MOBILITY
A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client? "Dizziness when you change position can occur when fluid volume in the body is decreased." "Dizziness can occur due to changes in the hospital environment." "Dizziness can occur when baroreceptors overreact to the changes in BP." "Dizziness is caused by very low blood pressure when you lie down."
"Dizziness when you change position can occur when fluid volume in the body is decreased." Explanation: Dehydration is a cause for orthostatic hypotension, which causes a temporary drop in BP when the client rises from a reclining position. Dizziness is not associated with environmental changes. Dizziness or changes in orthostatic BP occurs when baroreceptors do not respond quickly enough to restore adequate circulation to the brain. Dizziness may be caused by low blood pressure. However, the client is dizzy with ambulation not when lying down.
x The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response? "To preserve the client's functional ability to grasp and pick up objects." "To prevent foot drop." "To help client to turn independently." "To prevent the legs from rotating outward."
"To preserve the client's functional ability to grasp and pick up objects." Explanation: Trochanter rolls prevent the legs from rotating outward. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop. Side rails help a weak client turn independently and protect the client from falling out of bed.
x A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly." "Your elbows will be slightly bent when you are using your crutches." "When your crutches fit right, most of your body weight will be supported by your armpits." "We will have the unlicensed assistive personnel watch you while you walk around the unit the first time."
"Your elbows will be slightly bent when you are using your crutches." Explanation: When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel. The client should stop ambulating and sit down, if fatigued.
The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? Adduction Abduction Circumduction Extension
Adduction Explanation: Adduction is a lateral movement of a body part toward the midline of the body. An example of adduction is when a person's arm is moved from an outstretched position to a position alongside the body. Abduction is a lateral movement of a body part away from the midline of the body. An example of abduction is when a person's arm is moved away from the body. Circumduction is turning in a circular motion. This motion combines abduction, adduction, extension, and flexion. An example of this movement is the circling of the arm at the shoulder, as in bowling or a serve in tennis. Extension is the state of being in a straight line. An example of extension is when a person's cervical spine is extended, the head is held straight on the spinal column.
The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? Assess the client's response to the ambulation. Inform the client when ambulation is scheduled next. Discuss the client's feelings about the illness. Document the client's ambulation.
Assess the client's response to the ambulation. Explanation: After a nurse has performed an intervention, the next step is to evaluate the effectiveness of the intervention. The nurse should assess the client's response to the ambulation. Informing the client when ambulation is scheduled next, discussing the client's feelings, and documenting the ambulation are important, but not until after the client has been reassessed.
The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse documents the presence of what health problem? Ataxia Tremors Chorea Athetosis
Ataxia Explanation: Ataxia refers to a lack of muscle coordination. Tremors are rhythmic, repetitive movements. Chorea is spontaneous, brief, involuntary muscle twitching of the limbs or facial muscles. Athetosis refers to movement characterized by slow, irregular, twisting motions.
xxx Applying the principles of growth and development, place the following body parts in the correct sequence as they would develop from first to last. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 5Feet 1Brain 2Heart 3Intestine 4Legs
Brain Heart Intestine Legs Feet Explanation: Growth and development follow regular and predictable trends. Cephalocaudal (proceeding from head to tail) development is the first trend, with the head and brain developing first, followed by the trunk, legs, and feet.
x A nurse is caring for an older adult client who fell and sustained a hip fracture. Which intervention needs to be included in the nursing care plan? Select all that apply. Cough and deep breathe every 2 hours. Avoid massaging over bony prominences. Turn the client every 4 hours. Auscultate breath sounds every 1-2 hours. Monitor daily weights.
Cough and deep breathe every 2 hours. Avoid massaging over bony prominences. Auscultate breath sounds every 1-2 hours. An older adult is more likely to develop complications after illness occurs. An older adult with a hip fracture is at high risk for pneumonia and skin breakdown because of immobility, a decreased ability to expel pulmonary secretions, and thinner, more fragile skin. Coughing, deep breathing, and auscultating breath sounds are interventions used in preventing and detecting impaired gas exchange (pneumonia). Maintaining skin integrity can be achieved by the avoidance of massage over bony prominences. Repositioning the client every 4 hours is not frequent enough; it should be done every 2 hours. Monitoring daily weights is not an intervention useful in pneumonia or skin breakdown.
