chapter 33

The nurse cares for an older adult client who reports feeling dizzy when moving from sitting to standing. Which response by the nurse is most appropriate in addressing the physiological causes of the situation the client is experiencing?

Sometimes after periods of inactivity the blood vessels do not constrict quickly and a drop in your blood pressure occurs when you stand.

A nurse is recommending aerobic exercise for a client who is overweight. Which exercise might the nurse suggest?

Swimming

The nurse should intervene immediately when observing the nursing assistive personnel (NAP) performing which activity with a stable client?

Teaching a client range-of-motion exercises

A nurse assesses a client's alignment and documents which data as a normal finding?

The base of support is on the soles of the feet.

Using proper body mechanics, which motions would the nurse make to move an object?

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct?

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?

When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.

A nurse is teaching a client who has unilateral weakness how to walk with a cane. Which guideline promotes safe use of this device?

When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane.

Which type of mobility aid would be most appropriate for a client who has poor balance?

a cane with four prongs on the end (quad cane)

The proper use of the principles of body mechanics:

acts to prevent injury to the client and/or nurse.

The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher?

alongside the bed at the same height

The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse correctly documents the presence of:

ataxia

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?

bed trapeze

The nurse is leading an exercise class for a group of adults aged 65 years and older. The nurse incorporates isotonic, isometric, and isokinetic exercises into the class. Which activity is an isometric exercise?

contracting the gluteal muscles while holding a simple yoga pose

The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change?

decrease in flexibility

What is a benefit of regular exercise over time?

decreased heart rate

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

foot drop.

A client is discharged to his daughter's home. He weighs 250 lb (113.4 kg) and is immobile. The nurse should instruct the daughter on the use of a:

hydraulic lift.

During range-of-motion exercises, the nurse turns the sole of a client's foot toward the midline and then turns the sole of the foot outward. Which type of movement is this nurse promoting by these actions?

inversion and eversion of the ankle

When logrolling a client, the nurse should use supportive devices in turning the client in order to:

maintain the natural alignment of the client's body.

The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action?

move the client to edge of the bed opposite the side that client will be turning

The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select?

risk for impaired skin integrity

The nurse is performing a physical assessment on an adolescent. What assessment prioritiesare needed for this age group?

scoliosis

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern?

shortness of breath after walking up five stairs

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:

steps into the walker when walking.

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?

supine

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?

supporting the client's back

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

the 24-month-old child who is unable to walk unassisted

The nurse is caring for a client who is on bed rest. After revieiwng the image above, which is the most appropriate reason for the nurse to observe this client perform the activity?

"A client can perform this activity to prevent a permanent a condition in the feet caused by bed rest."

The occupational nurse is teaching an administrative assistant about proper posture when sitting. Which teaching will the nurse include?

"Both of your feet should rest on the floor."

A client works in a warehouse and has been having low-back pain. Which statement would indicate the need for more education regarding safe lifting?

"I hold the boxes away from my body so I don't drop them on my feet."

The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include?

"Picture yourself with good posture standing; that is how good lying posture works."

A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

"To prevent the legs from rotating outward."

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?

"Your elbows will be slightly bent when you are using your crutches."

A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply.

- Exercise increases intestinal tone. - Exercise increases blood flow to kidneys. -Exercise increases efficiency of the metabolic system.

A nurse is educating a client on how to walk with crutches. Which teaching points are recommended guidelines for this activity? Select all that apply.

- Keep elbows close to sides. - Support body weight with hands and arms. - When climbing stairs, advance the unaffected leg past the crutches, place weight on the crutches, and then advance the affected leg followed by the crutches.

The occupational nurse is teaching other nurses how to protect the back by using proper body mechanics. Which teaching will the nurse include? Select all that apply.

- Position a heavy load over the center of the feet when lifting. - Push, pull, or roll objects whenever possible. - Bend the knee and keep the back straight when lifting.

Which body system effects would the nurse state as occurring due to immobility? Select all that apply.

- increased cardiac workload - increased risk for renal calculi - Increased risk for electrolyte imbalance

The nurse is assisting the client who has dementia from the bed to the chair for mealtime. What actions by the nurse would facilitate cooperation from the client? Select all that apply.

- providing instructions one at a time - calling the client by the preferred name - being positive in statements when providing instructions - facing the client when speaking

The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply.

-Adjust the height of the work area. -Face the direction of the activity he is performing. -Use a wide stance and lift with the large leg muscles.

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.

-removing clutter from the floor - placing nightlights in the bathroom and hallways -moving the bedroom to the ground floor

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

A client who has leg strength and can cooperate with the movement

A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client?

Client is in supine position with arms in functional position and pillow support under the knees.

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?

Equipment is positioned to the side, 50 degrees away.

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?

Fowler's

Which gait is characterized by one leg being dragged and swung forward by hip motion?

Hemiplegic

A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction?

Hold your cane on the right side.

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.

The nurse is preparing the client for the administration of an enema. The nurse will place the client into which position?

Sims'

A 45-year-old woman is admitted after undergoing a hysterectomy. She has been immobile for 2 days. She has a 20-year history of smoking. She also takes oral estrogen to manage her hot flashes. As a nurse assesses the client, she notices that the client's left leg is dark purple and measures 2 inches (5 cm) larger than her right leg. What is the client most at risk for?

Pulmonary embolism

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?

Raise the head of the bed to a sitting position.

The nurse is performing range-of-motion exercises on a client's arm. The nurse starts by lifting the arm forward to above the head of the client. Which action would the nurse perform next?

Return the arm to the starting position at the side of the body.

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

Shift their weight back and forth, from back leg to front leg.

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body?

Short bones contribute to movement.

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

Sims'

The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination?

Sims'

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed?

near the client's hip, with legs shoulder width apart and one foot near the head of the bed

A nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program?

obtain a pre-exercise medical examination for clearance

The nurse is turning a client in bed. Where would the nurse stand when using the friction-reducing sheet to turn the client to the opposite side of the bed?

opposite the client's center

The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement?

place a small pillow under each arm

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate?

placing a small towel under the neck

The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?

placing the client in good alignment with joints slightly flexed

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse?

positioning a friction-reducing sheet under the client to facilitate movement

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

predisposition to renal calculi

The nurse is caring for a client who has a lower-body injury and who is able to partially assist with transfers. The nurse should:

provide the client with an overhead trapeze.

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity?

pull the shoulder blade forward and out from under the client

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?

thrombus formation

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is mostappropriate to assist in transferring?

transfer belt

The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care?

trapeze bar

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?

trochanter rolls