Chapter 28 fundamentals

Which of the following crutch gaits is most appropriate for a patient with a right knee replacement who is prescribed no weight bearing on the right leg? 1. Two-point gait 2. Three-point gait 3. Four-point gait 4. Swing-through gait

2. Three-point gait

Which assessment data does the nurse gather before transferring a patient from the bed to a stretcher? (Select all that apply.) 1. Patient's weight 2. Patient's level of cooperation 3. Patient's ability to assist 4. Presence of medical equipment 5. 24-hour calorie intake

1. Patient's weight 2. Patient's level of cooperation 3. Patient's ability to assist 4. Presence of medical equipment

A patient is experiencing some problems with joint stability. The physician has prescribed crutches for the patient to use while still being allowed to bear weight on both legs. Which of the following gaits should the patient be taught to use? 1. Four-point or four-point alternating 2. Three-point or three-point alternating 3. Two-point 4. Swing-through

1. Four-point or four-point alternating

The nurse recognizes that a decline in physical activity and joint changes that decrease flexibility experienced by the older adult will most likely: 1. Increase the patient's risk for falls and injuries 2. Result in less stress on the patient's joints 3. Decrease the amount of work of the patient to move 4. Allow for mobility despite the aging effects on the patient's joints

1. Increase the patient's risk for falls and injuries

Which of the following are necessary safety precautions when ambulating a patient? (Select all that apply.) 1. Placing a gait belt around patient's waist 2. Clear the immediate environment of safety hazards 3. Having patient wear well-fitting rubber-soled shoes or slippers 4. Having at least three people present to assist patient 5. Being sure that no pain medication was given for at least 3 hours before ambulation

1. Placing a gait belt around patient's waist 2. Clear the immediate environment of safety hazards 3. Having patient wear well-fitting rubber-soled shoes or slippers

A patient has experienced an injury to his lower extremity. The orthopedist has prescribed the use of crutches and a four-point gait. The nurse instructs the patient using this gait to: 1. move the right crutch forward first. 2. move both crutches forward together. 3. move the right foot and the left crutch together. 4. move the right foot and the right crutch together.

1. move the right crutch forward first.

Which of the following statements made by an older adult reflects the best understanding of the need to exercise regardless of age? 1. "You are never too old to begin an exercise program." 2. "My granddaughter and I walk together around the high school track 3 times a week." 3. "I purchased a subscription to a runner's magazine for my grandson for Christmas." 4. "When I was a child, I exercised more than what I see kids doing today."

2. "My granddaughter and I walk together around the high school track 3 times a week."

What is the proper alignment for a patient in the sitting position? 1. Body weight distributed totally to the buttocks. 2. Both feet supported on the floor. 3. Head flexed forward at a 60-degree angle. 4. A 10" space maintained between the edge of the seat and the popliteal space.

2. Both feet supported on the floor.

Which of the following indicates that additional assistance is needed to transfer a patient from the bed to the stretcher? 1. The patient is 5 feet 6 inches and weighs 120 lb (54.4 kg). 2. The patient speaks and understands English. 3. The patient received an injection of morphine 30 minutes ago for pain. 4. You feel comfortable handling a patient of this size and level of cooperation.

3. The patient received an injection of morphine 30 minutes ago for pain.

For inpatient early progressive mobility, Level 3 includes beginning to have the patient: 1. sitting in bed with the head of the bed or stretcher elevated to 45 degrees. 2. sitting on the edge of the bed. 3. actively transferring to a chair. 4. initiating ambulation.

3. actively transferring to a chair.

One of the expected benefits of exercise is: 1. decreased diaphragmatic excursion. 2. decreased cardiac output. 3. decreased resting heart rate. 4. increased fatigue

3. decreased resting heart rate.

A patient is able to bear weight on one foot. The crutch-walking gait that the nurse teaches this patient is the: 1. two-point gait. 2. swing-through gait. 3. three-point alternating gait. 4. four-point alternating gait.

