ATI: Self Concept & Mobility

A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor-vehicle crash. Which of the following statements indicates that the client has a distorted body image? A. I'll be able to function exactly as I did before the accident. B. I just can't stop crying. C. I am so mad at that guy who hit us. I wish he lost a leg. D. I don't even want to look at my leg. You can check the dressing."

D. I don't even want to look at my leg. You can check the dressing.

A nurse is performing a skin assessment on 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? Deep damage through the skin and tissue Damage beyond the skin layer Damage into the skin layer Damage with the skin intact

Damage into the skin layer

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following? Restricted movement due to abnormal fixation of a joint A drop in blood pressure that occurs with a change in position Altered gait with dragging of the toes while ambulating Diminished awareness of body position and balance

Diminished awareness of body position and balance

A nurse is reviewing factors that can affect a client's self-concept. The nurse should identify that empathy, motivation, and self-awareness are domains of which of the following factors? Emotional intelligence Body image Self-efficacy Role performance

Emotional intelligence

A nurse is reviewing the plan of care for a client who was recently divorced. Which of the following interventions should the nurse include to promote the client's positive self-concept? (Select all that apply.) Encourage the client to identify past and current accomplishments. Contact delivery services to provide the client with in-home meals. Encourage the client to verbalize perceptions that indicate a healthy self-esteem. Assists the client to identify healthy coping strategies and support systems. Collaborate with the client, family, and members of the health care team to ensure successful implementation of the plan of care.

Encourage the client to identify past and current accomplishments. Encourage the client to verbalize perceptions that indicate a healthy self-esteem. Assists the client to identify healthy coping strategies and support systems. Collaborate with the client, family, and members of the health care team to ensure successful implementation of the plan of care.

A nurse is assessing 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? Atrophy Foot drop Joint contracture Disuse osteoporosis

Foot drop Rationale: Foot drop occurs when the joint of the foot becomes contracted and results in the inability to perform dorsiflexion, or pulling the toes upward. This is due to nerve damage that causes shortening of the muscle. The foot is left with the toes pointing downward and in a dropped position.

A nurse is caring for an adolescent client who plans to attend the same law school their parent attended and work at their parent's law firm upon graduation. The client has never questioned their academic and career pathway and states, "If it's good enough for my parent, it's good enough for me." The nurse should identify that which of the following statuses describes the client's position? Identity achievement Foreclosure Identity diffusion Moratorium

Foreclosure Rationale: Individuals whose identity status is foreclosure have adopted beliefs and values without question, which are often imposed upon them by authority figures. Their belief system is generally carried forward from childhood into adulthood without challenge.

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis? Fowler's Lateral Prone Supine

Fowler's Rationale: The nurse should place the client in Fowler's position to promote lung expansion and to prevent atelectasis, which is the partial or complete collapse of a lung. In this position, the client is seated in a sem-sitting position and can have their knees bent or straight.

A nurse is meeting with a client at a community health center to assess their self-concept. Which of the following factors should the nurse consider during the assessment? (Select all that apply.) Life experiences Societal and cultural attitudes Health status Academic achievement Meditation

Life experiences Societal and cultural attitudes Health status Academic achievement

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? Twisting the torse when transferring the client. Bending at the waist when transferring the client. Placing the bed in the high position before transferring the client. Looking at the client face-to-face when transferring the client

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? Pivot disc Mechanical lift Sit-to-stand lift Gait belt

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 cleint? Gait belt Mechanical lift Cane Sit-to-stand lift

Mechanical lift

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture? Center of gravity Bones Muscles Synovial joints

Muscles

A nurse is preparing a presentation about muscle functions for a group of newly licensed nurses. Which of the following information should the nurse plan to include? Muscles store calcium and magnesium. Muscles produce red blood cells and platelets. Muscles assist with thermoregulation in the body. Muscles provide protection of internal organs.

Muscles assist with thermoregulation in the body.

A nurse is interviewing a client to assess their self-concept and asks, "What are some of the accomplishments that make you feel good about yourself?" The nurse is assessing which of the following components of self-concept? Body image Role performance Self-esteem identity

Self-esteem Rationale: Self-esteem is an indivual's generalized sense of self-worth and is measured by how much value a person places on themselves.

