ATI: Mobility

Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing [Conditions] due to [Findings]. Conditions lead poisoning pneumonia atherosclerosis pulmonary embolism constipation Findings possible deep vein thrombosis blood pressure diet breath sounds home environment

The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis. When analyzing cues, the nurse should note that the client is at risk for developing a pulmonary embolism due to possible deep vein thrombosis. The client reports they just returned from an 8-hr car trip. Extended periods of immobility place the client at an increased risk for a deep vein thrombosis which can lead to a pulmonary embolism. Manifestations of a deep vein thrombosis include unilateral edema, pain, and redness, which often develops in the lower extremities.

A nurse is teaching a newly licensed nurse about the peripheral nervous system. Which of the following statements should the nurse make? a. "The peripheral nervous system regulates the body's response to external stimulus." b. "The spinal cord is part of the peripheral nervous system." c. "The brain is part of the peripheral nervous system." d. "The peripheral nervous system is responsible for memory."

a. "The peripheral nervous system regulates the body's response to external stimulus." The peripheral nervous system is a network of thousands of nerves outside of the brain and spinal cord that regulates the body's response to external stimuli.

A nurse is ordering equipment for a medical-surgical unit. Which of the following equipment should the nurse identify as being ergonomic? Select all that apply. a. Height-adjustable beds b. Wrist supports for computer keyboards c. IV stands that are at a fixed height d. Standard height toilets e. Shower chairs

a. Height-adjustable beds b. Wrist supports for computer keyboards e. Shower chairs Height-adjustable beds are ergonomic because they allow nurses to adjust the height of beds to reduce muscle strain during client care. Wrist supports for computer keyboards are ergonomic because they decrease the risk of repetitive injury to the wrist. Shower chairs are ergonomic because they reduce the risk of client falls.

A nurse is assessing an older adult client who is experiencing age-related changes. Which of the following findings should the nurse expect? a. Increased joint stiffness b. Increased balance c. Increased calcification of bones d. Increased muscle mass

a. Increased joint stiffness Increased joint stiffness is an expected age-related change for an older adult client. This can cause decreased joint mobility and strength and increase the client's risk for falls.

A nurse is preparing to transfer a client who has left-sided weakness from a sitting position in bed to a chair. Which of the following actions should the nurse take? a. Lock the wheels on the client's bed. b. Place the chair on the client's left side. c. Place the chair at a 90° angle to the bed. d. Raise the height of the client's bed.

a. Lock the wheels on the client's bed. The nurse should lock the wheels on the client's bed to prevent the bed from moving and decrease the risk of injury.

A nurse is preparing to reposition a client. Which of the following actions should the nurse take first? a. Raise the height of the client's bed. b. Place their feet in line with their shoulders. c. Pivot their feet in the direction of the move. d. Tighten their abdominal muscles.

a. Raise the height of the client's bed. According to evidence-based practice, the first action the nurse should take is to raise the height of the client's bed. This ensures the client is close to the nurse's center of gravity and reduces the risk of injury.

A nurse is teaching a newly license nurse about the function of red bone marrow. Which of the following information should the nurse include? a. Red bone marrow produces white blood cells. b. Red bone marrow stores calcium. c. Red bone marrow provides protection for internal organs. d. Red bone marrow facilitates motion and flexibility.

a. Red bone marrow produces white blood cells. The nurse should include that red bone marrow produces white blood cells, red blood cells, platelets, and macrophages.

A nurse is teaching a newly licensed nurse about age-related changes to vision in older adult clients. Which of the following should the nurse include as an example of an expected age-related change? a. Reduced depth perception. b. Increased tone of eye muscles. c. Reduced thickness of the natural lens. d. Increased flexibility of the lens.

a. Reduced depth perception A decrease in depth perception is an expected age-related change in older adult clients. This change can result in an increased risk of tripping and falling.

A nurse is preparing to reposition a client towards the head of the bed. In which of the following positions should the nurse place the client before repositioning them to the head of the bed? a. Supine b. Lateral c. Prone d. High-Fowler

a. Supine The nurse should lower the head of the client's bed and place the client in a supine position to reduce the risk of injury to the client or the nurse.

A nurse is teaching a client about the musculoskeletal system. The nurse should include that which of the following is a fluid filled capsule that enables movement and flexibility? a. Synovial joints b. Cartilage c. Ligaments d. Tendons

a. Synovial joints Synovial joints are fluid filled capsules that enable movement.

A nurse is performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment? Select all that apply. a. The client's ability to sit. b. The condition of the client's skin. c. The client's health literacy level. d. The client's need for assistance with ADLs. e. The client's daily calcium intake.

a. The client's ability to sit. b. The condition of the client's skin. d. The client's need for assistance with ADLs. The nurse should include the client's ability to sit, stand, or walk, in a mobility assessment. The nurse should include the condition of the client's skin in a mobility assessment. A pressure injury could impair the client's ability to bear weight. The nurse should include the client's need for assistance with ADLs in a mobility assessment.

A nurse is planning care for a client who is immobile and is experiencing urinary retention. The nurse should plan to monitor the client for which of the following? a. Urinary tract infection b. Neurogenic bladder c. Bladder outlet obstruction d. Genitourinary System Effects

a. Urinary tract infection Incomplete emptying of the bladder can cause bacterial growth due to pooling of urine. The nurse should monitor the client for manifestations of a urinary tract infection, such as urgency, frequency, and burning during urination.