3. three-point alternating gait.

The first step in initiating an exercise program for a patient is to: 1. select the equipment. 2. design the fitness program. 3. schedule time during the day. 4. seek approval from the health care prescriber.

4. seek approval from the health care prescriber.

A student nurse is caring for 67-year-old patient who is experiencing left-sided weakness caused by a stroke. The student nurse is providing patient teaching regarding the use of a quad-cane for ambulation. Which of the following statements is correct? a. "You should use the cane on the stronger side of the body." b. "Move the stronger leg with the cane." c. "When walking, advance the weaker leg past the cane." d. "Your body weight should be supported by the cane and stronger leg."

a. "You should use the cane on the stronger side of the body."

The nurse delegates the task of ambulating a patient to the assistive personnel. The nurse ascertains that the assistive personnel understands how to intervene when the patient complains of dizziness when the assistive personnel verbalizes which of the following? a. "I call for help." b. "I gently lower the patient to the floor." c. "I support the patient and walk quickly back to the room." d. "I lean the patient against the wall and wait until the episode passes."

b. "I gently lower the patient to the floor."

The nurse is assigned to a 67-year-old comatose patient. To minimize the risk for aspiration, the nurse should avoid placing the patient in what position? a. Semi-Fowler's b. Sims' c. Supine d. Lateral

c. Supine

A nurse is caring for a patient with a neuromuscular condition. The nurse needs to assess the patient's muscle movement and strength. In doing so, the nurse recalls that chemicals that transfer electrical impulses from the nerve across the myoneural junction are called which of the following? a. Isometrics b. Synergistics c. Proprioceptors d. Neurotransmitters

d. Neurotransmitters

A 19-year-old patient with cerebral palsy has been admitted to the hospital with pneumonia. The patient has limited voluntary motor control. The student nurse caring for this patient, knows that the easiest intervention to maintain joint mobility would be to perform which of the following exercises? a. Active range-of-motion exercises b. Weight-bearing exercises c. Aerobic exercises d. Passive range-of-motion exercises

d. Passive range-of-motion exercises

A patient with arthritis is complaining of sensitivity and warmth in the elbow and wrist joints. To determine the degree of limitation or injury, the nurse can assess which of the following? a. Posture b. Activity tolerance c. Body mechanics d. Range of motion

d. Range of motion

There is strong evidence for the use of ergonomic solutions being effective in reducing _________________ pain and injuries.

musculoskeletal

A nurse selects which of the following for promoting resistive isometric exercise for a patient? 1. Whirlpool 2. Footboard 3. Weights 4. Stationary bicycle

2. Footboard

The nurse is assigned to take care of a 56-year-old patient with COPD. The patient does not tolerate a supine position for sleeping. In what position should the nurse place the patient? a. Lateral b. Prone c. Semi-Fowler's d. Sims'

c. Semi-Fowler's

An expected assessment of a toddler's alignment will indicate a: 1. slight swayback and protruding abdomen. 2. flexed spine without anteroposterior curves. 3. full musculoskeletal function and straight posture. 4. distinct thoracic curvature and weakness.

1. slight swayback and protruding abdomen.

The patient had a cerebrovascular accident (CVA/ stroke) with resultant left hemiparesis. The nurse is instructing the patient on the use of a cane for support during ambulation. The nurse instructs the patient to: 1. use the cane on the right side. 2. use the cane on the left side. 3. move the left foot forward first. 4. move the right foot forward first.

1. use the cane on the right side.

A patient is admitted to the rehabilitation facility for physical therapy after an automobile accident. To conduct an assessment of the patient's body alignment, the nurse should begin by: 1. observing the patient's gait. 2. explaining the process. 3. determining the level of activity tolerance. 4. evaluating the full extent of joint range of motion.

2. explaining the process.

