PN Mobility Assesment: ATI-

A nurse is reinforcing teaching with a client who has an unsteady gait about using a walker. Which of the following instructions should the nurse include?

"The top of the walker should be at the level of your wrist"

A nurse in a long-term care facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing?

Atrophy

A nurse is assisting with a skin assessment for a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage?

Damage into the skin layer

A nurse is collecting data from a client who had a stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions?

Deep vein thrombosis

A nurse is caring for a client who had a stroke and reports difficulty with proprioception. The nurse should plan to collect data from the client for which of the following?

Diminished awareness of body position and balance

A nurse is collecting data about a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?

Foot drop

A nurse is contributing to the plan of care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?

Fowler's

A nurse is assisting with performing a focused assessment on an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing an age-related change to their musculoskeletal system?

Increased curvature of the thoracic spine

A nurse is reinforcing teaching with a client who has kyphosis. Which of the following information should the nurse include?

Kyphosis is a rounded upper back with the pelvis tilted forward.

A nurse is preparing to transfer a client from a bed to a wheelchair. Which of the following actions by the nurse demonstrates proper use of body mechanics?

Looking at the client face-to-face when transferring the client.

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?

Mechanical lift

A nurse is caring for a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client?

Mechanical lift

A nurse is assisting with preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture?

Muscles

A nurse is assisting with preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?

Muscles assist with the thermoregulation in the body

A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client?

Occupational therapist

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage?

Prone

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take?

Remind the client to use the incentive spirometer.

A nurse is assisting with completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks?

Sit on the edge of the bed for 1 min.

A nurse is reinforcing teaching with a client who injured their ankle. Which of the following information should the nurse include?

Tendons connect muscle to bone.

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches?

The client has the crutches resting 5 cm (2in) below their axilla.

A nurse is assisting with preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following should the nurse plan to include regarding flexion of a join?

The contraction of a muscle results in flexion of a joint.

A nurse is assisting with teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?

The use of ergonomics increases job satisfaction

A nurse is reinforcing teaching with a newly hired assistive personnel (AP) about working with clients who require assistance with ADL's. Which of the following activities should the nurse include as an ADL?

Toileting

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include? (Select all that apply.)

• A stable center of gravity increases stability and balance. • A wide base lowers the center of gravity • Proper body alignment involves tightening the abdomen

A nurse is preparing to life a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics? (Place the steps in the selected order of performance)

• Stand as close to the object as possible • Keep abdominal muscles contracted and the lower back straight • Look straight ahead with shoulders raised up • Bend hips slightly and squat • Push up from the knees when lifting the object