Impaired Physical Mobility Flashcards, test questions and answers

Question 1

13. A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What is a priority nursing diagnosis for this patient? a. Imbalanced Nutrition: More Than Body Requirements related to immobility b. Impaired Physical Mobility related to pain and discomfort c. Chronic Pain related to immobility d. Risk for Infection related to altered skin integrity

Answer

d. Risk for Infection related to altered skin integrity
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Question 2

The nurse identifies a priority problem for Aaron’s plan of care as “Impaired skin integrity.” What etiology should the nurse identify? Noncompliance with turning schedule. Poor nutritional intake. Impaired physical mobility. Impaired adjustment.

Answer

Impaired physical mobility
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Question 3

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain that is interfering with her ability to ambulate. The nurse accurately documents which nursing diagnosis in the client’s records? Impaired physical mobility related to pain Impaired movements due to pain Ineffective physical mobility due to pain Ineffective movement related to arthritis

Answer

Impaired physical mobility related to pain
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Question 4

A patient is diagnosed with an abscess in the cerebellum. Which nursing diagnosis has priority for the plan of care? a. risk for falls related to loss of balance and equilibrium b. unilateral neglect related to impairments to perception c. impaired physical mobility related to spasticity and changes in muscle tone d. risk for impaired cerebral tissue perfusion related to obstruction secondary to infection

Answer

A. risk for falls related to loss of balance and equilibrium
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Question 5

Which nursing diagnosis would be most appropriate for a patient who is receiving an opiate analgesic that depresses the central nervous system (CNS)?: A. Fatigue. B. Impaired physical mobility. C. Risk for activity intolerance. D. Risk for injury.

Answer

D. Risk for injury.
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Question 6

The nurse identifies a priority problem for Aaron’s plan of care as “Impaired skin integrity”. What etiology should the nurse identify? A) Noncompliance with turning schedule B) Poor nutritional intake C) Impaired physical mobility D) Impaired adjustment

Answer

C) Impaired physical mobility Since Aaron is paraplegic, he has impaired physical mobility, a major factor that contributes to pressure ulcer development.
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Question 7

Nursing Plan of Care The nurse is assisting Ms. Jackson to the bedside commode on the second postoperative day. Ms. Jackson states, ”I have never had to depend on anyone before. I like to take care of myself. I feel so helpless.” 25. In response to these remarks, the nurse plans care for Ms. Jackson based on the identification of which nursing diagnosis? A) Disturbed body image. B) Altered self-concept. C) Anticipatory grieving. D) Impaired physical mobility.

Answer

B) Altered self-concept. CORRECT The client’s remarks regarding feelings of helplessness relate to her sense of how she perceives herself; her self-concept.
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Question 8

The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, impaired physical mobility related to tibial fracture as evidenced by patient inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Answer

Etiology
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Question 9

An 85-year-old client has a nursing diagnosis of Fluid Volume Excess. Which nursing diagnosis would be next in priority? A. Risk for Fluid Volume Deficit B. Risk for Impaired Physical Mobility C. Risk for Impaired Skin Integrity D. Risk for Imbalanced Nutrition

Answer

C. The client already has fluid volume excess. With fluid volume excess, the client is most likely to have edema and edematous skin is more fragile. Furthermore, the skin in older adults is most at risk for integrity issues. The client could have all of the other nursing problems with the least likely being the volume deficit; however, the risk for impaired skin integrity would be the next diagnosis of priority.
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Question 10

What is wrong with the following diagnostic statement? “Impaired Physical Mobility related to laziness and not having appropriate shoes.” The statement is 1) Judgmental 2) Too complex 3) Legally questionable 4) Without supportive data

Answer

ANS: 1 “Lazy” implies criticism of the client and therefore is judgmental. There need to be several (certainly more than two) etiological factors for the statement to be complex. There is no blame implied or harm resulting, so the statement is not legally questionable. There is no minimum “amount” of supportive data for a diagnosis and the stated etiology related to the nursing diagnosis. No supportive data are given in the stem of the question, so you could not choose “lack of data” as the best answer because all the options lack data as far as you can tell from the information given in the question. In addition, it is not necessary to include supportive data in the diagnostic statement (although some do prefer to use “A.M.B.” and include defining characteristics). PTS:1DIF:ModerateREF:p. 74 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis
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