While assessing a client's temporal mandibular joint (TMJ), the nurse feels grating and hears noise when the client flexes and extends their knee. The nurse should document what finding? Inflammation Arthritis Crepitus or Fremitus
Crepitus or Explanation: Problems with the temporomandibular joint include pain or a grating feeling called crepitus. Inflammation does not cause this palpable assessment result. Arthritis is a diagnosis, not an assessment finding. Fremitus is vibration on the chest wall.
The nurse is caring for a client who is postoperative 3 days from coronary artery bypass graft. The client has a prescription to ambulate. What is the best action by the nurse? Allow the client to slowly ambulate independently. Instruct the family to assist the client with ambulation. Discuss with the client the need for assistance during ambulation. Obtain a prescription for physical therapy consult to ambulate the client.
Discuss with the client the need for assistance during ambulation. Explanation: For members of some cultures, providing care and performing nursing interventions can intrude into personal space. The nurse should discuss with the client the need for assistance during ambulation and prepare the client for potential closeness. The client may ambulate independently, but the nurse should still assist. Having the family or physical therapy ambulate the client does not address the issue related to culture and nursing interventions.
A client has suffered an amputation of the right leg due to a motor vehicle accident. What would be an example of a maladaptive response? Expressing they will never be a whole person again Asking the nurse about a prosthetic device Learning to ambulate with a walker or a cane Talking to the family about the motor vehicle accident
Expressing they will never be a whole person again Explanation: A maladaptive response is one in which the self concept is disturbed and coping is not evident. The client stating that they will never be a whole person again is an example of this. Asking about a prosthetic device, learning to ambulate with a walker and talking to the family about the accident are all examples of adaptive responses.
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? supine prone Sims' Fowler's
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. The other position choices do not promote oxygenation.
A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records? Ineffective Movement related to arthritis Impaired Movements due to pain Impaired Physical Mobility related to pain Ineffective Physical Mobility due to pain
Impaired Physical Mobility related to pain Explanation: "Impaired Physical Mobility related to pain" is the correct nursing diagnosis because it consists of an accurate descriptor, diagnostic label, and related factor. "Ineffective Movement related to arthritis" is an incorrect entry because the descriptor is incorrect and the diagnostic label is not approved. "Impaired Movements due to pain" is an inaccurate entry because the descriptor is inaccurate and the related factor is not written using approved words. "Ineffective Physical Mobility due to pain" has an erroneous diagnostic label and the related factors are written incorrectly.
x A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client? Position the client in bed with pillows placed under his knees to hasten venous return. Keep the client from ambulating until the day after surgery. Implement leg exercises and turn the client in bed every 2 hours. Keep the client cool and uncovered to prevent elevated temperature.
Implement leg exercises and turn the client in bed every 2 hours. Explanation: Ambulation and leg exercises increase circulation, which prevents cardiovascular complications. The nurse should provide covers, forced warm air, or other warming devices/techniques as necessary to prevent shivering and hypothermia caused by the surgical procedure, the procedure's length, anesthetic agents, a cool environment, the client's age, or the use of cool irrigating/infusion fluids. Pillows placed under the knees can cause venous pooling, leading to thrombophlebitis.
The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse? Contact the health care provider for a restraint order. Administer the client's sedative as ordered. Put up all four side rails on the bed. Initiate use of a bed alarm.
Initiate use of a bed alarm. Explanation: To prevent a fall, the nurse should attempt to prevent the confused client from getting out of bed by himself by using the least restrictive action first. In this case, it would be to initiate the use of a bed alarm. Putting up all four side rails and use of a sedative are considered forms of restraints, and restraints should be used only as a last resort when the client is in danger of harming himself or others. Contacting the health care provider for a restraint order or sedative is appropriate if the least restrictive measures do not work.
The nurse is preparing to educate a client with restless legs syndrome who reports sleeplessness and prefers to use nonpharmacologic methods to promote sleep. Which recommendation will the nurse include in the teaching? Massage the legs before bed. Have a glass of wine before bed. Sleep in a warm environment. Go to bed whenever you feel tired.
