Chapter 28 Physical Activity & Immobility

1.A 15-year-old patient complains of left ankle pain after being tackled while playing football.

He asks the nurse what tests he needs to have to determine whether he has a strain or a fracture. How should the nurse reply?

a)“You don’t need an x-ray; I can tell by the way your ankle looks and feels whether you have a strain or fracture.”

b)“Sprains, strains, and fractures have similar symptoms at first; you will need an x- ray of the joint to be certain.”

c)“We will need to get a venous Doppler study to make sure that there is not a

fracture.”

d)“First, we need to get an MRI to diagnose your injury as a fracture instead of strain or sprain.”

ANS: B

Signs and symptoms associated with a sprain, strain, or fracture are the same. An x-ray allows the medical provider to visually observe for any breaks in a bone. An x-ray is more practical than an MRI to diagnose a fracture. A venous or arterial Doppler is used to detect blood flow.

Difficulty: Easy

Nursing Process: Interventions

Client Need: PHSI

Cognitive Level: Application

PTS: 1

2.The nurse planning the care of a frail, malnourished, immobile patient recognizes which of the following as the best treatment to protect the patient’s integument?

a)Offering the patient six small meals a day

b)Assisting the patient to sit in a chair three times a day

c)Turning the patient at least every 2 hours

d)Administering fluid boluses as directed by the healthcare provider

ANS: C

External pressure from lying or sitting in one position compresses capillaries and obstructs blood flow to the skin. Immobile patients confined to a bed should be turned at least every 2 hours to protect their skin and relieve pressure.

Difficulty: Easy

Nursing Process: Planning

Client Need: Safe and Effective Care

Cognitive Level: Comprehension

PTS: 1

3.What action is most important in limiting the nurse’s risk of back injuries?

a)Use good body mechanics at all times.

b)Work with another nurse or an aide when lifting and turning patients.