Learning Unit 5| PrepU | Chapter 26 | Ambulatory Aids

The nurse is caring for an older adult client who is recovering from hip surgery. Which assistive device will the nurse use to facilitate client ambulation? cane gait belt crutches walker

walker

A young client, 3 months after a right below-the-knee amputation (BKA), is brought to the clinic by the caregiver over concerns that the stump is turning red. Which question should the nurse prioritize? "What are you using to wash the stump socks?" "Do you take time to lay down during the day?" "How long are you wearing the prosthesis during the day?" "When do you wash the stump?"

"How long are you wearing the prosthesis during the day?"

A nurse is helping a client perform gluteal setting exercises. Place the steps of these exercises in the correct order. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Tighten (contract) the quadriceps muscles by flattening the backs of the knees into the mattress. 2Repeat two to three times each hour. 3Hold the contracted position for a count of five. 4Relax. 5Check to see that the kneecaps move upward.

1 Tighten (contract) the quadriceps muscles by flattening the backs of the knees into the mattress. 5 Check to see that the kneecaps move upward. 3 Hold the contracted position for a count of five. 4 Relax. 2 Repeat two to three times each hour.

A nurse is preparing to assist a client in dangling at the bedside. Place the actions in the order that the nurse would complete them, from first to last. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Lower the height of the client's bed. 2Fold back the top linen from the bed. 3Place the client in a Fowler's position. 4Have the client put on a robe and slippers. 5Have the client pivot a quarter turn. 6Have the client swing legs over the side to sit.

3 Place the client in a Fowler's position. 1 Lower the height of the client's bed. 2 Fold back the top linen from the bed. 4 Have the client put on a robe and slippers. 5 Have the client pivot a quarter turn. 6Have the client swing legs over the side to sit.

A client is being sized for a cane. The nurse is checking to make sure the cane is the right height for the client and that it is parallel with the client's hip. What degree of elbow flexion should the cane provide? 45° 90° 30° 60°

30°

A client is practicing the use of a cane. While evaluating the client's technique, the nurse makes sure that the client's cane is at what distance from the side of the toes? up to 2 in (up to 5 cm) 2 to 3 in (5 to 7.5 cm) 4 to 6 in (10 to 15 cm) 7 to 9 in (17.5 to 22.5 cm)

4 to 6 in (10 to 15 cm)

The nurse is assisting a client into the sitting from the supine position in bed. As the client comes into the sitting position the client states, "I feel a little dizzy." In response to this, what action will the nurse take first? Assist the client to stand slowly. Asses the client's blood pressure in seated position. Assure the client the feeling is normal. Lie the client back into the supine position.

Asses the client's blood pressure in seated position.

A 91-year-old female client was admitted to the geriatric unit of the hospital with diagnoses of Hyponatremia, Dehydration, and Failure To Thrive. The care team is aware of the importance of early ambulation and has taken steps to facilitate this. How can the client be best prepared to begin ambulating? Use a mechanical ceiling lift when transferring the client into or out of bed. Educate the client on the correct use of forearm crutches. Teach the client about energy conservation techniques. Assist the client with the performance of isometric exercises.

Assist the client with the performance of isometric exercises.

An older adult client with generalized weakness who lives in a two-story home has a bathroom upstairs and a bedroom downstairs. Which nursing teaching is appropriate? Restrict liquids so bathroom trips are infrequent. Sell the home and relocate to one-floor living quarters. Allow plenty of time to ascend steps when feeling urinary urgency. Consider a bedside commode.

Consider a bedside commode.

The nurse is observing an unlicensed assistive personnel (UAP) ambulate a client. Which UAP behavior requires nursing intervention? uses a gait belt on the client for support allows the client to pause ambulation when tiring walks slightly ahead of the client to clear pathways praises client with fatigue for efforts even if goal is not met

walks slightly ahead of the client to clear pathways

The nurse is caring for a client with cerebral palsy who requires crutches to ambulate. Which crutch-walking gait will the nurse teach? three-point partial weight-bearing swing-through two-point four-point

four-point

A client is beginning to ambulate with crutches after surgery on his right leg. He is allowed to bear weight only on his left leg. The nurse would work with the client to use which gait? four-point two-point three-point swing-through

three-point

The nurse is instructing a postoperative client to dangle prior to changing position from supine to standing. The client states, "Why can I not just get up now?" How will the nurse respond? "You will be safe in this position while I look around for any obstacles." "It is a good way to give you a moment to breathe before you stand." "Dangling will help to normalize your blood pressure." "Your legs will be way too weak to support you."

