chapter 8 and 10
what is the number of GRY can be absorbed before falling sick
0.75
the following information is needed when delegating the skill of position changes to an cna
1. have the patient wear shoes with a nonslip surface 2.make slow gradual position changes 3. help the patient sit in a chair or return to bed if the patient has symptoms of orthostatic hypotension
the nurse is conducting a fall risk assesment for an older adult pt . he is moving into an assisted living faculity , which question would the nurse ask
1. have you had any falls in the last year 2.do you feel unsteady when you stand up 3. are you able to walk independently from room to room 4. have you ever lost of consciousness after a fall 5. do you use a cane or other assisted devices
place the nursing activity in priority order in preparation of pt to ambulate
1. inform pt of activity 2. roll up head of bed 3. dangle on side of bed 4 apply a gait belt 5 then assist pt to stand
patients who have maintained bed rest for long period of time pt.3
1. perform periodic assessments to ensure that the pt is using ambulation device properly 2.consult the physical therapist for additional assistance or exercises and ascertain the pt response to the exercise program 3. group activities are useful in maintaining range of motion (walking , tossing a ball in a large circle
patients who have maintained bed rest for a long time
1. revert to a favorite position 2.frequently assess these patients 3 turn them more often as needed
patients who have maintained bed rest for a long time pt 2
1. use a lift (draw) sheet often as possible to prevent shearing force on fragile skin 2.allow pt to assist with moving to promote independence 3.perform safety Maintenace checks of ambulation devices on routine basis
when assisting with ambulation
1.do not try to hold patients if they become dizzy or faint, ease them into a sitting position in a chair or onto the floor 2.use assistive devices such as walkers, crutches, gait belt , or cane when appropriate 3.be sure the area is free of clutter, wet areas and rugs that may slide
what is considered to be the minimum number of hours of daily activity necessary to prevent the negative consequences of immobility
2
the morase fall scale indicate high risk for fall
35 or higher
the nurse is performing passive range of motion on a pt. following a traumatic energy what is the number of times a nurse should move each joint when performing passive range of motion
5
pateints who absorb more GY usually die how much
8 GRY usually die , and 30 GRY is always fatal
the nurse is teaching a new group of cna how to evacuate residents in case of emergency. what piece of equipment for the universal carry method does the nurse have to teach about
a blanket
used to maintain the legs in abduction after total hip replacement surgery
abductor splint
fire extinguishers marked ABC
acceptable for use on any type of fire
what is the term for range of motion when performed by the pt ,
active
how should the nurse assist the pt, with moving when pain is anticipated
administer medication before ambulation
post-operative pt demostrates some mild dizziness and mild shortness of breath removing from sitting to standing postion , what action would the nurse do first
assist the pt to sit back down
provides additional firmness to mattress
bed board
what should the nurse do to protect there back when lifting and moving a pt.
bend knees and hips
a confused pt is yelling at the cna. as the nurse enters the room he throws food tray at cna. what should the nurse do first
calmly talk to the pt respectively calling him by name
associated with long term immobile or disuse syndrome
cde muscle weakness , contractors ,shallow respirations, constipation , uti ,thrombophitiis ,orthostatic hypotension ,pneumonia
where should the nurse place the load when carrying heavy object
close to the body midline
nurse instruct cna about the proper use of a gait belt and is observing a return demonstration what action from cna should the nurse intervene
cna is walking on pt strong side, should always be weaker side
mercury spill has occurred in pt room what should you do
dispose of collected mercury according to environmental safety regulation
the nurse instructs a nursing assistant to use large muscle groups when lifting what is the rational for this instruction
distributes workload more evenly
the pt will be immoblized for an extended time, due to extensive injury, which intervention will the nurse use to prevent respirtory complication
encourage deep breathing and coughing every hour
when weather is bad what do you refer to
faculty disaster manual
what should nurse do when offering a cup of hot coffee to an older adult pt
fill it half way
maintains the foot in dorsiflexion position, which prevents foot drop (planter flexion)
foot drop boots or foot boards
maintains hand in a normal position, prevents skin to skin contact of palm of hand, maintain fingers in slightly flexed position
hand roll
maintain proper alignment of the lower arm and hand, maintains wrist in slight dorsiflexion
hand-wrist splint
the nurse is giving instruction to a cna a pt safety and fall prevention . what should the nurse tell the cna about helping the pt to the bathroom
have her sit up slowly and dangle her legs before standing
where should the handle of cane be
hip level
what is important for the nurse to determine in order to decrease the risk of injury to a pt.