A patient is getting up to ambulate for the first time since a surgical procedure. While ambulating in the hallway, the patient complains of severe dizziness. The nurse should first: 1. call for help. 2. lower the patient gently to the floor. 3. lean the patient against the wall until the episode passes. 4. support the patient and move quickly back to the room.

2. lower the patient gently to the floor.

A nurse is working with a patient who is able only to assist the nurse in moving from the bed to the chair. The nurse needs to help the patient to stand. The correct technique for lifting the patient to stand and pivot to the chair is for the nurse to: 1. keep the legs straight. 2. maintain a wide base with the feet. 3. keep the stomach muscles loose. 4. support the patient away from the body.

2. maintain a wide base with the feet.

A nursing assistive personnel asks for help to transfer a patient who weighs 125 lb (56.8 kg) from the bed to a wheelchair. The patient is unable to assist. What is the nurse's best response? 1. "As long as we use proper body mechanics, no one will get hurt." 2. "The patient weighs only 125 lb. You don't need my assistance." 3. "Let's call the lift team for additional assistance." 4. "The two of us can easily lift the patient."

3. "Let's call the lift team for additional assistance."

Place the first five steps of Assessment for the performance of the Skill of Safe and Effective Transfer Techniques in the correct order. 1. Perform hand hygiene. 2. Directly assess physical capacity of a patient to transfer. 3. Assess for weakness, dizziness, or risk for orthostatic (postural) hypotension. 4. Identify the patient using at least two identifiers. 5. Refer to medical record for most recent recorded weight and height for patient.

4. Identify the patient using at least two identifiers. 1. Perform hand hygiene. 2. Directly assess physical capacity of a patient to transfer. 3. Assess for weakness, dizziness, or risk for orthostatic (postural) hypotension. 5. Refer to medical record for most recent recorded weight and height for patient.

A patient has a cast on the right foot and is being discharged home. Crutches will be used for ambulation, and the patient has stairs to manage to enter the house and to get to the bedroom and bathroom. The nurse observes that the patient is not that confident with the use of the crutches, so plans to teach the patient to use which of the following techniques for the stairs? 1. Advance the crutches first to ascend the stairs. 2. Use one crutch for support while going up and down. 3. Sit on the stairs and lift with the arms and weight-bearing leg to move up. 4. Use the banister or wall for support when descending the stairs.

4. Use the banister or wall for support when descending the stairs.

An average-size female patient who resides in the extended care facility requires assistance to ambulate down the hall. The nurse has noticed that the patient has some weakness on her right side. The nurse assists this patient to ambulate by: 1. standing at the patient's left side and holding her arm. 2. walking in front of her and having her hold onto her waist. 3. standing behind her and encircling one arm around the patient's waist. 4. standing at her right side and using a gait belt.

4. standing at her right side and using a gait belt.

Which of the following actions are effective in reducing friction when repositioning a patient in bed? (Select all that apply.) a. Lifting rather than pushing b. Pushing the patient up in bed c. Asking the patient to bend his or her knees and lift the hips when moving up in bed d. Asking the patient to lie still as you reposition him or her; even when the patient offers to help e. The use of a draw sheet f. The use of a transfer board

a. Lifting rather than pushing c. Asking the patient to bend his or her knees and lift the hips when moving up in bed e. The use of a draw sheet f. The use of a transfer board

A small business owner has noted an increase in back injuries at his company in recent years. During a discussion with an occupational health nurse, knowledge of statistical information regarding this trend throughout the country is exchanged. The occupational health nurse explains that the most common back injury is caused by a strain to which of the following muscle groups? a. Lumbar b. Cervical c. Thoracic d. Trapezius

a. Lumbar

The nurse manager is concerned with the safety of the staff as they transfer patients. Facility policy reinforces the principles of appropriate body mechanics, which include which of the following? (Select all that apply.) a. A wide base of support increases stability b. A higher center of gravity increases stability c. Facing the direction of movement prevents abnormal twisting of the spine d. Pivoting requires less work than lifting e. Manually lift the patient in sections f. Dividing balanced activity between arms and the legs

a. A wide base of support increases stability c. Facing the direction of movement prevents abnormal twisting of the spine d. Pivoting requires less work than lifting f. Dividing balanced activity between arms and the legs