"Dangling will help to normalize your blood pressure."

The nurse is visiting a client at home to assess the progress of the client's exercise program. Which is the best response if the client reports that the mattress is too soft to perform the upper arm strengthening exercises? "Maybe we need to get you a ball to use instead?" "Do you have a sturdy armchair available?"" "Would you like me to check with your health care provider about this?" "Have you tried lying face down to do the push-ups?"

"Do you have a sturdy armchair available?""

The nurse is teaching a client who had a below-the-knee amputation about a temporary prosthetic limb. Which client statement requires further nursing teaching? "If I have an incisional infection, I will not wear the limb." "This device will help to control swelling of the stump." "This is a lightweight artificial limb." "I will tighten the belt when I go to sleep."

"I will tighten the belt when I go to sleep."

The nurse is teaching a client who had a below-the-knee amputation about a temporary prosthetic limb. Which client statement requires further nursing teaching? "This device will help to control swelling of the stump." "This is a lightweight artificial limb." "I will tighten the belt when I go to sleep." "If I have an incisional infection, I will not wear the limb."

"I will tighten the belt when I go to sleep."

The nurse is caring for an older adult client who has difficulty walking. The client states, "I hate that I can barely walk. I'm such a burden to my family." What is the appropriate nursing response? "Let's talk about how mobility can increase your independence." "Who told you that you are burden?" "Put that thought out of your mind, and let's focus on using a walker." "I'm sure no one feels that way about you."

"Let's talk about how mobility can increase your independence."

A client's plan of care specifies the goal that the client perform quadriceps setting four times daily. The nurse has explained the rationale for this exercise to the client and is now teaching the client to perform the exercises safely and effectively. What instructions should the nurse provide to the client? "Flex the muscles in your thighs and then slowly rotate your feet outward." "Progressively tighten your muscles in your toes and then your calves." "Slowly bend your leg at the knee then gradually return it to a straight position." "Slowly alternate between tightening the muscles in your thighs and then relaxing them."

"Slowly alternate between tightening the muscles in your thighs and then relaxing them."

The nurse is providing community education about the benefits of isometric exercise for clients with disuse syndrome. When discussing this topic, what information will the nurse include? Select all that apply. "Some of these exercises can be performed in your bed or chair." "Focused periods of isometric activity can reestablish good mobility." "Isometric exercise should begin when you first try walking independently." "Exercising the gluteal muscles is essential for standing and supporting body weight." "Upper arm strength is important if you require a mobility aid."

"Some of these exercises can be performed in your bed or chair." "Focused periods of isometric activity can reestablish good mobility." "Upper arm strength is important if you require a mobility aid."

A client is preparing to mobilize for the first time following the surgical removal of a bunion on her left foot. How should the nurse instruct the client to ambulate with her crutches? "Keep your crutches as close as possible to your feet when you're walking." "Try to avoid putting too much pressure on your armpits with the tops of the crutches." "When you rise from a chair, use your left foot to stabilize yourself." "Keep your elbows well away from your sides in order to keep yourself as stable as possible."

"Try to avoid putting too much pressure on your armpits with the tops of the crutches."

A nurse is teaching a client how to perform quadriceps setting exercises. The nurse determines that the client is performing them correctly when the nurse notes which of the following? Stand within the walker. Grip the walker by the front bar. Pick up the walker and advance it 10 to 12 inches. Move the walker in tandem with taking a step forward.

Both of the client's kneecaps move upward.

A nurse is teaching a client how to perform quadriceps setting exercises. The nurse determines that the client is performing them correctly when the nurse notes which of the following? The client holds the position for a count of five. Both of the client's kneecaps move upward. The client pinches the buttocks together. The client's elbows remain in a flexed position.