if the pt. is left handed
the nurse manager is providing a Inservice regarding a safe hospital environment, what will this education mainly focus on preventing
injury
disaster situation occurs involves explosion in hospital laundry room what would this be classified as
internal
exercise where pt. tightens and releases certain muscle groups helpful in strengthens muscles needed for ambulation
isometric
all of the following are true regarding basic guidelines for assisting with range of motion except
keep pillow and other postion device in place while performing range of motion( you have to remove them )
pt lying with knees and hip flex and thighs exterior rotated
lithotomy
when helping a pt into a wheelchair the nurse must
lock wheelchair brakes , remove foot rest and move to the side upright postion, assist pt with robe and non- slippers . ( all the above )
which medication are most likely to lead to orthostatic hypotension
medication used to reduce hypertension
nurse should never attempt to lift
more than 35 pounds at a time
a pt using walker should pick it up
move 6 to 12 inches forward at a time
all the following are true regarding dangling except
nurse should assist from supine to sitting ( pt is already danging )
what should nurse do when encountering a mercury spill
open any outside windows
what is an early sign of acute compartment syndrome
pain with stretching
what will nurse include when assess neuro -vascular statues
pain, sensation, color and temp
what is the term for range of motion when we assist the pt.
passive
provides support of body or extremity, elevation of body parts, splinting of the incision in post-op during activity or coughing
pillow
ed nurse admits a pt. of poisoning who should the nurse call for assistants' with handling this pt
posion contol center
a nurse walkes into a pt room notices pt is having trouble breathing . which postion will the nurse put pt in to help with pt respiatory distress?
raise the head of the bed to 90 degrees , have pt lean forward over the table
An infant has a wound with a dressing on the left upper arm. He repeatedly attempts to remove the dressing. Which SRD would the nurse select? 1. Mummy wrap 2. Wrap jacket 3. Bilateral wrist SRDs 4. Right elbow SRD
right elbow SRD
helps the patient to roll from side to side or to sit up in bed, gives a sense of security in a hospital bed
side rail
monitor and documentation of pt on restraints include
skin condition , signs of injury , range of motion , diet hydration status , psychological Stauses
what information will be included in consideration to mobility in older adult
skin of older adults are more fragile, aging results in lost of flexabilty joint mobility , fearful when hydralic lifts are used in transfer
devices used to provide support and assistance with ambulation
stable Funiture , walking belt , and a nurse
if falling seems likely in a client you're assisting to ambulate
support pt by the axilla ( under the arms) and ease to the floor
a nurse instructs a cna about moving a older person in bed when should the nurse intervene when observing cna return a return demonstration
the cna is pulling pt across bed linen
the lpn assist a pt into semi-flower position per physician order. what will indicate the pt is in the correct position
the head is at 30 degrees
the nurse counsels an immobilized pt regard to prevention of muscle atrophy and contractors. what would the nurse be sure to include when counseling this pt.
the need for some exercise
which of the following best describes range of motion exercises
therapeutic activity which joints are moved in natural direction
what implementation should the nurse use to improve safety during a transfer
transfer belt aka gait belt
allows the patient to raise the trunk from bed to assist in movement, allows patient to perform exercises that strengthen upper arms
trapeze bar
prevents external rotation of legs when patient is in supine position
trochanter roll
most Longterm facility evaluate for fall risk on admission and at least
twice daily, every shift
paper, wood, and cloth fires
type A
flammable liquids caused by grease and anesthetics
type B
electrical fires
type C
completed care of pt 4 hours later pt is coughing ,redness , itching and hives on the body, and complain of itchy eye and running nose
type IV latex allergy
what type of fire extinguisher will nurse use , when oxygen machine malfunctions and causes an electoral fire
type c
pt has left sided weakness what action should nurse take
use gait belt, keep leg nearest the pt behind pt knee,
most stable form of ambulatory aid
walker
what should the nurse do to reduce effort of moving a heavy object
widen the base of support in the direction of movement
could a cna change the position of a pt. with restraints every 2 hours
yes , leave it a little loose so they can move
