NUR 102 Exam 1 Review: Mobility & Positioning & Body Mechanics, Self-Care and Hygiene

Sims position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back

Anaerobic exercise

occurs when the muscle cannot extract enough oxygen from the blood, and anaerobic pathways provide additional energy for a short time.

Four point crutch walking

one crutch, opposite foot, other crutch, remaining foot

When assisting a client with ambulation using an assistive device such as parallel bars or a walking belt, what should the nurse observe the client for?

pallor, weakness, or dizziness

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate?

placing a small towel under the neck

functional braces

provide stability for an unstable joint.

assessing neurologic integrity

reflexes

aerobic exercise

requires oxygen to use the energy provided by the metabolic activities of the skeletal muscles.

plantar wart

round or irregular area that is flattened by pressure and is surrounded by cornified epithelium.

A nurse is providing postoperative care for a client who is immobilized, due to rod fixation. The nurse would place the client in which position?

semi-fowlers'

A nurse is preparing to provide oral care to a client who is unconscious. The nurse would place the client in which position?

side-lying

disuse syndrome

signs and symptoms that result from inactivity, -the consequences of inactivity - Weak muscle strength and unsteady gait

Fowler's position

sitting position

isometric exercise

static exercise by which the client tenses a muscle, holding it stationary while maintaining the tension.

Semi-Fowler's Position

the head of the bed is raised 30 degrees; or the head of the bed is raised 30 degrees and the knee portion is raised 15 degrees

A nurse is caring for an inactive client and assisting the client in performing range-of-motion (ROM) exercises. What care should the nurse take when performing range-of-motion exercises?

Move each joint until there is resistance but no pain.

Rehabilitative braces

allow protected motion of an injured joint that has been treated operatively

bunion

an inflammation and thickening of bursa at the great toe joint which causes an enlargement of the joint and a displacement of the toe.

Keratolytic shampoo

applied to the client's hair to manage dandruff.

Elevation of the stump, post amputation can result in what?

contractures

contractures

- due to inactivity of the musculoskeletal system -a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints.

A nurse is preparing to make an occupied bed for a client who is unable to get out of bed. What would be necessary for the nurse to do?

-The nurse should raise the bed to a comfortable height to prevent back strain - gather all necessary linens before beginning to conserve time and energy -put all soiled linens into a linen bag, not the floor. -The nurse makes one side of the bed as completely as possible before moving to the other side. -Bed linens should be handled carefully without shaking them to maintain asepsis.

sitz bath

-a warm soak of the perineal area to clean perineal wounds and reduce inflammation and pain - usually lasts 20 minutes. The temperature of the water should be maintained at 105°F (40.5°C) to 110°F (43.3°C) with care taken not to burn the client.

Activity Intolerance

-physical inability to withstand activity -shortness of breath after a small amount activity would be of most concern

The nurse is caring for a client who has generalized weakness and requires crutches to ambulate. Which crutch-walking gait will the nurse teach?

4-point crutches

A nurse is assessing a client after knee surgery in a health care facility. Which intervention should the nurse follow to avoid complications associated with disuse syndrome?

Encourage active exercise with a bed trapeze

A nurse is logrolling a client who has a spinal injury. Which nursing action follows the recommended guidelines for this procedure?

Enlist the assistance of two or three other nurses to perform the procedure.

Right lateral recumbent position

Patient lying on their right side

what position is best for administering an enema

Sims'

boric acid

formally found in eye drops and eyewash, not appropriate for eye cleansing, toxic when absorbed.

The nurse is providing pin site care for a client who is in traction. Which assessment finding requires the nurse to intervene?

White blood cell count of 13,000/mL.

three-point non-weight-bearing

a client with one amputated, injured, or disabled extremity

traction

a pull to the arm or leg muscles to bring a bone back into place when it is dislocated or fractured

assessing muscles

bilateral mass, tone, and strength

seborrheic keratoses

brown patches of skin, benign, wart-like tumors; more common on elderly skin

When should the nurse observe gait?

clients who ambulate with crutches, walkers, or canes, to ensure they are using correctly

corn

cone-shaped lesion, which is usually found on the fourth or fifth toe over a toe joint

The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change?

decrease in flexibility

isotonic excercise

dynamic form of exercise with constant muscle tension, muscle contraction, and active movement.

spica cast

encircles one or both legs, but when applied to a lower extremity, the cast is trimmed in the anal and genital areas to allow for the elimination of urine and stool.

kyphosis

excessive outward curvature of the spine, causing hunching of the back.

applying make up demonstrates?

fine motor skills

callus

flattened thickening of epidermis which is often found on the bottom or side of the foot, over a bony prominence.

assessing joints

flexion and range of motion

supine position

lying on back, facing upward

ball and socket joint

hip and shoulder joints

The nurse is positioning a client with limited mobility who is lying down to go to sleep. Which positioning technique is most appropriate?

horizontal position with knees slightly flexed and head centered between the shoulders

What is one serious effect of immobility on the cardiovascular system?

increased cardiac workload

pediculosis capitis

infestation of the hair and scalp with head lice, inflammed bites along the hairline

isotonic exercise

involves contracting and relaxing your muscles through the full range of a joint's motion ie marathon running

hinge joint

knee and elbow

left lateral recumbent position

laying on left side

When a client has a spinal injury or is recovering from neck, back, or spinal surgery, it is often necessary to keep the body in straight alignment when turning the client.

logrolling

prone position

lying on abdomen, facing downward

slight trendelenburg

lying on back with body tilted at a slight incline so that the head is lower than the feet

Reverse Trendlenburg's position

lying on back with body tilted so that the head is higher than the feet

Trendlenburg Position

lying on back with body tilted so that the head is lower than the feet

lithotomy position

lying on back with legs raised and feet in stirrups

enema

the placement of a solution into the rectum and colon to empty the lower intestine through bowel activity

saddle joint

thumb

Why is it important for the nurse to soak the client's hands in warm water prior to nail care?

to soften the keratin and loosen trapped debris.

prophylactic braces

used to prevent or reduce the severity of a joint injury

condyloid joint

wrist and knuckles