Chapter 25 Mobility

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Fowler's explanation- Fowler's position optimizes cardiac function and respiratory function in addition to being the best position for eating.

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?

Fowler's explanation- Fowler's position, a semi-sitting position, will assist the client with dyspnea because this position allows the abdominal organs to drop away from the diaphragm for oxygenation

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

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight alignment when the client is being turned.

When lifting a heavy object, it is best to ...

Use large leg muscles, bend knees , and maintains posture

The nurse is caring for a client with cerebral palsy who requires crutches to ambulate. Which crutch-walking gait will the nurse teach?

four-point explanation- The client with generalized weakness would benefit from four-point crutch-walking. Other choices are inappropriate for a client with generalized weakness.

What is primarily responsible for the body's equilibrium ?

The vestibular apparatus of the ear

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?

transfer belt explanation- A transfer belt is designed for clients who can bear weight and help with the transfer but are unsteady.

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?

walker

Factors that affect mobility

•lifestyle and habits •good oxygen and circulation throughout the body •nervous system control •Disorders

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?

"How long are you wearing the prosthesis during the day?" explanation- The reddened skin could be an early sign of impaired skin integrity. This could be related to the client wearing the prosthetic device for too long a period

The nurse is teaching a client on the proper use of the knee immobilizer. Which statement by the client will indicate to the nurse the teaching has been effective?

"I can take the immobilizer off to shower and dress each morning."

A nurse is working with a female client with osteoporosis on an exercise program. The nurse instructs the client to increase her tolerance gradually. The nurse determines that the education was effective when the client states:

"If I experience pain when I'm exercising, I should stop."

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?

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

The charge nurse has just completed an in-service to educate the staff about the principles of mobility when participating in physical activities. Which responses are appropriate for the charge nurse to share with the nurse after reviewing the image? Select all that apply.

"You can hurt yourself performing the activity in this manner." "Your posture is awkward and could increase the risk of back injuries." "Elevate the height of the bed to waist level when making the bed."

One's independence is defined by their mobility, or their ability to perform ADLs. What are ADLs?

Activities of daily living

The cerebral correct facilitates movement, but the _________ maintains coordination of movement

Cerebellum

When lifting objects, should they be kept close or far away from the body ?

Close [this is an example of body mechanics: posture, balance, and coordination]

While performing passive range-of-motion exercises on the lower extremities of a client with a spinal cord injury, the nurse assesses permanent flexion of the muscles. What term will the nurse use to document this finding related to the muscles?

Contractures Contractures are permanent contraction of a muscle

A nurse is following a plan of care for passive range-of-motion (ROM) exercises. What specifics will be included on the plan?

Do ROM exercises twice a day, each exercise two to five times. explanation- Do not move joints to the point of pain. Passive ROM exercises should be done twice a day, with each exercise carried out two to five times.

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?

Equipment is positioned to the side, 50 degrees away.

A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply.

Exercise increases intestinal tone. Exercise increases efficiency of the metabolic system. Exercise increases blood flow to kidneys

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 will improve muscle tone and strength.

The meal tray has been delivered to the client's room. The client needs to be repositioned higher in the bed with the head raised. The client is unable to assist with moving in the bed. What action is best for the nurse to perform to prevent injury to the nurse and/or the client?

Obtain assistance from another nursing staff member.

A 45-year-old woman is admitted after undergoing a hysterectomy. She has been immobile for 2 days. She has a 20-year history of smoking. She also takes oral estrogen to manage her hot flashes. As a nurse assesses the client, she notices that the client's left leg is dark purple and measures 2 inches (5 cm) larger than her right leg. What is the client most at risk for?

Pulmonary embolism explanation- The client is exhibiting signs of a deep vein thrombosis (DVT). She also has several risk factors for developing a DVT (hormone use, smoking)

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?

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

Using proper body mechanics, which motions would the nurse make to move an object?

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

A college student fell and sprained his right ankle. The student health physician 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. Teach the client that the support of body weight should come primarily on the hands and arms when using the crutches, not in the axillary area, where pressure may damage nerves and cut off circulation.

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) Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance.

