ATI RN MED SURG ALTERATIONS IN MOBILITY ASSESSMENT
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6. A nurse is presenting a class on injury prevention to a group of clients. Which of the
following are the best ways to prevent soft-tissue injuries? (Select all that apply.)
A. Drink plenty of water while exercising.
B. Begin with running a half-marathon race.
C. Participate in a well-balanced exercise program.
D. Maintain good physical health.
E. Include a warmup and cool down period.
Answer: A. Drink plenty of water while exercising.
C. Participate in a well-balanced exercise program.
D. Maintain good physical health.
E. Include a warmup and cool down period.
Explanation:
• Drink plenty of water while exercising is correct. This restores hydration to the body
• Begin with running a half-marathon race is incorrect. Soft-tissue Injuries can be prevented
by maintaining good physical health and getting regular activity. Activities programs should
be well balanced and include warm-ups, and cool downs. The client should drink plenty of
water during activity. A half-marathon is too long of a race for preventing-soft tissue injuries.
• Participate in a well-balanced exercise program is correct. Soft-tissue injuries can be
prevented by maintaining good physical health and getting regular activity.
Activities programs should be well balanced and include warm-ups, and cool downs. The
client should drink plenty of water during activity.
• Maintain good physical health is correct. Soft-tissue injuries can be prevented by
maintaining good physical health and getting regular activity. Activities programs should be
well balanced and include warm-ups, and cool downs. The client should drink plenty of water
during activity.
• Include a warmup and cool down period is correct. Soft-tissue injuries can be prevented by
maintaining good physical health and getting regular activity. Activities programs should be
well balanced and include warm-ups, and cool downs. The client should drink plenty of water
during activity.
7. A nurse Is caring for a client who has been immobile for several days following a
musculoskeletal injury. The client is refusing to get out of bed, Which of the following
actions should the nurse take? Select all that apply.
A. Manually lift client out of bed to begin mobilizing.
B. Be consistent and offer mobilization every day
C. Assess mobility needs.
D. Allow client to determine when it is appropriate to begin mobilizing.
E. Assist the client with mobilizing.
F. Remove any restrictions from the environment
Answer: B. Be consistent and offer mobilization every day
C. Assess mobility needs.
E. Assist the client with mobilizing.
F. Remove any restrictions from the environment
Explanation:
• Manually lift client out of bed to begin mobilizing is incorrect. This does not promote
mobility and leads to a client's dependence on nursing staff.
• Be consistent and offer mobilization every day is correct. This will encourage mobility and
a routine.
• Assess mobility needs is correct. Each client is unique and will need different equipment
and support.
• Allow client to determine when they are ready to begin mobilizing is incorrect. This will
allow them to continue to refuse and convince themselves they are unable to move.
• Assist the client with mobilizing is correct. This will encourage mobility and safety.
• Remove any restrictions from the environment is correct. This will make movement easier
and prevent injury to the client and staff.
8. A nurse is caring for a client who has compromised perfusion to the left lower limb. Which
diagnostic test should the nurse anticipate an order for?
A. Doppler studies
B. MRI
C. Bedside stress testing
D. Standard x-rays
Answer: A. Doppler studies
9. A nurse is caring for a client who has low back pain. Which statement by the client is
consistent with low back pain?
A. "I was scrubbing the floor and suddenly felt this sharp pain in my back.”
B. "I was ice skating last week and fell a few times. My back hurt afterwards and I tried to ice
it and take medication, but the pain won't go away.”
C. "I have been dealing with this pain in my low back for about a year. I don't know what
caused it, but nothing I have tried seems to help."
D. "A little over a month ago, I hurt my back when I was out dancing. I have tried everything
and it won't go away."
Answer: C. "I have been dealing with this pain in my low back for about a year. I don't know
what caused it, but nothing I have tried seems to help."
10. A client is admitted to the emergency department after an injury on the football field.
Which method will be used to diagnose the client with a soft-tissue injury?
A. Client and family medical history
B. Standard x-ray and bedside stress examination
C. History of injury with MRI
D. CT with IV contrast along with standard x-rays
Answer: B. Standard x-ray and bedside stress examination
11. A nurse is caring for a client who has undergone an open reduction internal fixation to
correct a fracture. Which of the following puts the client at greater risk for developing
pneumonia?