A nurse is meeting with a client who was recently diagnosed with rheumatoid arthritis. The client tells the nurse, "I'm never going to be able to do anything fun." Which of the following questions should the nurse ask to assess the client's identity? "Can you describe one of your primary roles?" "How do you respond when you feel you have failed?" "What aspect of your body would you like to change?" "How do others' opinions impact the way you see yourself?"

"How do others' opinions impact the way you see yourself?" Rationale: By asking the client how others' opinions impact the way they see themselves, the nurse is assessing the client's identity.

A nurse is assessing the self-concept of a client who recently lost their job and, as a result, might lose their home to foreclosure. Which of the following questions should the nurse ask the client when gathering information regarding self-concept? "What did your partner say when you lost your job?" "Why do you think that you were fired?" "How would you describe yourself and your situation?" "What are you going to tell your friends about losing your job?"

"How would you describe yourself and your situation?" Rationale: By asking the client to describe their self and their situation, the nurse is assessing the client's identity, which can be a self-concept stressor.

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. Leaning slightly back while carrying an object equalizes the center of gravity. Bending at the waist when picking up objects stabilizes the spine.

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 planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hours. B. Instruct the client to cough and deep breathe every 4 hours. C. Restrict the client's fluid intake. D. Reposition the client every 4 hours.

A. Encourage the client to perform antiembolic exercises every 2 hours.

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Place the cane 38 mm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane.

A. Hold the cane on the right side. B. Keep two points of support on the floor. D. After advancing the cane, move the weaker leg forward.

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? Sarcopenia Disuse osteoporosis Atrophy Joint contracture

Atrophy

A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements indicates an issue with self-concept? A. "I was having difficulty with attaching the appliance at first, but my partner was able to help." B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" C. "I met a neighbor who also has a colostomy, and they taught me a few things." D. "It can take me a while to get the hang of this. I have to admit, I am pretty nervous."

B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?"

A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that there has been a decreased desire for sexual relations since the surgery, stating, ""My body is so different now." Which of the following responses should the nurse make? A. "Really, you look just fine to me. There's no need to feel undesirable." B. "I'm interested in finding out more about how your body feels to you." C. "Consider an afternoon at a spa. A facial will make you feel more attractive." D. It's still too soon to expect to feel normal. Give it a little more time.

B. "I'm interested in finding out more about how your body feels to you."

A nurse is evaluating a client's understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding? A. "This device will keep me from getting sores on my skin." B. "This device will keep the blood pumping through my leg." C. "With this device on, my leg muscles won't get weak. D. "This device is going to keep my joints in good shape."

B. "This device will keep the blood pumping through my leg."

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at increased risk for body-image disturbances? (Select all that apply.) A. A client who had a laparoscopic appendectomy B. A client who had a mastectomy C. A client who had a left above-the-knee amputation. D. A client who had a cardiac catherization. E. A client who had a stroke with right-sided hemiplagia.

B. A client who had a mastectomy C. A client who had a left above-the-knee amputation.

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) A. Instruct the client not to perform the Valsalva manuever. B. Apply elastic stockings. C. Review laboratory values for total protein level. D. Place pillows under the client's knees and lower extremities. E. Assist the client to change positions often.

B. Apply elastic stockings. E. Assist the client to change positions often.

A nurse is caring for a client who is recovering from a myocardia infarction and a cardiac catheterization. The client states, ""I am concerned that things might be a little, you know different with my partner when I get home." Which of the following statements should the nurse make? A. Sounds like something you should discuss with them when you get home. B. It sounds like you are concerned about sexual functioning. Let's discuss your concerns. C. Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home. D. Just make sure you take your medication as directed, and you should be fine.

