Chapter 8: Body Mechanics and Patient Mobility

The nurse is receiving a report on a patient. The nurse giving the report states that the patient has foot drop. The nurse receiving the report knows that which is the correct terminology for footdrop? 1. Plantar flexion of the foot 2. dorsiflexion of the foot 3. ankle extension 4. ankle hyperextension

1. plantar flexion of the foot

A patient has been on bed rest for a few days and is getting up for the first time. What is the best nursing intervention for this patient? 1. Assess the patient's respiratory function 2. Obtain the patient's temperature 3. Assist the patient to a sitting position on the side of the bed 4. Ask the patient if he or she feels dizzy or light-headed

3. Assist the patient to a sitting position on the edge of the bed

The prone position is lying on ones A. back B. side C. stomach D. side with knees flexed

C. Stomach

Capillary refill usually takes how many seconds?

3 seconds, 5 seconds for older adults

The use of a lift (draw) sheet prevents which type of injury to the patient? A. Shearing B. Fracture C. Ulcerations D. Laceration

A. Shearing

The patient experienced a cerebrovascular accident (CVA) that left her with severe left-sided paralysis and very limited mobility. Which device would prevent plantar flexion? 1. Footboard 2. Bed board 3. Trapeze bar 4. Trochanter roll

1. footboard

Patients who are immobilized in health care facilities require that their psychosocial needs be met along with their physiologic needs. Which statement by the nurse acknowledges these needs? 1. "Visiting hours will be limited so you can rest." 2. "We will help you do everything so you don't have to worry." 3. "Let's talk about what you used to do at home during the day." 4. "A private room can be arranged for you."

3. "Let's talk about what you used to do at home during the day."

The nurse weighs 106 pounds. According to the National Institute for Occupational Safety and Health (NIOSH) Division of Safety research, what is the maximum weight she should safely lift? 1. Depends on the nurse's health and personal strength 2. No more than 35 pounds of the patient's weight 3. No more than 35% of her own 106 pounds 4. Maximum of 50 pounds regardless of patient's or nurse's weight

B. No more than 35 pounds of the patient's weight. (no matter what the nurse weighs)

The patient states the doctor informed her that her cervical spine is out of alignment. This means the cervical spine: A. is straight B. must be manipulated C. Is not inline with the thoracic vertebrae D. is normal

C. Is not in line with the thoracic vertebrae

What complications come from not properly supporting the patient's joints when moving them?

Dislocation, increased stress, hyperextension of joints, and shearing

When is an air mattress used?

To prevent pressure ulcers in immobile patients

Supination

Kind of rotation that allows palm of hand to turn upward

Flexion

Movement of certain joints that decreases angle between 2 adjoining bones

Extension

Movement of certain joints that increases angle between 2 adjoining bones

What is the orthopneic position?

The patient is seated and chest is bent slightly over a bedside table

Hyperextension

extreme or abnormal extension

What is the most likely complication if an elderly patient gets pulled across the bed when changing wet linens? 1. Dislocation of the joint 2. Increased stress to the joints 3. Abnormal hyperextension of a joint 4. Shearing or tearing of the skin

4. Shearing or tearing of the skin

How can nurses prevent immobility complications?

-turning patients every 1-2 hours -providing range of motion exercises -obtaining an order for laboratory to assess nutritional status -obtaining nutritional consult as needed -obtaining an order for a specialized mattress or a sheepskin covering

A patient becomes faint while sitting on the side of the bed. To prevent injury to the patient and nurse, which action should the nurse take? (select all that apply) 1. The nurse should call for assistance 2. The nurse should lay the patient straight back and support the head 3. The nurse should allow the patient to lower the head to rest on the nurse's abdomen. 4. The nurse should find an emesis basin because the patient will probably vomit 5. The nurse should continue to assist the patient to a standing position, looking forward and taking deep breaths

1, 2

The range of motion (ROM) that can be safely performed on the neck includes: (select all that apply) 1. flexion 2. supination 3. lateral flexion 4. rotation 5. hyperextension

1, 3, and 4

When assessing the neurovascular status of a patient, what is an expected finding? 1. Capillary refill after 8 seconds 2. Pulses strong and easily palpated 3. Loss of sensation to an affected area 4. Mild localized discomfort

2. Pulses strong and easily palpated

The nurse and a UAP are to move a dependent patient from the supine to the lateral position. Which action should be performed first? 1. Move the patient to the side of the bed 2. Ensure that the upper arm and leg are supported with pillows 3. Explain to the patient what actions the nurse and UAP are going to perform 4. Turn the patient with use of a lift sheet.