A. Airways are less responsive to irritants after surgery.
B. The use of anesthetics during surgery.
C. The client has increased inflammation due to the stress of surgery.
D. Lungs are more distensible after surgery.
Answer: B. The use of anesthetics during surgery.
12. A nurse is caring for a client who has multiple fractured bones. There is an external
fixation device on the lower left leg and a cast on the left forearm. Which of the following
focused assessments should the nurse include to recognize complications? (Select all that
apply.)
A. Assess the affected extremities for color, sensation, pulse, temperature, and movement
B. Check any dressings for signs of bleeding.
C. Assess skin underneath cast for flakiness.
D. Assess pin sites for drainage
E. Monitor cast for tightness.
F. Evaluate pain based on the OPQRST mnemonic.
Answer: A. Assess the affected extremities for color, sensation, pulse, temperature, and
movement
B. Check any dressings for signs of bleeding.
D. Assess pin sites for drainage
E. Monitor cast for tightness.
F. Evaluate pain based on the OPQRST mnemonic.
Explanation:
• Observing the extremities for color, sensation, pulse, temperature, and movement is correct.
This will detect any neurovascular compromise such as the presence of compartment
syndrome.
• Checking the dressing for signs of bleeding is correct. This will show if it needs to be
changed to avoid infection.
• Assessing under a cast for flakiness is incorrect. Dry skin is common under a cast, but no
lotions or ointments should be placed under It.
• Assessing the pin sites for drainage is correct. The nurse needs to know when they need to
be cleaned and assess for infection.
• Assessing the cast for tightness is correct. If it is too tight it can cut off circulation, and this
is an emergency.
• Evaluating pain using the OPQRST mnemonic is correct This will allow the nurse to
intervene and keep the client comfortable.
13. A nurse is planning home care for a client who recently experienced a fall. Which medical
condition increases the risk for fractures?
A. Diabetes mellitus
B. Osteoporosis
C. Cardiovascular disease
D. Epilepsy
Answer: B. Osteoporosis
14. A nurse is caring for a client with a cast on the right forearm. The client is being evaluated
today for a potential sprain in the right ankle. The client states, ’I am not sure how this
happened." Which of the following responses should the nurse make?
A. “It may be that, with your previous injury, your are not at your high test fitness level and it
was easier to injure yourself”
B. "I do not know. What kind of medications do you take every day?"
C. "I guess you are just clumsy. It just happens sometimes.'
D. "I am not sure. Have you had many falls before? Is your right forearm still bothering
you?"
Answer: A. “It may be that, with your previous injury, your are not at your high test fitness
level and it was easier to injure yourself”
15. A nurse is assessing a client who presents to the clinic a few days after falling off of a
bicycle. The chest x-ray indicates several fractured ribs. Which statement by the client
indicates that there is an impact on the client's ability to perform their activities of daily
living? (Select all that apply}
A. “I am having trouble when I take a deep breath or try to lift my arms”
B. “It hurts when I touch my chest."
C. "I have had to take my pain medication in order to sleep."
D. "I can't rest unless 1 am propped up with three pillows."
Answer: A. “I am having trouble when I take a deep breath or try to lift my arms”
16. A nurse is working with a client scheduled for a below-the-knee amputation. The client
expresses fear of what life will be like after the surgery. Which of the following actions
should the nurse take?
A. Encourage the client to practice deep breathing and meditation.
B. Discontinue use of electronic devices for a week before surgery.
C. Provide antianxiety medication for a week prior to surgery.
D. Encourage the client to meet with another amputee before surgery.
Answer: D. Encourage the client to meet with another amputee before surgery.
17. A nurse is caring for a group of clients who have impaired mobility. Which physical
clinical manifestations should the nurse be alert for? (Select all that apply.)
A. Urinary tract infection
B. Bleeding disorders
C. Inflammation over bony prominences
D. Deep vein thrombosis
E. Aspiration
Answer: A. Urinary tract infection
C. Inflammation over bony prominences
D. Deep vein thrombosis
E. Aspiration
Explanation:
• Urinary tract infection is correct. Urinary tract Infections is correct, They are a common
manifestation seen with immobility.
• Bleeding disorders is incorrect. There are many clinical manifestations that occur with
immobility, including urinary tract infections, aspiration, inflammation over bony
prominence, and deep vein thrombosis. Bleeding disorders are not usually associated with
immobility.