A nurse is performing a mobility assessment on a client. Which of the following actions should the nurse take first? a. Ask the client to stand for 5 seconds. b. Ask the client to sit on the edge of the bed for 2 min. c. Ask the client to march in place. d. Ask the client to place their feet on the floor.

b. Ask the client to sit on the edge of the bed for 2 min. According to evidence-based practice, the first step the nurse should take when performing a mobility assessment is to ask the client to sit on the edge of the bed for 2 min.

A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following? a. Bone density b. Joint flexibility c. Muscle strength d. Muscle mass

b. Joint flexibility Passive range of motion increases joint flexibility and reduces joint stiffness.

A nurse is evaluating ergonomic practice in the workplace. Which of the following should the nurse identify as an example of safe ergonomic practice? a. Nurses are required to work frequent overtime. b. Nurses are required to take breaks during a shift. c. A nurse reaches across a client's bed to lift an object. d. A nurse lifts a client by themselves.

b. Nurses are required to take breaks during a shift. Breaks provide time for rest and muscle recovery, which reduces the risk for injury

Click to highlight the information in the client's medical record that requires intervention by the nurse. To deselect a finding, click on the finding again. a. Client is repositioned every 2 hr. b. Passive range of motion exercises to affected extremities performed once each day. c. Feet warm, pedal pulses 2 + bilaterally. d. Joint contracture noted to right wrist. e. Right heal with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable redness, skin intact.

b. Passive range of motion exercises to affected extremities performed once each day. d. Joint contracture noted to right wrist. e. Right heal with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable redness, skin intact. Joint contractures noted to right wrist requires intervention by the nurse. The nurse should apply a splint to the client's affected joint to reduce the contracture. Right heal with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable redness requires intervention by the nurse. The client has a stage 1 pressure injury on the heal. The nurse should use pillows and cushions to protect and promote blood flow to bony prominences. Passive range of motion exercises to affected extremities performed once each day requires intervention by the nurse. The nurse should perform passive range of motion to the client's affected extremities at least every 8 hr to reduce the risk for contractures.

A nurse is teaching a client who is at risk for osteoporosis. Which for the following instructions should the nurse include? a. Take 400 IU of vitamin D supplement each day. b. Perform moderate-intensity exercise for 150 min per week. c. Perform vigorous exercise at least 2 times per week. d. Take 250 mg of a calcium supplement each day.

b. Perform moderate-intensity exercise for 150 min per week. The client should perform moderate-intensity exercise for 150 min per week to strengthen bones and muscles and decrease the risk of osteoporosis.

A nurse is teaching a class about skeletal muscles. Which of the following should the nurse identify as a function of skeletal muscles? a. Skeletal muscles enable the heart to contract with each heartbeat. b. Skeletal muscles enable a hand to contract and form a fist. c. Skeletal muscles enable the bronchioles to dilate in the lungs. d. Skeletal muscles enable the bladder to contract during voiding.

b. Skeletal muscles enable a hand to contract and form a fist. The contraction and relaxation of skeletal muscles enable movement in bones and joints, such as forming a fist with the hand.

A nurse is teaching a client about using a cane for ambulation. Which of the following statements should the nurse make? a. "Advance the cane 12 inches forward when walking." b. "Move your unaffected leg before your affected leg when walking." c. "Keep the cane at the same level as the affected leg when climbing stairs." d. "Hold the cane on the side of your affected leg when walking."

c. "Keep the cane at the same level as the affected leg when climbing stairs." The client should keep the cane at the same level as the affected leg when climbing stairs to ensure balance and optimal support.

A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement? a. Encourage the client to drink cold fluids. b. Request a prescription for mineral oil for the client. c. Increase the client's fluid intake. d. Place the client on a low-fiber diet.

c. Increase the client's fluid intake. The nurse should increase the client's fluid intake to soften stools.

A nurse is performing a mobility assessment on a client. The client can rise from a seated position using a cane for support. The nurse should assign the client which of the following activity levels? a. Maximum assist b. Moderate assist c. Minimal assist d. No assist

c. Minimal assist The nurse should assign a "minimal assist" activity level to client's who require an assistive device, such as a cane, to stand.

A nurse is teaching a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include? a. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg. b. Orthostatic hypotension increases a client's risk of a pulmonary emboli. c. Orthostatic hypotension increases a client's risk of a fall. d. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg.

c. Orthostatic hypotension increases a client's risk of a fall. Orthostatic hypotension is a decrease in blood pressure when a client changes from lying down to sitting or standing. The drop in blood pressure can cause the client to become dizzy and increases the client's risk for a fall.

A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates an understanding of body mechanics? a. They keep their feet together when lifting an object. b. They twist their spine when lifting. c. They stand close to the object being moved. d. They bend at the hip when lifting.

c. They stand close to the object being moved. The nurse should stand close to the object being moved to reduce reaching and decrease the risk of injury. This action indicates an understanding of the teaching.

A nurse is teaching a newly licensed nurse about maintaining correct posture when transferring clients. Which of the following statements should the nurse make? a. "Loosen your abdominal muscles." b. "Keep your knees straight." c. "Tilt your head toward your chest." d. "Keep your back straight."

d. "Keep your back straight." The nurse should keep their back straight to support the spine and reduce the risk of injury.

A nurse is providing teaching about calcium to a client who is at risk for osteoporosis. The nurse should inform the client that calcium is stored in which of the following locations? a. Red bone marrow b. Tendons c. Synovial joints d. Bones

d. Bones The nurse should include that calcium, phosphorus, and magnesium are stored in the bones.