Both of the client's kneecaps move upward.

To avoid postural hypotension, which teaching will the nurse provide to the client? Dangle feet before moving from a reclining position. Eat something with protein before getting up in the morning. Apply antiembolism stockings before rising. Rise quickly from lying down.

Dangle feet before moving from a reclining position.

A nurse is caring for an older client with osteoarthritis who is recovering from the West Nile virus. Isometric exercises have been prescribed. What will the nurse teach the client about isometric exercises? Isometric exercises measure the extent of muscle weakness caused by the virus. Isometric exercises promote tissue perfusion for quick recovery. Isometric exercises will promote cardiovascular conditioning. Isometric exercises will improve muscle tone and strength.

Isometric exercises will improve muscle tone and strength.

A nurse is assisting a client to ambulate at the health care facility using a walking belt. How does the walking belt assist the client when ambulating? It enables the client to stand and support body weight. It allows the nurse to support the client. It helps the client to practice ambulating. It aids the client in extending the leg.

It allows the nurse to support the client.

A client has been diagnosed with multiple sclerosis and will permanently require crutches. Which type of crutch would be most appropriate for this client? Lofstrand axillary, wood rocker axillary, metal

Lofstrand

The nurse is preparing to discharge a client who has a tibial fracture and requires axillary crutches to aid mobility. What action(s) will the nurse take when measuring the client for the correct fit of axillary crutches? Select all that apply. Measure the distance from the anterior skinfold of the axilla to the heel. Encourage the client to practice adjusting the length of the crutches. Adjust the hand grips to allow 30 degrees of elbow flexion. Adjust the hand grips to allow 15 degrees of wrist hyperextension. Ask the client for height measurement in inches or centimeters.

Measure the distance from the anterior skinfold of the axilla to the heel. Adjust the hand grips to allow 30 degrees of elbow flexion. Adjust the hand grips to allow 15 degrees of wrist hyperextension.

The nurse is fitting a client for forearm crutches. Which nursing action is appropriate? Measure the forearm from 6 inches below the elbow to the wrist, and add the distance between the elbow and floor. Measure the forearm from 3 inches below the elbow to the wrist, and add the distance between the wrist and floor. Measure from the anterior skinfold of the axilla to approximately 4-8 inches diagonally from the foot. Measure distance from anterior skinfold of the axilla to heel, and add 2 inches to the client's height.

Measure the forearm from 3 inches below the elbow to the wrist, and add the distance between the wrist and floor.

The nurse is educating the older adult client and family about home safety. Which teaching will the nurse provide? Select all that apply. Replace worn rubber handgrips on walker. Ask client to use a "step-stop" pattern when using a cane. Rearrange furniture if necessary to have clear pathways. Remove scatter rugs from floors. Have client use stairs to facilitate mobility.

Replace worn rubber handgrips on walker. Rearrange furniture if necessary to have clear pathways. Remove scatter rugs from floors.

The nurse is planning to teach a client about crutch-walking. Which is the priority nursing action? Review the health care provider's order. Consult with the client about the preferred time for ambulation. Assist the client to put on supportive shoes with nonskid soles. Clear a pathway where the client will ambulate.

Review the health care provider's order.

A male client with a history of type 1 diabetes has had a below-the-knee (BK) amputation. The client states that he is eager to be fitted for his prosthesis and to resume activities of daily living. When assisting the client with his adjustment to using his prosthesis, the nurse should prioritize what nursing diagnosis? Risk for Impaired Skin Integrity Risk for Sedentary Lifestyle Risk for Disuse Syndrome Risk for Impaired Bed Mobility

Risk for Impaired Skin Integrity

A client who had a hip replacement 2 days ago is reluctant to move for fear of experiencing pain. The client has received pain medication regularly and reports pain is a "3" on a 1 to 10 scale. Which nursing action encourages activity? Require client to ambulate before next meal. Contact the health care provider. Sit with client to provide emotional support while client uses trapeze. Tell client that family cannot visit until the client performs activity.

Sit with client to provide emotional support while client uses trapeze.

