Ch. 32 prac. questions

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that he is able to move onto the stretcher without her help. What is the nurse's best response?

"You are free to move onto the stretcher without assistance, but I will supervise for your safety."

A nurse is ambulating a 48-year-old female patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient:

1. Place feet wide apart with one foot in front. 2. Rock your pelvis out on the side of the patient. 3. Grasp the gait belt. 4. Pull the weight of the patient backward against your body. 5. Gently slide patient down to the floor, protecting her head. 6. Stay with the patient and call for help.

A nurse is using the Katz Index of Independence in Activities of Daily Living to assess the mobility of an 80-year-old hospitalized female patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index?

4 (for each self ADL)

A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical development milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones?

A 6-month-old infant who is unable to hold his head up himself

The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which of the following reasons?

Acts to prevent injury to the client and/or nurse

When a client is lifted or held by a nurse, the additional weight becomes a part of the nurse's weight and should be...

Balanced over the center of gravity

An immobile client who weighs over 250 pounds is discharged to his daughter's home. The nurse should instruct the family to arrange for which of the following?

Bariatric lift

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. The nurse correctly instructs the patient to do which actions? Select all that apply.

Breathe in and out smoothly during quadriceps drills Place the bed in the lowest position or use a footstool for dangling Perform quadriceps 2-3 times per hours, 4-6 times a day

A nurse working in a long-term care facility uses proper patient-care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures?

Carefully assessing the patient care environment

A nurse stretches out a patient's leg and moves it in a circle. This is an example of what type of body movement?

Circumduction

A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop?

Dorsiflexion

The nurse has asked the client to grasp his overbed trapeze and pull his torso up off the surface of the bed. What movement will the client perform with his arms?

Flexion

A nurse applies padded boots to maintain the foot in dorsiflexion on a client who is comatose. The nurse is protecting the client from what?

Food drop

A nurse is caring for a 73-year-old male patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity?

Fowler's position

A nurse is caring for a 26-year-old male patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side?

Have the patient cross his arms on his chest and place a pillow between his knees

A nurse is preparing an exercise program for a 65-year-old male patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply.

Instruct the patient to avoid sudden position changes that may cause dizziness Instruct the patient to avoid exercising in very cold or very hot temperatures

When an older adult client walks with her knees slightly flexed and body leaning, the nurse determines that the client...

Is demonstrating a common gait for the older adult

A 17-year-old has a fractured left leg, which as been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient?

Keep elbows close to the sides of the body

A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What should the nurse do in this situation?

Lower the patient back to the side of the bed and pivot her back into bed

Logrolling requires the nurse to use supportive devices in turning the client, in order to...

Maintain the natural alignment of the body

The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What should be the nurse's next action?

Move the client to the edge of the bed opposite the side that client will be turning

After positioning a client to move from the bed into a wheelchair, how would a nurse stand when helping the client to sit up on the side of the bed?

Near the client's hip, with legs shoulder-width apart and one foot near the head of the bed

A nurse is preparing to turn a hospitalized client age 65 years. Which of the following is a recommended guideline for performing this skill?

Position a friction-reducing sheet under the client

A 49-year-old who injured his spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for him correctly tells the aide not to place him in which position?

Prone position

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which of the following actions should you take next to decrease the risk of impaired skin integrity?

Pull the shoulder blade forward and out from under the client

The nurse is assisting a patient from the bed into a wheelchair. Which of the following is a recommended guideline for this procedure?

Raise the head of the bed to a sitting position

The nurse is assisting a client to ambulate following knee surgery. What is a key concern when assisting clients with activity?

Safety

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

Shift their weight back and forth, from back leg to front leg

What position would you ask your position to do a rectal exam or enemas?

Sims position

A nurse is providing range-of-motion exercises for a 53-year-old female patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be be the nurse actions. Select all that apply

Stop performing the exercises Re-evaluate the nursing plan of care Assess the patient for other symptoms

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient?

Support weight on stronger leg and cane and advance weaker foot forward

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?

Supporting the client's back

When assessing for proper body alignment of a standing client, which of the following is a normal finding?

The weight of the body is distributed on the soles and heels

While being measured for anti-embolism stockings, the client asks the nurse why they are necessary. What would be the nurse's best response?

They promote venous blood return to the heart

A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as which of the following?

Tremor

A nurse is caring for an 82-year-old woman in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient?

Urinary stasis

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. What statement is correct regarding logrolling?

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement

What is abduction?

occurs with the *lateral movement* of a body part *away from the midline* of the body

What is dorsiflexion?

the *backward* bending of the *hand/foot*

What is flexion?

the state of being *bent*

What is circumduction?

when the distal part of the limb is moved to trace a circle while the proximal end of the bone remains fixed