3. Explain to the patient what actions the nurse and UAP are going to perform.

What does passive-ROM mean? A. A nurse or other person performs exercises to a patient's extremities B. A patient moves extremities minimally without exertion C. The patient moves the extremities in an extreme manner D. The patient does not perform exercises to his/her full ability

A. A nurse or other person performs exercises to a patient's extremities

A common complication of patients with limited mobility is a thrombus or emboli. Which nursing intervention assists in the prevention of a thrombus? 1. Applying TED stockings 2. Assessing the circulation of lower extremities 3. Assessing for a positive Homan sign 4. Elevating lower extremities off the bed

A. Applying TED stockings. (The application of a thromboembolic deterrent (TED) hose is an antiembolism measure.)

Which system must be protected to minimize injury to the nurse and patient? A. Respiratory B. Musculoskeletal C. Cardiovascular D. Gastrointestinal

B. Musculoskeletal

Semi-fowlers position is a position in which the head of the bed is: A. elevated at a 90-degree angle B. flat C. slightly lower than the foot of the bed D. elevated at a 30-degree angle

D. elevated at a 30-degree angle

When preparing to transfer a patient with a weak side, where should you place the chair?

On the patients stronger side

Lateral position with knee and leg drawn up can be used for what?

Procedures, such as giving an enema

Contracting stomach muscles protects

The back

Dorsiflexion

To bend or flex backward

Can family members help assist with ROM exercises?

Yes. The nurse just has to teach the family how to do the exercises and the underlying principles.

Complications of immobility include:

-muscle atrophy -contractures -pressure ulcers -reduced peristalsis -postural hypotension

The nurse is preparing to assist the patient to transfer from the bed to the chair. Which action demonstrates the proper use of body mechanics? 1. Stands by the chair and reaches out to guide the patient towards the chair 2. Stands by the side of the patient and pulls up on the stronger arm 3. Stands directly in front of the patient and places hands at the patients waist level 4. Stands to the side of patient and assists as the patient pivots

3. Stands directly in front of the patient and places hands at the patient's waist level

Which profession has the highest workers' compensation claims? A. Iron workers B. CNAs C. Farmers D. Nurses

B. CNAs

How often should you turn immobile patients?

Every 2 hours

Adduction

Movement of limb toward axis of body

Shearing results when

Skin surface is pulled one way and the underlying tissues do not move in t he same direction or at the same speed. Shearing results when tissue layers become torn and separated

A footboard is used to prevent

The complication of footdrop

A trochanter roll is used to prevent

the external rotation of the legs

The nurse is assigned to care for an 82-year old patient who weighs 252 lbs and has undergone a bilateral below-the-knee amputation. Which transfer method is the safest for the patient and the nurse? 1. Log-rolling 2. Using 2 nurses to lift 3. A mechanical lift with a sling 4. A gurney lift

3. A mechanical lift with a sling

Which medications are most likely to contribute to orthostatic hypotension? 1. Medications used to treat osteoporosis 2. Medications to prevent thrombophlebitis 3. Medication to reduce high blood pressure 4. Medications to treat arthritis pain

3. Medication to reduce high blood pressure

The nurse explains to the patient that the log-rolling technique will be used to help the patient change position. The patient asks why this is necessary. Which response is accurate? 1. "Log-rolling will help you keep your hips slightly flexed toward your chest." 2. "By having you dangle your legs at the bedside, you will be more comfortable." 3. "because of your injury, it is extremely important that the head of your bed remain up at all times." 4. "It is important to keep your neck and spine in straight alignment while we help you move onto your side."

4. "It is important to keep your neck and spine in straight alignment while we help you move onto your side."

What are nebulizers used for?

To open narrowed airways in pathological conditions, such as asthma

A bedboard improves

Vertebral alignment

What position helps facilitate respiratory efforts?

Raising the head of the bed and assisting patients to sit upright or even to lean slightly forward over an overbed table

Which techniques are most appropriate for the nurse to use to prevent self-injury when providing patient care? (select all that apply) 1. Flex knees slightly 2. Stand with feet together 3. Keep head erect and chest up 4. Push, pull, or slide heavy objects 5. Lift with the arms

1, 3, 4

What are types of medical equipment that are used to lift patients?

-hydraulic lift -roller board -gurney lift

Symptoms of acute compartment syndrome

-pain within the muscle, especially when stretched - a full or tight feeling within the muscle -tingling, burning, or a feeling of pins and needles in the affected area -Numbness and paralysis are late sights and may be indicative of permanent damage

What special problems should be considered when transferring an immobile patient?