Massage the legs before bed. Explanation: Massaging the legs is a recommended technique for improving discomfort from restless legs syndrome. It is recommended to avoid alcohol, sleep in a cool environment, and set a regular sleep routine.
The health care provider has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? Medicate the client and wait to ambulate later. Ambulate the client and medicate later. Emphasize to the client the importance of following the treatment plan. Explain to the client the benefits of ambulation.
Medicate the client and wait to ambulate later. Explanation: It is most appropriate to manage the client's pain first. The client will be able to ambulate more easily and it is not necessary to cause the client further pain. Ambulating first considers the needs of the nurse, not the client. The client has not indicated misunderstanding of benefits or the importance of ambulation.
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? Make sure the bed brakes are unlocked. Put the chair at the foot of the bed. Place the bed in the highest position. Raise the head of the bed to a sitting position.
Raise the head of the bed to a sitting position. Explanation: When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair.
The nurse assists a postoperative client with ambulation. The nurse recognizes that assisting the client when performing this skill meets which of Maslow's basic human needs? Safety and security Self-esteem Love and belonging Self-actualization
Safety and security Explanation: Nurses carry out a wide variety of activities to meet clients' physical safety needs, such as moving and ambulating clients. Assisting the client to ambulate ensures that the client will not experience a fall. From the bottom of the hierarchy upwards, the needs are: physiological, safety, love and belonging, esteem and self-actualization. The third stage in Maslow's hierarchy of needs is the social stage (also known as the love and belonging stage), which includes interpersonal relationships. Human behavior is driven by needs, one of which is the need for a sense of personal importance, value or self-esteem. Self-actualization represents growth of an individual toward fulfillment of the highest needs; those for meaning in life, in particular.
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 the legs to the back muscles. Rock the client back and forth to raise the client up in bed. Turn the client from side to side while pushing upward. Shift their weight back and forth, from back leg to front leg.
Shift their weight back and forth, from back leg to front leg. Explanation: The nurses would use a rocking motion to counteract the client's weight. The nurses would shift their weight back and forth, from back leg to front leg, count to three, and then move the client up toward the head of the bed. Rocking the client or turning the client from side to side is not used to move a client.
A client is admitted to the facility after fracturing a hip. The client has undergone surgery to repair the fracture and is receiving services to promote healing of the surgical site and regain mobility. Which discussion should the nurse have with a member of the interdisciplinary team member to promote the goal of regaining mobility? Speak with the physical therapist about exercises to strengthen muscles. Discuss oxygen administration with the respiratory therapist. Talk with the occupational therapist about providing assistance with activities of daily living. Discuss transfer to a rehabilitation facility with the social worker.
Speak with the physical therapist about exercises to strengthen muscles. Explanation: The nurse should discuss the goal of regaining mobility with a physical therapist. A physical therapist assists with restoring mobility, strengthens muscle groups, and teaches ambulation with new devices. Respiratory therapists are trained in techniques that improve pulmonary function and oxygenation. Occupational therapists evaluate functional level and teach activities to promote self-care in activities of daily living. Speech therapists deal with swallowing difficulties and help clients speak more clearly.
The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? Sedate her with sleeping pills and leave the restraints on. Take the restraints off, stay with her, and talk gently to her. Leave the restraints on and talk with her, explaining that she must calm down. Talk with the client's family about taking her home because she is out of control.
Take the restraints off, stay with her, and talk gently to her. Explanation: Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death. The best action in this situation is for the nurse to remove the restraint, stay with the client and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leaving the restraints on the client to talk to her is going to cause further agitation and bruising of her wrists. The client's condition—not confusion and agitation—dictates when the client is discharged.
A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action? Tell the UAP that the RN will assist the UAP with the client's ambulation. Tell the UAP that a different UAP should ambulate the client. Tell the UAP not to ambulate the client at this time. Tell the UAP to ask the client whether the client is comfortable with the UAP assisting ambulation.
