NUR 102 Exam 1 Review: Mobility & Positioning & Body Mechanics, Self-Care and Hygiene
Sims position
lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back
Anaerobic exercise
occurs when the muscle cannot extract enough oxygen from the blood, and anaerobic pathways provide additional energy for a short time.
Four point crutch walking
one crutch, opposite foot, other crutch, remaining foot
When assisting a client with ambulation using an assistive device such as parallel bars or a walking belt, what should the nurse observe the client for?
pallor, weakness, or dizziness
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
functional braces
provide stability for an unstable joint.
assessing neurologic integrity
reflexes
aerobic exercise
requires oxygen to use the energy provided by the metabolic activities of the skeletal muscles.
plantar wart
round or irregular area that is flattened by pressure and is surrounded by cornified epithelium.
A nurse is providing postoperative care for a client who is immobilized, due to rod fixation. The nurse would place the client in which position?
semi-fowlers'
A nurse is preparing to provide oral care to a client who is unconscious. The nurse would place the client in which position?
side-lying
disuse syndrome
signs and symptoms that result from inactivity, -the consequences of inactivity - Weak muscle strength and unsteady gait
Fowler's position
sitting position
isometric exercise
static exercise by which the client tenses a muscle, holding it stationary while maintaining the tension.
Semi-Fowler's Position
the head of the bed is raised 30 degrees; or the head of the bed is raised 30 degrees and the knee portion is raised 15 degrees
A nurse is caring for an inactive client and assisting the client in performing range-of-motion (ROM) exercises. What care should the nurse take when performing range-of-motion exercises?
Move each joint until there is resistance but no pain.
Rehabilitative braces
allow protected motion of an injured joint that has been treated operatively
bunion
an inflammation and thickening of bursa at the great toe joint which causes an enlargement of the joint and a displacement of the toe.
Keratolytic shampoo
applied to the client's hair to manage dandruff.
Elevation of the stump, post amputation can result in what?
contractures
contractures
- due to inactivity of the musculoskeletal system -a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints.
A nurse is preparing to make an occupied bed for a client who is unable to get out of bed. What would be necessary for the nurse to do?
-The nurse should raise the bed to a comfortable height to prevent back strain - gather all necessary linens before beginning to conserve time and energy -put all soiled linens into a linen bag, not the floor. -The nurse makes one side of the bed as completely as possible before moving to the other side. -Bed linens should be handled carefully without shaking them to maintain asepsis.
sitz bath
-a warm soak of the perineal area to clean perineal wounds and reduce inflammation and pain - usually lasts 20 minutes. The temperature of the water should be maintained at 105°F (40.5°C) to 110°F (43.3°C) with care taken not to burn the client.
Activity Intolerance
-physical inability to withstand activity -shortness of breath after a small amount activity would be of most concern
The nurse is caring for a client who has generalized weakness and requires crutches to ambulate. Which crutch-walking gait will the nurse teach?
4-point crutches
A nurse is assessing a client after knee surgery in a health care facility. Which intervention should the nurse follow to avoid complications associated with disuse syndrome?
Encourage active exercise with a bed trapeze
A nurse is logrolling a client who has a spinal injury. Which nursing action follows the recommended guidelines for this procedure?
Enlist the assistance of two or three other nurses to perform the procedure.
Right lateral recumbent position
Patient lying on their right side
what position is best for administering an enema
Sims'
boric acid
formally found in eye drops and eyewash, not appropriate for eye cleansing, toxic when absorbed.
The nurse is providing pin site care for a client who is in traction. Which assessment finding requires the nurse to intervene?
White blood cell count of 13,000/mL.
three-point non-weight-bearing
a client with one amputated, injured, or disabled extremity
traction
a pull to the arm or leg muscles to bring a bone back into place when it is dislocated or fractured
assessing muscles
bilateral mass, tone, and strength
seborrheic keratoses
brown patches of skin, benign, wart-like tumors; more common on elderly skin
When should the nurse observe gait?
clients who ambulate with crutches, walkers, or canes, to ensure they are using correctly
corn
cone-shaped lesion, which is usually found on the fourth or fifth toe over a toe joint
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
isotonic excercise
dynamic form of exercise with constant muscle tension, muscle contraction, and active movement.
spica cast
encircles one or both legs, but when applied to a lower extremity, the cast is trimmed in the anal and genital areas to allow for the elimination of urine and stool.
kyphosis
excessive outward curvature of the spine, causing hunching of the back.
applying make up demonstrates?
fine motor skills
callus
flattened thickening of epidermis which is often found on the bottom or side of the foot, over a bony prominence.
assessing joints
flexion and range of motion
supine position
lying on back, facing upward
ball and socket joint
hip and shoulder joints
The nurse is positioning a client with limited mobility who is lying down to go to sleep. Which positioning technique is most appropriate?
horizontal position with knees slightly flexed and head centered between the shoulders
What is one serious effect of immobility on the cardiovascular system?
increased cardiac workload
pediculosis capitis
infestation of the hair and scalp with head lice, inflammed bites along the hairline
isotonic exercise
involves contracting and relaxing your muscles through the full range of a joint's motion ie marathon running
hinge joint
knee and elbow
left lateral recumbent position
laying on left side
When a client has a spinal injury or is recovering from neck, back, or spinal surgery, it is often necessary to keep the body in straight alignment when turning the client.
logrolling
prone position
lying on abdomen, facing downward
slight trendelenburg
lying on back with body tilted at a slight incline so that the head is lower than the feet
Reverse Trendlenburg's position
lying on back with body tilted so that the head is higher than the feet
Trendlenburg Position
lying on back with body tilted so that the head is lower than the feet
lithotomy position
lying on back with legs raised and feet in stirrups
enema
the placement of a solution into the rectum and colon to empty the lower intestine through bowel activity
saddle joint
thumb
Why is it important for the nurse to soak the client's hands in warm water prior to nail care?
to soften the keratin and loosen trapped debris.
prophylactic braces
used to prevent or reduce the severity of a joint injury
condyloid joint
wrist and knuckles