A nurse is teaching a crutch walking technique that requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. What is the term for this gait? a. Four-point gait b. Three-point gait c. Two-point gait d. Three-point alternating gait

a. Four-point gait

Which of the following assessment findings indicates that exercise should be discontinued? a. Heart rate = 145 beats/minute b. Blood pressure 140/82 c. Respirations 32 breaths/minute d. Oxygen saturation 95%

a. Heart rate = 145 beats/minute

Which of the following trouble points are common in the side-lying position? (Select all that apply.) a. Lack of support for the feet b. Lack of protection for pressure points for the ears, shoulders, anterior iliac spine, trochanter, and ankles c. Adduction of the shoulder and hip joints d. Hyperextension of the neck e. Spinal curves out of normal alignment

a. Lack of support for the feet b. Lack of protection for pressure points for the ears, shoulders, anterior iliac spine, trochanter, and ankles c. Adduction of the shoulder and hip joints e. Spinal curves out of normal alignment

The nurse is taking care of a 78-year-old comatose patient. The nurse has placed the patient in a supine position. To prevent foot drop, the nurse applies which of the following? a. Pillows to dorsiflex the foot b. Trochanter rolls to the feet c. Foot boots as ordered d. Pillows to elevate the feet

c. Foot boots as ordered

The nurse is in charge of caring for five orthopedic patients during a shift. Nursing assistive personnel are available to assist the nurse with care of the patients. Which of the following tasks is most appropriate for the nurse to delegate to the nursing assistive personnel? a. Moving a 45-year-old patient who had a CVA toward the head of the bed b. Transferring an 85-year-old patient for the first time after a total hip replacement c. Providing discharge teaching for a 49-year-old patient who had a stroke d. Preparing a 77-year-old patient for hip replacement surgery

a. Moving a 45-year-old patient who had a CVA toward the head of the bed

A nurse is assisting a patient with right-sided hemiplegia to transfer from the bed to a chair. The most appropriate action for the nurse is to do which of the following? a. Use a transfer belt. b. Grab the patient under the arms while assisting with the transfer. c. Stand on the unaffected side of the patient to ensure less strain on the nurse's back. d. Encourage the patient not to use the hand rests because of their restrictions on movement.

a. Use a transfer belt.

stroke. The nurse understands the interventions to prevent skin breakdown for this bedfast patient is to include repositioning of the patient at least every _____ hour(s). a. 1 b. 2 c. 3 d. 4

b. 2

Which group of muscles is involved with joint stabilization? a. Skeletal muscles b. Antigravity muscles c. Synergistic muscles d. Antagonistic muscles

b. Antigravity muscles

A patient has been hospitalized for 5 days after pancreatic surgery. The nurse is preparing the patient to ambulate for the first time. What is the best action for the nurse to perform to prevent the patient from suffering orthostatic hypotension? a. Have him sit up in bed for a few minutes before standing. b. Have him sit up with his legs dangling over the side of his bed for a few minutes before standing. c. Place him in a high-Fowler's position for a few minutes before standing. d. Place him in a low-Fowler's position for a few minutes before standing

b. Have him sit up with his legs dangling over the side of his bed for a few minutes before standing.

A nurse and another staff member are preparing to reposition a patient in bed. To prevent back strain, these two health care providers must do which of the following? a. Keep their knees stiff to enhance their lifting strength potential. b. Keep the weight of the patient as close to their bodies as possible. c. Loosen their stomach muscles to keep from injuring the pelvic region. d. Twist their upper torsos to enhance the use and strength of their upper extremities

b. Keep the weight of the patient as close to their bodies as possible.