• Inflammation over bony prominences is correct. There are many clinical manifestations that
occur with immobility, Including inflammation over bony prominences.
• Deep vein thrombosis is correct. There are many clinical manifestations that occur with
immobility, including deep vein thrombosis.
• Aspiration is correct. There are many clinical manifestations that occur with immobility,
Including aspiration.
18. A client requires crutches for ambulation. Which safety factor is Important for the nurse
to determine prior to discharging the client?
A. Need for use of crutches on stairs
B. Assistance at home to help as needed
C. Availability of anti-inflammatory medications
D. Ability to apply ice
Answer: A. Need for use of crutches on stairs
19. A nurse is caring for a client who has a second-degree sprain. Which is the best
description of a second-degree sprain injury?
A. The strain has caused a stretching of some of the muscle fibers.
B. The strain has caused a complete tearing of the affected muscle fibers.
C. The strain has caused stretching of the muscles and a stress fracture.
D. The strain has caused a tearing of most of the muscle fibers.
Answer: D. The strain has caused a tearing of most of the muscle fibers.
20. A nurse is reviewing bone structure with a group of clients. Which bones change with
maturation to differentiate assigned sex?
A. Vertebral bones
B. Bones of the skull
C. Pelvic bones
D. Ribs and sternum
Answer: C. Pelvic bones
21. A nurse is caring for a client after a fracture, and is monitoring for complex regional pain
syndrome (CRPS). Which of the following manifestations should the nurse be alert for?
(Select all that apply.)
A. Acute shortness of breath
B. Swelling below the level of injury
C. Change in color of affected limb
D. Sudden onset of extreme pain
E. Affected limb warm to touch
Answer: B. Swelling below the level of injury
C. Change in color of affected limb
D. Sudden onset of extreme pain
Explanation:
• Acute shortness of breath is incorrect. CRPS does not cause acute shortness of breath.
• Swelling below the level of injury is correct. Manifestations of CRPS include sudden,
extreme pain, coolness, a change of color of the affected limb when compared to other areas
of the client's skin, and swelling below the level of injury.
• Change in color of affected limb is correct. Manifestations of CRPS include sudden,
extreme pain, coolness and a change in color of the affected limb when compared toother
areas of the client's skin, and swelling below the level of injury.
• Sudden onset of extreme pain is correct. Manifestations of CRPS include sudden, extreme
pain, coolness, a change in color of the affected limb when compared to other areas of the
client's skin, and swelling below the level of injury.
• Affected limb warm to touch is incorrect. The affected limb would be cool to the touch, not
warm, with CRPS.
22. A client who has chronic kidney disease is admitted to the emergency department with a
stress fracture. Chronic kidney disease is a possible comorbidity with which mobility
disorder?
A. Osteoarthritis
B. Osteoporosis
C. Soft-tissue injury
D. Low back pain
Answer: B. Osteoporosis
23. A nurse is working in a rehabilitation unit caring for a group of clients with complications
of immobility. Which of the following factors contribute to alterations in physical mobility?
(Select all that apply.)
A. Presence of visitors
B. Low confidence
C. Medical devices that restrict movements
D. Fear of burdening staff
E. Loss of dignity
Answer: B. Low confidence
C. Medical devices that restrict movements
D. Fear of burdening staff
E. Loss of dignity
Explanation:
• Presences of visitors is incorrect. Visitors can encourage mobility and lift the client's spirits.
• Low confidence is correct. There are many physical and psychosocial reasons that
contribute to a client's reluctance to participate In physical activity. These Include a loss of
dignity, a loss of confidence, a fear of burdening staff, and medical devices that restrict
movement.
• Medical devices that restrict movement is correct. There are many physical and
psychosocial reasons that contribute to a client's reluctance to participate in physical activity.
These Include a loss of dignity, a loss of confidence, a fear of burdening staff, and medical
devices that restrict movement.
• Fear of burdening staff is correct. There are many physical and psychosocial reasons that
contribute to a client’s reluctance to participate in physical activity.
These include a loss of dignity, a loss of confidence, a fear of burdening staff, and medical
devices that restrict movement.
• Loss of dignity is correct. There are many physical and psychosocial reasons that contribute
to a client's reluctance to participate in physical activity. These include a loss of dignity, a loss
of confidence, a fear of burdening staff, and medical devices that restrict movement.