B. It sounds like you are concerned about sexual functioning. Let's discuss your concerns.

A nurse is caring for a client who is 4 days postoperative following a below-the-knee amputation related to a work injury. The nurse should identify that which of the following are components of the client's self-concept that this injury can impact? (Select all that apply.) Body image Role performance Identity Health promotion Self-esteem

Body image Role performance Identity Self-esteem

A nurse is caring for a client who has been sitting in a chair for 1 hour. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction

C. Pressure injury

A nurse is caring for 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 Asthma Hernia Hypertension

Deep vein thrombosis

A nurse is 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 Reduced depth perception Narrower stance when standing Quick steps when ambulating

Increased curvature of the thoracic spine

A nurse is caring for a client who reports enjoying retirement because they are reading more, visiting with children and grandchildren, and playing bridge with their friends. The nurse should identify that the client is experiencing which of the following stages of Erikson's theory of psychosocial development? Trust vs. mistrust Autonomy vs. shame and doubt Identity vs. role confusion Integrity vs. despair

Integrity vs. despair Rationale: Integrity is achieved when older adults reflect on life and feel a sense of fulfillment and accomplishment.

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include? Kyphosis is when the upper back extends posteriorly to the lower back. Kyphosis is an inward curvature of the lower back. Kyphosis is a sideways curvature of the spine. Kyphosis is a rounded upper back with the pelvis tilted forward.

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

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

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 good postural drainage? Lateral Supine Prone Fowler's

Prone (Lying flat on abdomen with their head turned to the side.)

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take? Reposition the client every 2 hours while in bed. Remind the client to use the incentive spirometer. Obtain the client's weight daily. Encourage the client to eat foods that are high in fiber.

Remind the client to use the incentive spirometer.

A nurse is meeting with a client who is recovering from a bilateral mastectomy. Since being discharged, the client has changed dressings as prescribed and completed arm exercises. The client tells the nurse, "I'm pleased with my postoperative progress." The nurse should identify that the client is displaying which of the following self-concept characteristics? Self-efficacy Emotional intelligence Self-awareness Generativity

Self-efficacy Rationale: Clients who have a higher levels of self-efficacy are more effective in the self-management of various health conditions, are more confident when dealing with stressful situations, and engage in behaviors to preserve or restore health.

A nurse is 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 minute Stand in place for 5 seconds Walk in place Step forward and backward

Sit on the edge of the bed for 1 minute Rationale: The nurse should identify that the client, who is at Level 1 Mobility of the MAT requires maximum assistance. The client should be able to sit on the edge of the bed for 2 minutes and extend their arms across their chest to shake hands with the nurse before advancing to the next level. If the client is unable to complete both tasks, they remain at Level 1 Mobility of the MAT.

A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Look straight ahead with shoulders raised up. Keep abdominal muscles contracted and the lower back straight. Stand as close to the object as possible. Bend hips slightly and squat. Push up from the knees when lifting the object.

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.

A nurse is proving teaching for a client who injured their ankle. Which of the following information should the nurse include? Cartilage is always remodeling and changing. Tendons connect muscle to bone. Ligaments are flexible connective tissue that coat bony areas. Synovial joints attach to the skeleton to maintain posture.

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 hand grips of the crutches are at the level of the client's umbilicus. The client's elbows are bent 45° when holding the crutches. The client places their weight on their axilla when using the crutches. The client has the crutches resting 5 cm (2 in) below their axilla.

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

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint? Synovial joints contain sensory receptors that trigger flexion. The contraction of a muscle results in flexion of a joint. Neurotransmitters coordinate with cartilage to initiate flexion. Ligaments extend to enable flexion of a joint.

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

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include? The top of the walker should be at the level of your wrist. When using the stairs, place the walker before taking a step. When holding the walker, bend your elbows 30°. Take a step first before moving the walker.

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

A nurse is 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 improves blood circulation in the body. The use of ergonomics eliminates costs related to worker's compensation. The use of ergonomics increases job satisfaction. The use of ergonomics maintains the body's balance and a lower center of gravity.

The use of ergonomics increases job satisfaction. Rationale: The use of ergonomics increases job satisfaction along with productivity of staff members. When staff members can work safely and effectively, they can perform at a higher level.

A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL? Toileting Writing Ambulating Talking

Toileting