Chp 33 UPrep: Activity

The nurse would like to assist a client out of bed and into a chair. The client is uncooperative, has a leg cast, and can bear weight on the unaffected leg. Which equipment or assistive device should the nurse use?

powered full-body lift

The nurse is caring for a client with multiple areas of skin breakdown on the back. In which position will the nurse choose to place the client to improve arterial oxygenation?

prone

The nurse is caring for a client who is on bed rest. After reviewing 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."

Which nursing actions would the nurse perform when assisting clients with passive ROM exercises? Select all that apply

Adjust the bed to the flat position or as low as the client can tolerate. Begin ROM exercises at the client's head and move down one side of the body at a time. Move each joint in a smooth, rhythmic manner.

The nurse is performing an assessment of a client's joint mobility. What documentation should the nurse provide related to this assessment if joint function is considered normal? Select all that apply.

No masses, deformities, or muscle atrophy Full range of motion with each joint No swelling, heat, tenderness, pain, nodules, or crepitation

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 is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take?

Tell the client he can remove them for 20 or 30 minutes during this shift.

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.

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

The nurse is caring for a client who is postoperative from a hip fracture repair. The nurse must be careful to avoid:

adduction of the affected leg.

A 90-year-old widower lives alone in her home. The nurse knows that older clients are at increased risk for falls. What other factors contribute to increased risk for falls in clients? Select all that apply

ataxic gait history of a fall 5 years ago diuretics

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

An infant develops one extremity that is shorter than the other. This occurs with

hip dislocation.

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

Sims'

The nurse has been educating a client about health promotion and exercise. What statement made by the client demonstrates that the education has been successful?

"I will invite a friend to exercise with me."

A nurse is assisting in the transfer of a client with a diagnosis of Alzheimer's disease to a stretcher. The client experiences frequent periods of agitation and is unable to follow cues or directions. Which device would be the best choice for transferring this client?

Transfer chair

A home health nurse is visiting a client who was taught to crutch-walk in the hospital following a knee surgery. The client says, "My armpits are so sore." Which information does the nurse provide?

Try to bear your weight on your hands, not your armpits."

The nurse is performing an admission for a client determined to be a high fall risk. What interventions should be a priority for the nurse to employ to provide a safe environment for the client? Select all that apply.

Use a chair alarm when the client is out of the bed. Use a bed alarm to signal when the client gets up

The nurse is transferring a client who has dementia from the bed to a wheelchair. Which instructions will the nurse use? Select all that apply.

I am going to put your shoes on you. Stand up by the bed. Sit down in the wheelchair.

Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer?

If the client is in pain, administer analgesics in advance of the transfer.

The nurse is orienting a new unlicensed assistive personnel (UAP) to hospital policies. While a client is participating in physical therapy the UAP decides to make the bed. What are appropriate action(s) by the nurse after entering a hospital room and observing the UAP in the image? Select all that

Inform the UAP the linens should not be placed on the floor for any reason Communicate the importance of using proper body mechanics to avoid straining the back

When assessing correct body alignment when the client is standing, the nurse would document which abnormal findings? Select all that apply.

The arms are bent at the elbows. The knees are bent.

The nurse is assessing a client's ability to use a walker. The nurse would provide additional information if which behavior were observed?

The client pushes the walker ahead, following behind it

The nurse observes an unlicensed assistive personnel (UAP) placing a client in the Fowler position. To prevent complications for the client, in which situation should the nurse intervene? Select all that apply.

There is a large pillow under the client's head. The knee gatch on the bed is engaged. The client's foot is in the plantar flexion position.

A nurse is explaining to a caregiver the value of nonpharmacologic methods of pain management. Which statement best describes the proper rationale for using nonpharmacologic methods to help manage pain?

Use of nonpharmacologic methods can diminish the emotional component of pain.

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

A nurse is assessing a client's mobility status. What data would the nurse document as normal findings? Select all that apply.

independent maintenance of correct alignment head, shoulders, and hips aligned in bed full range of motion

As a part of his workout regimen, a 21-year-old college football player often engages in squats and lateral arm holds. These are examples of what type of exercise?

isometric

A nurse is interviewing a client about the client's usual activity level. The client states, "I swim laps 2 to 3 times a week and walk 1 to 2 miles twice a week. The nurse interprets this activity as which type of exercise?

isotonic

The nurse is preparing to transfer a client from the bed to a stretcher. What action should the nurse take to prevent injury to the client and nurse?

leave the friction-reducing sheet in place once the client is transferred

When turning a client in bed, what muscle groups would the nurse use to pull the client to the opposite side of the bed?

leg

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 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

The nurse is developing a plan of care for a client who has been in the (protective) prone position. What should the nurse be sure to monitor the client for, related to the positioning?

plantar flexion of the feet

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene?

raising the height of the bed to the waist level prior to moving the client

An 85-year-old white woman walks 1 mile (1.6 km) every morning and every evening. She continues to smoke but has cut back to half a pack per day. She had a total oophorectomy at age 45 secondary to stage I ovarian cancer. This client is currently not on any medications. Which is not a primary risk factor for osteoporosis for this client?

sedentary lifestyle

The nurse is assessing the client for muscle mass, tone, and strength and determines that there is increased tone that interferes with movement. How does the nurse document this finding?

spasticity.

Which clients will develop mobility issues in the future? Select all that apply

the 50-year-old landscaper the 55-year-old clinical secretary who is to retire after 30 years working the same job

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

transfer belt