromboembolic device [TED] hose) are ordered for the client on bed rest following surgery. The nurse explains to the client that the primary purpose for the TEDs is to: Apply external pressure 12. To provide for the psychosocial needs of an immobilized client, an appropriate statement by the nurse is which of the following? "Let's discuss the routine to see if there are any changes we can make."

13. To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse should implement the use of a: Trochanter roll 14. To reduce the chance of plantar flexion (footdrop) in a client on prolonged bed rest, the nurse should implement the use of: High-top sneakers 15. Which of the following is the most important to consider when assisting the client in passive rangeof-motion exercises? Support the distal joints while performing range-of-motion exercises. 16. Which of the following clients is most at risk for losing his or her balance? A woman who is 9 months pregnant walking down a flight of stairs 17. It has been determined that all of the following clients are at risk for falling. Which one requires the nurse's priority for ambulation? A 45-year-old postoperative client up for the first time since knee surgery 18. Which of the following statements made by ancillary staff reflects the most informed knowledge regarding the benefit of having a client assist with his or her own activities of daily living (ADLs) to that client's activity tolerance? "By washing and dressing himself he is building muscle strength that lets him actually walk a little better." 19. Which of the following statements regarding physical activity and its effect on activity tolerance made by a client shows the most informed knowledge regarding the connection between the two? "I try to walk a little farther each afternoon so I can dance at my grandson's wedding." 20. A client recovering from hip surgery tells the nurse that she wants to get better so she can walk down the aisle to her seat at her granddaughter's wedding. Which of the following nursing interventions will have the greatest impact on achieving that goal? Walking with the client to and from the dining room where she eats her meals 21. An infant born via cesarean section because of a breech presentation is diagnosed with bilateral congenital hip dysplasia. The primary nursing intervention directed toward this diagnosis is: Maintaining the infant in the position of continuous abduction of both hips 22. A 16-year-old had a full leg cast for 4 months, and it is being removed today. Which of the following statements made by the client shows the most informed understanding of the effects of immobilization of a muscle on its strength and stamina? "I'll practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring." 23. A staff member experienced a shoulder injury while assisting with a client transfer. The nurse manager's most therapeutic response to this situation is to: Have a nonpunitive meeting with all the involved staff to discuss correcting the factors that resulted in the injury

24. Which of the following statements made by a nurse caring for a client who experienced a myocardial infarction 8 hours ago shows the greatest insight as to the purpose for keeping the client on bed rest? "Keeping her on bed rest decreases the need her body has for oxygen" 25. The nurse recognizes that a client who is inactive is at a risk for decreased muscle mass as a result of increased muscle atrophy and: Catabolic tissue breakdown 26. A 78-year-old inactive client diagnosed with acute renal failure is at risk for which of the following skeletal maladies? Pathological fractures of long bones 28. The nurse is providing ancillary personnel with instructions regarding the performance of passive range-of-motion (ROM) exercises for a client experiencing paralysis from the waist down (paraplegia) as a result of an automobile accident. Which of the following statements made by the ancillary personnel reflects the greatest insight regarding the frequency with which the intervention should be provided for this client? "Bath time, bedtime, after lunch, and at least once more; she can pick when." 29. The nurse is discussing joint mobility exercises with a client who experienced a stroke and now has left-sided weakness. Which of the following statements made by the client reflects the greatest insight regarding the best method for him to maintain mobility of the joints on his left side? "I will do those passive range of motion exercises you taught me to my left side at least 3 times a day." 30. The nurse caring for a 38-year-old female client with multiple fractures in the trauma intensive care unit knows that this client is at high risk for pulmonary complications such as atelectasis from her immobility. One of the interventions that the nurse can do to help prevent this from occurring is to: Instruct the client to deep breathe and cough every hour while awake 31. The nurse is caring for a 48-year-old male client who was involved in a motor vehicle accident and had a fractured pelvis, a ruptured spleen, and multiple contusions. The client has been in the hospital for 5 days on bed rest. The nurse knows that this client is at risk for venous thrombus formation because of prolonged bed rest, potential damage to vessel walls during surgery, and the platelets he received in the trauma unit. These three factors are also known as: Virchow's triad 32. The nurse caring for a 73-year-old female client who has been hospitalized with a stroke instructs the client's daughter to continue to do passive range-of-motion exercises with her mother on her affected side to prevent contractures. The nurse explains to the daughter that this is very important in an immobile older adult client because contractures can form in as little as: 8 hours 33. The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in an immobile client is to: Turn the client a minimum of every 2 hours

34. The nurse caring for a 78-year-old male client recovering from hip replacement surgery is assessing for signs of improvement of the client's activity tolerance. The nurse determined a baseline for ongoing assessments by: Determining how much time it takes the client to recover from an activity 35. The nurse and a nursing assistive personnel (NAP) are going to move an older adult client up in bed. Before moving the client, the nurse explains to the NAP that they will need to lift the client off the bed with an assistive device instead of using the drawsheet. The most important reason for using the assistive device is: To avoid shearing the client's skin 36. The nurse understands that using metabolic functioning, measures of height, weight, and skinfold thickness, to evaluate muscle atrophy in an immobilized client is known as: Anthropometric measurements

1. The nurse recognizes that facilitating correct body alignment for a dependent client may well result in which of the following positive client outcomes? (Select all that apply.) 1. A comfortable night's sleep 2. Minimized activity intolerance 3. Muscle tone that promotes ambulation 4. Reduction of falls caused by general weakness 5. Minimal strain placed on the spinal column 2. The nurse chooses to use a mechanical lift to move an obese immobile client. The nurse recognizes that the positive outcomes for both the client and the staff resulting from this intervention will be: (Select all that apply.) 1. Less of the client's body will be dragged along the sheets during the transfer 2. There will be less chance of injuring the skin on the client's elbows and buttocks 3. The staff involved in the transfer will have less likelihood of self-injury 4. The staff will have a greater degree of control over the move 3. A 16-year-old has had a full leg cast in place for 2 months, and it is being removed today. Which of the following assessment findings would be expected following the removal of the cast? (Select all that apply.) 1. Popliteal pulse equal in both legs 4. Weight bearing less stable on affected leg 5. Calf circumference greater in unaffected leg 6. Greater range of motion of knee of unaffected leg 4. Which of the following factors has an impact on the severity of physical impairment a client will experience from a period of immobility? (Select all that apply.) 1. The client's age 2. Prior overall health 3. Length of immobility 4. The degree of immobility

5. A client who experienced a myocardial infarction has been placed on bed rest. The nurse caring for the client recognizes that the inactivity will result in certain assessment findings that include: (Select all that apply.) 1. Lethargy 4. Poor appetite 5. Hypoactive bowel sounds 6. Decrease in baseline respiratory rate