Tell the UAP that the RN will assist the UAP with the client's ambulation. Explanation: The client's safety is always the nurse's primary concern. If the nurse believes that the UAP is unable to safely ambulate the client at this time, the nurse could offer assistance. By assisting the UAP, the nurse ensures the client's safety while still allowing the new UAP to learn. Having a different UAP ambulate the client or instructing the UAP not to ambulate the client does not assist the UAP in learning. Asking the client whether the client feels comfortable having the UAP ambulate the client is inappropriate.
x The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? The client calls for assistance to get out of bed. The client is free of falls. The client is taught safety precautions. The client verbalizes risks for injury.
The client is free of falls. Explanation: Interventions for risk diagnoses are directed at prevention. The most appropriate way to evaluate the success of the interventions is to determine if the risk was prevented. The best evaluation criteria would be if the client remained free of falls. The client calling for assistance might prevent a fall, but does not signify that a fall will not occur. Teaching clients safety precautions and having the client verbalize risk for injuries is important but does not necessarily mean that an injury is prevented.
x The nurse assesses a 68-year-old client being treated for heart failure who reports dyspnea with mild activity, sitting at a desk most of the day while working, and preferring an orthopneic position. Recognizing that the client is at risk for disuse syndrome, which intervention(s) will the nurse initiate? Select all that apply. Instruct the client to sit upright to prevent dyspnea. Offer activity options and their benefits that match the client's interests and address the client's needs. Collaborate with physical, occupational, and recreational therapists to implement an individually tailored exercise program. Encourage active range-of-motion exercises. Encourage the client to elevate legs instead of standing up at times in the day.
The consequences of inactivity are referred to as disuse syndrome and, because the client is at risk for the condition, the nurse will teach the client to initiate a high Fowler position when dyspnea occurs. This will help alleviate the dyspnea and allow the client better oxygenation and energy to increase activity level. The nurse also offers activity options and their benefits to the client that match the client's interest and address the client's needs, so the client can understand the reasons for the activities and make good choices. The nurse collaborates with physical, occupational, and recreational therapists to implement an individually tailored exercise program, so that each professional can contribute from his or her area of expertise and the different types of activities that can motivate the client and enhance adherence to the program. Whenever possible, it is important to encourage the client to stand up from the sitting position even for brief periods throughout the day, as repositioning can improve circulation that prevents disuse syndrome. Although elevating the legs is an effective way to prevent edema of the lower legs, it is not as effective as standing to prevent muscle atrophy associated with disuse.
A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response? "To preserve your functional ability to grasp and pick up objects." "To prevent foot drop." "To avoid contractures." "To prevent your legs from rotating outward."
To prevent your legs from rotating outward." Explanation: Trochanter rolls prevent the client's legs from rotating outward. The other statements do not describe trochanter rolls. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop.
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 can be performed by one experienced nurse. Logrolling will maintain straight alignment when the client is sitting in a chair. It is acceptable to twist the client's head, but not the hips, while logrolling.
Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Explanation: Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight alignment when the client is being turned. The nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement. The nurse should avoid twisting the client's head, spine, shoulders, knees, or hips while logrolling. A chair is not used with logrolling.
Which action(s) is appropriate to safely bathe an older adult client? Select all that apply. Use a tub/shower seat if balance problems are present. Use vigorous rubbing motions when drying the skin to increase circulation. Carefully monitor water temperature. Provide the client a long-handled shower brush or attachment if experiencing limited mobility. Pour scented bath oils into the tub to improve dryness of the skin and decrease odors.
Use a tub/shower seat if balance problems are present. Carefully monitor water temperature. Provide the client a long-handled shower brush or attachment if experiencing limited mobility. Several considerations are necessary when planning care for the older adult client, including reducing the risk of falls by using nonskid mats and using a tub/shower seat. Also, care is taken to promote independence by providing the client with long-handled shower brushes or attachments if there is limited mobility. Skin care measures are important and the nurse should be cautious to check the temperature of the bath water. The nurse should use soap sparingly because it is drying to the skin, and avoid using bath oils in the tub because they increase the risk of slipping. The nurse should avoid using perfumed soaps and lotions, as well as avoid rubbing the skin when drying. The nurse should use gentle patting motions to maintain skin integrity.
Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent? Verb (action) Subject Conditions Performance criteria
Verb (action) Explanation: The action is one of the essential pieces of an outcome statement. The verb "ambulate" in this case represents the action that the client will perform and that the nurse will monitor and evaluate. The subject refers to the one who performs the action, which is always the client. The conditions are the particular circumstances in or by which the client is to achieve the outcome, such as "with the assistance of a cane" and "during a physical therapy session." The performance criteria are the expected client behaviors or other manifestations described in observable, measurable terms, such as "without incident."
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) a single-ended cane with a half-circle handle a single-ended cane with a straight handle axillary crutches
a cane with four prongs on the end (quad cane) Explanation: 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. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold but are not recommended for clients with poor balance. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.
The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? activity and rest health promotion nutrition self-perception
activity and rest Explanation: A nursing diagnosis should be based on the collection of data from the client and should contain a precise statement related to the client's health problems. The question stem specifies that the nursing diagnosis should be based on the client's musculoskeletal issues; therefore, the domain of activity and rest would be most pertinent for a nursing diagnosis. The domains of health promotion, nutrition, and self-perception are less relevant than activity and rest to a client with a musculoskeletal injury.
A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate? bed trapeze foot board bed cradle trochanter roll
bed trapeze Explanation: A trapeze bar is a handgrip suspended from a frame near the head of the bed. A client can grasp the bar with one or both hands and raise the trunk from the bed. The trapeze makes moving and turning considerably easier for many clients and facilitates transfers into and out of bed. A foot board helps reduce the risk of foot drop. A bed cradle is usually a metal frame that supports the bed linens away from the client while providing privacy and warmth. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward.
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed? near the client's hip, with legs together near the client's hip, with legs shoulder width apart and one foot near the head of the bed to the dominant side of the client, with legs together and one foot near the head of the bed to the nondominant side of the client, with legs together and one foot near the head of the bed.
near the client's hip, with legs shoulder width apart and one foot near the head of the bed Explanation: When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight to assist the client to a sitting position safely. The dominant or nondominant side is not relevant when moving a client with equal strength but would be helpful with a client who has had a stroke.
A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse? standing at the top of the bed and having a colleague stand at the bottom of the bed placing the bed in its lowest position to reduce the client's risk for falls positioning a friction-reducing sheet under the client to facilitate movement using back muscles to gently and gradually pull the client to the side
positioning a friction-reducing sheet under the client to facilitate movement Explanation: After placing the bed in a comfortable working position (usually elbow height of the caregiver), position a nurse on either side of the bed, place a friction-reducing sheet under the client, and use the leg muscles to pull the client to the side.
x The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? increase in the movement of secretions in the respiratory tract increase in circulating fibrinolysin predisposition to renal calculi increased metabolic rate
predisposition to renal calculi Explanation: 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 client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.
A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor installing hardwood floors
removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor Removing clutter from the floor, placing nightlights in the bathroom and hallways, and moving the bedroom to the ground floor will reduce the risk of falling and encourage the client to increase his mobility. Installing hardwood floors may induce falls due to the smooth surface; wall-to-wall carpeting would provide traction.
The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: uses the sides of the walker to rise from a chair. places the walker far in front when walking. steps into the walker when walking. leans over the walker when walking.
steps into the walker when walking. Explanation: A walker is mechanical aid that enhances the client's balance and ability to bear weight. Education is usually done by physical medicine or physical therapy, but the nurse should continue to assess the client's ability to use the walker properly. The client should step into the walker when walking rather than walking behind it. When the client is rising from a seated position, the arms of the chair, not the walker, should be used for support. The client should be cautioned to avoid pushing the walker out too far in front. Also, the client should avoid leaning over the walker but should instead stay upright while moving.
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? under the client's head supporting the client's back in front of the client's abdomen under the client's feet
supporting the client's back Explanation: The nurse would place the pillow under the client's back to provide support and help maintain the proper position. A pillow can also be placed between the knees. More than one pillow under the client's head is not necessary. Placing a pillow in front of the client's abdomen would be helpful for a client who has undergone abdominal surgery. Placing a pillow under the client's feet is not helpful for the side lying position.
x A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? elevate the head of the bed 90 degrees use pillows to maintain a side-lying position as needed provide incontinent care every 4 hours as needed place a foot board on the bed
use pillows to maintain a side-lying position as needed Explanation: Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.