-patient may be weak/have vertigo -orthostatic hypotension

When lifting and moving a patient up in bed, a lift sheet may be used. Where is the best place for a lift sheet under the patient? 1. Between the upper back and the thighs 2. Between the head and buttocks 3. Between the waist knees 4. Between the waist and ankles

1. Between the upper back and the thighs

Which position would be most comfortable for the patient and provide the best access for the nurse to insert a rectal suppository? 1. Sims 2. Lithotomy 3. Trendelenberg 4. Orthopneic

1. Sims

In which position is the patient lying face/chest down? 1. Supine 2. Lateral 3. Prone 4. Fowler's

3. Prone

Pronation

Kind of rotation that allows palm of hand to turn downward

For an older female who is at risk for osteoporosis, which associated complication can be minimized by participating in a regular exercise program as prescribed by the health care provider? 1. Bone loss that results in fractures 2. Immobility secondary to joint degeneration 3. Tissue ischemia and pressure ulcers 4. Thrombophlebitis secondary to blood clots

1. Bone loss that results in fractures Patients who are at risk for osteoporosis should be encouraged to exercise. This strengthens bones and reduces the risk for fractures. The other complications are more related to mobility

What is a major benefit of active ROM procedures? (select all that apply) 1. Preventing contractures 2. Preventing the patient from getting arthritis 3. Maintaining joint movement and mobility 4. Preventing atrophy of muscle near the joints 5. Increasing the patient's self esteem and motivation

1, 3, 4, 5,

It is the patient's first night after an abdominal hysterectomy. She has not voided for 9 hours, and the nurse is to insert a 16Fr. Foley catheter into her bladder. What patient position best allows insertion of the catheter? 1. Dorsal recumbent 2. Lithotomy 3. Sims 4. Prone

1. Dorsal recumbent

The patient has a cast on the left lower leg. When should assessment be performed to prevent compartment syndrome? 1. Every 3-4 hours as ordered 2. At the beginning of the shift 3. When the patient reports pain 4. Immediately after cast application

1. Every 3-4 hours as ordered. Tissue damage can occur within 4 hours, so the minimum assessment should be done every 4 hours. Assessment at the beginning of the shift is appropriate to establish baseline information, but once per shift is not adequate. Pain is a later sign; thus early detection is essential. Assessment immediately after cast application is to assess comfort and tolerance of procedure (Note: compartment syndrome can occur without a cast; for example, crush injuries can cause swelling within the fascial compartments.)

The nurse is working with a patient who has poor balance to move from the bed to the chair. What is included in the correct technique for assisting the patient to stand and pivot the chair? 1. Keep the knees slightly bent 2. Maintain a narrow base with the feet 3. Keep the stomach muscles loose 4. Stand arm's length from he patient

1. Keep the knees slightly bent

The patient accidentally knocks the emesis basin to the floor. When picking up the emesis basin, which movement demonstrates proper body mechanics by the nurse? 1. The nurse lowers the body by flexing the knees and bending the hips 2. The nurse bends from the waist and hips 3. The nurse flexes the knees and bends at the waist 4. The nurse keeps the legs straight and flexes at the waist

1. The nurse lowers the body by flexing the knees and bending the hips

What is a necessary safety precaution when helping a patient who has an unsteady gait to ambulate? (select all that apply) 1. Have family members present 2. Have patient wear well-fitting nonskid shoes or slippers 3. Have at least 2 people present to assist the patient 4. Be sure no pain medication was given for at least 3 hours before ambulation 5. Use a gait belt when assisting the patient to stand and to ambulate

2, 3, 5,

A 56-year-old patient had an open cholecystectomy. The nurse is going to assist the patient with dangling on the side of the bed before ambulation. After sitting him on the edge of the bed, which nursing intervention should the nurse perform before proceeding with the ambulation? 1. Measurement of his temperature 2. Assessment of his pulse and respirations 3. Performance of an oximetry check 4. Removal of antiembolism stockings

2. Assessment of his pulse and respirations

What is important consideration for an older patient who is using a continuous passive motion (CPM) machine after knee arthroplasty? 1. CPM is a potential fire hazard, so care must be taken to avoid flammable materials. 2. CPM creates a risk for skin impairment so pressure points must be frequently assessed 3. CPM is preferred for home-bound seniors because it is easy to use 4. Many older patients prefer CPM because it is less strenuous than physical therapy

2. CPM creates a risk for skin impairment so pressure points must be frequently assessed

An 82-year-old patient has had a cerebrovascular accident that affects her right side. The nurse repositions the patient to her left side, placing a pillow between her legs and another to her back. What is the primary purpose of this intervention? 1. Maintaining the patient's comfort 2. Ensuring the patient's proper body alignment 3. Keeping the patient in the desired position for at least 2 hours 4. Preventing the patient from development of contractures

2. Ensuring the patients proper body alignment

The student nurse demonstrated principles of good body mechanics with which activity? 1. Keeping the knees in a locked position 2. Maintaining a wide base of support and bending at the knees 3. Bending at the waist to maintain one's balance 4. Holding objects away from the body for improved leverage