The nurse is assisting an older adult to ambulate. The nurse observes the client has developed pallor and the client states, "I am feeling weak." What is the nurse's first action? Retrieve the call bell and request assistance. Slide an arm under the client's axilla and place a foot to the side. Bring a chair in close and instruct the client to sit. Check the client's heart rate and blood pressure.

Slide an arm under the client's axilla and place a foot to the side.

A nurse is walking with a client, who stops walking and states, "I am suddenly feeling very lightheaded." What action would the nurse take next? Balance the client on one of the nurse's hips until help arrives. Slide the client down the length of the nurse's leg to the floor. Slide an arm under the client's axilla and place the nurse's foot to the side. Reassure the client that the feeling will pass while continuing to walk.

Slide an arm under the client's axilla and place the nurse's foot to the side.

An older adult client with weakness on one side of the body needs to use a cane for walking. How should the nurse determine the correct height of the cane to be used by the client? The cane's handle should be parallel with the hip. The cane should provide elbow flexion of 50 degrees. The cane's handle should be straight with a hand grip. The cane's handle should be at waist level.

The cane's handle should be parallel with the hip.

A college student fell and sprained his right ankle. The student health health care provider recommends the student use crutches to facilitate healing. What would the nurse teach the student? The support of the body should be the hands and arms. Walk fast and use long steps when using the crutches. The crutches should be as long as the student is tall. The support of the body should be in the axilla.

The support of the body should be the hands and arms.

The nurse is caring for an older adult client who had a stroke and has regained ambulatory function. As the client is being discharged to home, which safety education will the nurse provide regarding use of stairs? Take each step up with the weaker leg followed by the stronger one. Avoid using stairs at any time. Use a stair rail when going up or down. When going up stairs, place a foot onto the step, and then follow with a cane.

Use a stair rail when going up or down.

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) axillary crutches a single-ended cane with a straight handle a single-ended cane with a half-circle handle

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

The nurse is caring for a client with impaired physical mobility related to a hip replacement surgery. Which joint position of the operative hip will the nurse maintain? flexion abduction rotation adduction

abduction

The nurse is preparing to help a client ambulate after hip surgery. Which nursing action promotes client autonomy? allowing client to select time of day to ambulate assisting client to put on supportive shoes washing hands before interacting with the client placing gait belt onto client

allowing client to select time of day to ambulate

The nurse is caring for a client with postural hypotension. Which nursing intervention is appropriate? applying antiembolism stockings before rising using a tilt table to move from supine to standing using a gait belt to quickly get the client out of bed asking the client to dangle before moving from a reclining position

asking the client to dangle before moving from a reclining position

While walking behind a client using a walker, the nurse notes the client appears to be favoring the left foot. Which action should the nurse prioritize? ensure assistive device is functioning properly ask if client needs pain medication make sure shoes are on correct feet assess for abnormalities in the feet

assess for abnormalities in the feet

The nurse is caring for a client who has had a total knee replacement. Which nursing action would be most important postoperatively to prevent deep vein thrombosis for this client? providing crutches to the client administering low dose aspirin orally providing postoperative education assisting the client with early ambulation

assisting the client with early ambulation

A nurse is caring for a client whose fractured leg is in a cast. Which ambulatory device could the nurse suggest for the client to use at the health care facility? platform crutch axillary crutch walker cane

axillary crutch

A client with paralysis has been prescribed swing-through crutch-walking. Which teaching regarding gait pattern will the nurse provide? one crutch, opposite foot, other crutch, remaining foot both crutches are moved forward, one or both legs are advanced beyond crutches both crutches move forward, followed by the weight-bearing leg one crutch and opposite foot moved in unison, followed by remaining pair

both crutches are moved forward, one or both legs are advanced beyond crutches

A client with an above-the-knee amputation has been prescribed three-point non-weight bearing crutch-walking. Which teaching regarding gait pattern will the nurse provide? both crutches move forward, followed by the weight-bearing leg one crutch, opposite foot, other crutch, remaining foot both crutches are moved forward, one or both legs are advanced beyond crutches one crutch and opposite foot moved in unison, followed by remaining pair