24. A nurse is administering medications to a client who has a recent lower limb amputation.
The client asks why they are prescribed gabapentin. Which of the following responses should
the nurse give?
A. "I am not sure. You will have to check with your provider about it."
B. "Don't you have a history of epilepsy?"
C. "Gabapentin alleviates the pain caused by the nerve endings that remain."
D. "Gabapentin will help the surgical site to heal.'
Answer: C. "Gabapentin alleviates the pain caused by the nerve endings that remain."
25. A nurse is reviewing the medical record of a client who reports a new onset of back pain.
Which of the following findings should the nurse identify as an increased risk for low back
pain?
A. Works in construction
B. Has a BMI of 24
C. Recently received an influenza vaccination
D. Presence of a heart murmur
Answer: A. Works in construction
26. A nurse is evaluating a client after an injury to the wrist. Which assessment finding
demonstrates an injury to the range of motion?
A. Extending and flexing the elbow without problem
B. Pain when flexing and extending the wrist
C. Pain relief when the wrist is supported
D. Pronation and supination of the arm without problem
Answer: B. Pain when flexing and extending the wrist
27. A client who has been living with chronic back pain verbalizes a fear of returning to
normal exercise. Which of the following responses should the nurse give?
A. "It's like riding a bike. It will all come back to you."
B. “I know it is scary. Let’s review the steps on how to be safe while exercising”
C. "It's OK. You can wait to start exercising."
D. "Well, we are going to have to talk to the provider about this."
Answer: B. “I know it is scary. Let’s review the steps on how to be safe while exercising”
28. A client presents to the clinic after a fall from a stepladder. Which assessment finding
suggests possible fracture in the ankle?
A. Deformity noted in the ankle
B. 1 + pedal pulse in both feet
C. Pain In the heel
D. Presence of bruising on the foot
Answer: A. Deformity noted in the ankle
29. A nurse is caring for a group of clients who have movement disorders and overhears
another nurse say, "These people are just lazy. They just want to be supported by the
government and not have to work." Which is the correct response for the nurse to make?
A. "Yes, you are probably right. Only in the United States do we see this."
B. “These clients did not choose this, and may face financial burdens that impact their quality
of life because of their disorder”
C. "I think we should go to their insurance companies and report them."
D. "I can’t believe you just said that. Didn't you just take a few extra days off?"
Answer: B. “These clients did not choose this, and may face financial burdens that impact
their quality of life because of their disorder”
30. A client is admitted to the emergency department reporting severe low back pain. Which
of the following are potential causes of acute back pain? (Select all that apply.)
A. Dissecting aortic aneurysm
B. Abdominal aortic aneurysm
C. Fat embolism
D. Angina
E. Compartment syndrome
F. Osteoarthritis
Answer: A. Dissecting aortic aneurysm
B. Abdominal aortic aneurysm
D. Angina
F. Osteoarthritis
Explanation:
• Dissecting aortic aneurysm is correct. Serious causes of acute low back pain include
abdominal aortic aneurysm, aortic dissection, angina, and osteoarthritis. A dissecting aortic
aneurysm can cause pain that presents in the lower back.
• Abdominal aortic aneurysm is correct. Serious causes of acute low back pain include
abdominal aortic aneurysm, aortic dissection, angina, and osteoarthritis. An abdominal
aneurysm can cause pain that presents in the lower back.
• Fat embolism is incorrect. Serious causes of acute low back pain include abdominal aortic
aneurysm, aortic dissection, angina, and osteoarthritis. Fat embolism is a potential lifethreatening event after a fracture but is not a cause of lower back pain.
• Angina is correct. Serious causes of acute low back pain include abdominal aortic
aneurysm, aortic dissection, angina, and osteoarthritis. Angina can present as pain In the
lower back.
• Compartment syndrome is incorrect. Serious causes of acute low back pain include
abdominal aortic aneurysm, aortic dissection, angina, and osteoarthritis.
Compartment syndrome can lead to loss of limb but is not a cause of low back pain.
• Osteoarthritis is correct. Serious causes of acute low back pain include abdominal aortic
aneurysm, aortic dissection, angina, and osteoarthritis. Osteoarthritis is a common cause of
low back pain due to the inflammation of the joints.