2. Maintaining a wide base of support and bending at the knees

Which patient behavior should be corrected to reduce the risk of thrombophlebitis? 1. Patient gets out of bed and forgets to put on slippers 2. Patient sits in a chair and crosses legs while reading a book 3. Patient forgets to rise slowly when getting out of bed 4. Patient sits in a slouched position on a soft couch

2. Patient sits in a chair and crosses legs while reading a book.

Which patient has a contracture? 1. Patient has abnormal extension of a finger joint 2. Patient's wrist is abnormally flexed and joint is fixed 3. Patient's knee is hyperextended 4. Patient has abnormal lateral movements of ankle joint

2. Patient's wrist is abnormally flexed and joint is fixed

The patient has had a surgical procedure and is getting up to ambulate for the first time. While ambulating down the hallway, the patient says "I'm going to faint". What should the nurse do first? 1. Call out for someone to obtain a wheelchair 2. Pull the patient close and lower him 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. Pull the patient close and lower him gently to the floor

An older adult has been lying in the supine position for 3 hours and tells the nurse that she is too uncomfortable to move right now. What is the best response by the nurse? 1. The nurse should express concern that she is uncomfortable and promise to come back later. 2. The nurse should assess the patient's need for pain medication before helping her change position 3. The nurse should explain to the patient that if she does not move now, she will develop pneumonia 4. The nurse should find another nurse to help move the patient to the lateral position immediately

2. The nurse should assess the patient's need for pain medication before helping her change position

A 72-year-old patient with a stroke slid to the foot of the bed. With use of proper body mechanics, the nurse maintains a wide base of support and faces the patient in the direction of movement. What do these actions allow the nurse to do? 1. Use back muscles 2. Use large muscles across the scapula 3. Exert less physical effort 4.Use the gluteal muscles

3. Exert less physical effort

The patient will be immobilized for an extended period due to extensive injuries. Which intervention will the nurse use to prevent respiratory complications? 1. Suction the airway every hour 2. Change the patient's position every 4-8 hours 3. Use oxygen and nebulizer treatments regularly 4. Encourage deep breathing and coughing every hour

4. Encouraging deep breathing and coughing every hour.

When using a lift sheet to assist in moving a patient up in bed, what should the nurse ask the patient to do? 1. Bend the knees to assist in moving 2. keep the hands at the sides 3. Raise the arms above the head 4. Maintain a straight body position

4. Maintain a straight body position

The nurse is assigned to care for a 64-year-old patient who was admitted for exacerbation of chronic obstructive pulmonary disease and pneumonia. He has dyspnea and is unable to rest in a supine position. The nurse elevated the head of the bed to 90 degreed, places a pillow on the overhead table, and assists the patient to lean forward, placing his head on the pillow. What position should the nurse document the patient as being in? 1. Semi-fowlers 2. Dorsal 3. Sims 4. Orthopneic

4. Orthopneic

A nurse walks into a patients room and notices that the patient is having trouble breathing. Which position will the nurse immediately use to help relieve the patients respiratory distress? 1. Lower the head of the bed and place the patient in a supine anatomical position. 2. Position the patient on the side with the knee and thigh drawn up towards chest. 3. Lower the patient's head and place the body and legs on a slightly inclined plane. 4. Raise the head of the bed to 45-60 degrees and with the head in an anatomical position.

4. Raise the head of the bed to 45-60 degrees and with the head in an anatomical position.

A patient has been immobilized for 5 days because of extensive abdominal surgery. When this patient is helped out of bed for the first time, which nurses diagnosis related to safety applies to this patient? 1. Pain 2. Impaired skin integrity 3. Altered tissue perfusion 4. Risk for activity intolerance

4. Risk for activity intolerance

The term supine indicated a position in which the patient is lying on the: A. back B. side C. stomach D. side with knees flexed

A. back

The nurse must assess neurovascular function, also called CMS assessment. CMS stands for A. constant movement and sensation B. contained movement of systems C. circulation, movement, and sensation D. circulation, movement, and saturation

C. circulation, movement, and sensation

Before assisting a patient to ambulate to the bathroom, the nurse should first assess: A. the patient's footwear B. the bed alarm has been disarmed C. the patient's ability to assist with ambulation D. that assistive devices are within the patient's reach

C. the patient's ability to assist with ambulation

What will sitting in a slouched position do?

Cause muscle fatigue and bad posture increases back strain

What position is appropriate for patients in shock?

Laying supine. (Trendelenburg or head downwards with body and legs elevated was also historically used for shock, but is used less frequently now)

Abduction

Movement of limb away from body

What is the lithotomy position?

The patient lies supine with knees bent and hips and thighs are abducted. In order to easily access the rectum in this position, the patients feet have to be in stirrups on a gynecology table or hips have to be placed on the flat side of a bedpan if the patient is in bed

Circumduction

movement in a particular pattern