both crutches move forward, followed by the weight-bearing leg

The nurse is reading documentation that indicates that a client has a Syme's amputation. Which client does the nurse associate with this condition? client with full leg and portion of the hip amputated client with amputation at the foot client with above-the-knee amputation client with below-the-knee amputation

client with amputation at the foot

A nurse checks that two fingers can be placed between the client's axilla and the axillary bar of crutches. This technique helps prevent which condition? crutch palsy orthostatic hypotension venous stasis Volkmann contracture

crutch palsy

The nurse is educating a client who will be using crutches for approximately 6 weeks. Which exercise would be beneficial to help with crutch use? gluteal setting exercises quadriceps setting exercises sit-ups flexion and extension of the arms and the wrists

flexion and extension of the arms and the wrists

The client's strength and type of disability are guides to the best possible crutch-walking gait or style of walking. The client is using each crutch and each leg separately. What would be the best description of this type of crutch-walking gait to include in the documentation in the electronic medical record? swing-through gait four-point gait three-point gait two-point gait

four-point gait

The nurse is caring for a client with impaired mobility who needs help to improve muscle tone and strength. What type of exercise will the nurse recommend for this client to begin the exercise regimen? isometric isotonic dangling ambulating

isometric

A bedridden client has become debilitated. What would the nurse include in the client's plan of care to prepare him for ambulation? Select all that apply. upper arm strengthening dangling isometric exercises crutch walking tilt table

isometric exercises upper arm strengthening dangling tilt table

Which nursing strategy will prevent the dislocation of the hip prosthesis? maintaining abduction turning on the affected side elevating the head of the bed to 90° crossing the legs when sitting

maintaining abduction

A nurse is ambulating a client who has had a cerebrovascular accident (CVA). The client has paresis on the right side of the upper body. Where would the nurse stand to walk the client? in front of the client in back of the client on the weak side on the strong side

on the weak side

A client with arthritis has been prescribed four-point crutch-walking. Which teaching regarding gait pattern will the nurse provide? both crutches move forward, followed by the weight-bearing leg one crutch, opposite foot, other crutch, remaining foot one crutch and opposite foot moved in unison, followed by remaining pair both crutches are moved forward, one or both legs are advanced beyond crutches

one crutch, opposite foot, other crutch, remaining foot

The nurse is assisting a client to use a double row of stationary bars as handrails to gain practice in ambulating. What is the name for the device the client is using? uneven bars parallel bars horizontal bars walking belt

parallel bars

The nurse is caring for a client who will be using forearm crutches after having spinal surgery. To improve upper body strength for crutch-walking, the nurse will instruct the client to regularly perform which type of exercise? doing 30 minutes of aerobic activity per day performing normal activities of daily living climbing stairs with the crutches performing modified push-ups in an armchair

performing modified push-ups in an armchair

A client requires crutches but cannot bear any weight with the hands or wrists. What type of crutches would the nurse prepare to assist this client with? Canadian crutches Lofstrand crutches platform crutches axillary crutches

platform crutches

A nurse is teaching a client with crutches how to sit down in a chair. The nurse instructs the client to: place each crutch 4 to 8 inches to the side of each foot. use one crutch for support of the weaker leg while keeping the other crutch off to the side. grab onto the armrests of the chair with both hands with the crutches lying in front. put both crutches in the hand on the same side as that of the weaker leg.

put both crutches in the hand on the same side as that of the weaker leg.

After teaching a client how to perform a four-point crutch gait, the nurse determines that the teaching was successful when the client first moves the left crutch and then follows with: the right foot. the right crutch. the left foot. both feet.

the right foot.

The nurse is preparing to use a tilt table with a client who recently had the pins and traction removed from the right leg. Which action should the nurse take while operating the tilt table? monitor client for hypertension tilt slowly at 15 to 30 degrees until in vertical position if client becomes dizzy, hold at current position apply compression stockings

tilt slowly at 15 to 30 degrees until in vertical position

The nurse is providing client education on crutch-walking. Into which shape should the client place the feet and crutches to provide balance and support? triangle square circle oval

triangle

The nurse is planning discharge care for an older adult client who had been on prolonged bed rest. Which assistive device will the nurse plan to use to facilitate client ambulation? cane crutches walker gait belt

walker