A client has chronic obstructive pulmonary disease (COPD) and is unable to perform basic self-care activities or activities of daily living (ADLs). What would be an appropriate nursing diagnosis?

activity intolerance explanation- Activity intolerance is any condition that interferes with the transport of oxygenated blood to tissue. Chronic obstructive pulmonary disease is one condition that meets these criteria.

A nurse is performing range-of-motion exercises for a client and moves the client's fingers apart and then back together. The nurse is performing which range of motion?

adduction/abduction explanation- Spreading the fingers apart and then bringing them back together reflects adduction and abduction.

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?

assess for abnormalities in the feet

The nurse is teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when the graduate states that back injuries:

can occur when uncooperative clients are being repositioned.

An unlicensed assistive personnel (UAP) has alerted the nurse that a client who is 36 hrs postoperative for a fracture of the tibia/fibula is having difficulties. Which action should the nurse prioritize after reviewing the UAP's report?

contact health care provider immediately

A group of nursing students is reviewing the aspects of motor function control by the nervous system. The students demonstrate understanding of this information when they identify what as a function of the cerebellum?

coordination of movement motor activities explanation: The cerebellum coordinates motor activities of movement. The cerebral cortex initiates voluntary motor activity. The pyramidal tract transmits impulses to the spinal cord. The extrapyramidal tract inhibits and dampens impulses.

The nurse in a long-term care facility is checking on a client who had a cast applied 48 hours ago to the right ankle for a fracture. Which action should the nurse take?

ensure client changes position every 2 hours

A nurse is preparing to move a client up in bed. How can the nurse best demonstrate the principles of correct body mechanics?

facing the direction of movement

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair 3 times per day. Which action will be most effective to transfer the client safely into the chair?

having the client sit on the side of the bed for several minutes before moving to the chair explanation- Having the client sit at the side of the bed minimizes the risk for blood pressure changes (orthostatic hypotension) that can occur with position change

Bed rest, with resultant immobility, affects the whole body. What is one effect on the musculoskeletal system?

increased risk for contractures The effects of bed rest and immobility include decreased muscle mass and strength, joint mobility, and endurance. Bone demineralization occurs, and there is an increased risk for contracture formation

As a part of his workout regimen, a 21-year-old college football player often engages in both a 10-minute squat hold and 10-minute lateral arm hold. These are examples of what type of exercise?

isometric Isometric exercise isolates a specific muscle or muscle group and exercises it by holding the muscle steady and maintaining tension.

The nurse is teaching a client about moving joints into positions of abduction and adduction. Which client action reflects that teaching has been effective?

moves the legs away from the midline and then toward the midline

A nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program?

obtain a pre-exercise medical examination for clearance The client has underlying medical conditions and should obtain a pre-exercise medical examination before beginning any exercise program

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

predisposition to renal calculi In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume.

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

pull the shoulder blade forward and out from under the client explanation- Positioning the shoulder blade in this manner removes pressure from the bony prominence and thus helps decrease the risk of impaired skin integrity. The other actions should also be performed but do not decrease the risk of impaired skin integrity.

An immobile person has decreased movement of respiratory secretions. Which condition is a greater risk as a result?

respiratory tract infection When a person is immobile, the movement of secretions in the respiratory tract is decreased, causing secretions to pool and leading to respiratory congestion

A nurse is demonstrating the proper use of body mechanics to a group of nursing students. What would be most appropriate for the nurse to do?

stand with legs wide apart

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client?

the client's ability to assist

When assessing the physical activity of clients, the nurse would be most concerned about which client?

the middle-aged computer programmer

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?

thrombus formation Prolonged sitting can increase a client's risk for thrombus formation.

The nurse is teaching a client about moving joints into positions of pronation and supination. Which client action does the nurse identify that appropriately reflects these movements?

turns the arms downward and then upward explanation- Pronation and supination involve turning downward and then upward. Moving the legs away from the midline and then toward the midline is reflective of abduction and adduction. Tilting the chin downward and then stretching the head backward comfortably reflects flexion and extension. Turning the sole of the foot toward and then away from the midline is reflective of inversion and eversion.