The nurse working on an orthopedic unit has to assist many of the patients because of limited mobility. The nurse's goal is to maintain a position that most favors function, requires the least muscular work to maintain, and places the least strain on muscles, ligaments, and bones. What is the term that best describes this goal? a. Body alignment b. Posture c. Center of gravity d. Balance

b. Posture

A nurse is caring for a patient who has pneumonia. To facilitate respiration and lung drainage this patient should be placed in what position? a. Sims' b. Prone c. Lateral d. Supine

b. Prone

The patient has been diagnosed with a progressive neuromuscular disease and is having difficulty walking and has decreased awareness of the body's position. What is the term that best describes this phenomenon? a. Balance b. Proprioception c. Posture d. Hemiplegia

b. Proprioception

A patient presents to the emergency department with a fractured leg that requires a full leg cast. The nurse needs to teach the patient to ambulate with crutches using which of the following? a. Two-point gait b. Three-point gait c. Four-point gait d. Tripod alternating position

b. Three-point gait

Which of the following statements is appropriate for a nurse to teach a patient regarding the use of crutches? a. "The axillae should support all your body weight." b. "Your elbows should be straight when your hands are on the crutch handgrips." c. "The distance between the crutch pad and axillae should be three to four finger widths." d. "Your elbows should be flexed about 45 degrees when the handgrip position is correct."

c. "The distance between the crutch pad and axillae should be three to four finger widths."

A nurse is caring for a patient with osteogenesis imperfecta. The nurse needs to assess the patient's muscle movement and strength. In doing so, the nurse recalls that osteogenesis imperfecta is characterized by fractures and bone deformities. This condition is known as which of the following? a. A form of osteoporosis b. A form of arthritis c. A congenital defect d. A neurological defect

c. A congenital defect

As the result of a brain tumor, a patient is having trouble with balance. The patient's significant other is concerned and asks the nurse how a tumor could affect the patient's balance. The nurse explains that the tumor is growing in the part of the brain that is responsible for balance. The significant other asks, "Which part of the brain controls balance?" The nurse's response would be which of the following? a. Pons b. Cerebrum c. Cerebellum d. Hypothalamus

c. Cerebellum

A student nurse is assisting a patient who is ambulating with a new walker. Which of the following is appropriate information for student nurse to provide to the patient? a. "The top of the walker should line up with the crease on the inside of your elbows." b. "You should walk behind the walker to maintain balance." c. "You should lean forward over the walker to maintain balance." d. "When walking, you should take a step, move the walker forward, and take another step."

d. "When walking, you should take a step, move the walker forward, and take another step."

A nurse is caring for a patient with a broken tibia and fibula. The patient is in a half cast to his knee and is unable to bear weight. The nurse has instructed the patient on how to walk and climb stairs with his injuries. What is the best way to assess the patient's knowledge of how to ascend and descend stairs? a. Incorrectly re-demonstrate the procedure and have the patient point out any errors. b. Have the family member explain the procedure. c. Have the patient explain the procedure. d. Have the patient demonstrate the procedure.

d. Have the patient demonstrate the procedure.

A nurse who works on the orthopedic unit knows that in addition to providing support, bones perform other functions in the body. Besides support, which of the following is an important bone function used during activity and exercise? a. Hematopoiesis b. Protection c. Mineral storage d. Movement

d. Movement

The patient is a 46-year-old woman who is a devout Muslim and who is being evaluated for weight-loss surgery. One aspect of the comprehensive bariatric program is that clients begin an exercise program. The patient is self-conscious about her weight and concerned about maintaining her modesty. Which of the following exercise programs would be the best choice for the nurse to suggest? a. A private trainer at a local fitness center b. An aerobics class at the local YMCA c. The evening yoga class at a local country club d. Walking 30 minutes a day at the mall with a friend

d. Walking 30 minutes a day at the mall with a friend