Prep U Chapter 26

A nurse is assisting a client to ambulate at the health care facility using a walking belt. How does the walking belt assist the client when ambulating?

Allows the nurse to support the client

A client with a nursing diagnosis of Impaired Physical Mobility related to a new prosthetic limb has come for a follow-up appointment. Which does the nurse document as an outcome for this client?

Ambulate 10ft

The nurse is caring for a client who needs to use a tilt table to move from supine to standing. Which intervention will the nurse perform first?

Apply elastic stocking

A nurse is helping a client perform gluteal setting exercises. Place the steps of these exercises in the correct order. Use all options.

-Tighten (contract) the quadriceps muscles by flattening the backs of the knees into the mattress. -Check to see that the kneecaps move upward. -Hold the contracted position for a count of five. -Relax. -Repeat two to three times each hour.

The nurse is assessing a client's ability to walk with a new cane. What degree of the client's elbow flexion does the nurse assess as appropriate?

30

A client is practicing the use of a cane. While evaluating the client's technique, the nurse makes sure that the client's cane is at what distance from the side of the toes?

4 to 6 in (10 to 15 cm)

The nurse is assisting a client into the sitting from the supine position in bed. As the client comes into the sitting position the client states, "I feel a little dizzy." In response to this, what action will the nurse take first?

Asses the client's blood pressure in seated position.

A 91-year-old female client was admitted to the geriatric unit of the hospital with diagnoses of Hyponatremia, Dehydration, and Failure To Thrive. The care team is aware of the importance of early ambulation and has taken steps to facilitate this. How can the client be best prepared to begin ambulating?

Assist the client with the performance of isometric exercises.

A nurse is teaching a client how to perform quadriceps setting exercises. The nurse determines that the client is performing them correctly when the nurse notes which of the following?

Both of the client's kneecaps move upward.

The nurse is caring for a client who needs minimal support and assistance, but would benefit from an ambulatory aid to go from sitting to standing. Which device does the nurse recommend?

C-cane

A nurse checks that two fingers can be placed between the client's axilla and the axillary bar of crutches. This technique helps prevent which condition?

Crutch palsy

The nurse is caring for a client with impaired mobility who needs help to improve muscle tone and strength. What type of exercise will the nurse recommend for this client to begin the exercise regimen?

isometric

The nurse is teaching a client who has been on prolonged bed rest about using a walker. Which teaching will the nurse include?

Stand within the walker.

The nurse is conducting an assessment of a client who has been performing modified push-ups to build up upper arm strength. The client asks the nurse how often these exercises should be performed. Which response from the nurse is best?

three or four times per day

The nurse is caring for a client who sustained a foot fracture while playing football. Which crutch-walking gait will the nurse teach?

three-point non-weight-bearing

The nurse is caring for a client with a previous knee injury that is healing. Which crutch-walking gait will the nurse teach?

three-point partial weight-bearing

The nurse is preparing to use a tilt table with a client who recently had the pins and traction removed from the right leg. Which action should the nurse take while operating the tilt table?

tilt slowly at 15 to 30 degrees until in vertical position

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 nurse is instructing a postoperative client to dangle prior to changing position from supine to standing. The client states, "Why can I not just get up now?" How will the nurse respond?

"Dangling will help to normalize your blood pressure."

The nurse is visiting a client at home to assess the progress of the client's exercise program. Which is the best response if the client reports that the mattress is too soft to perform the upper arm strengthening exercises?

"Do you have a sturdy armchair available?!

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?"

The nurse is teaching a client who had a below-the-knee amputation about a temporary prosthetic limb. Which client statement requires further nursing teaching?

"I will tighten the belt when I go to sleep."

A tilt table has been ordered for a client who has been bedridden for several weeks. After teaching the client about this procedure, the nurse determines that the teaching was successful when the client states:

"I'Il be wearing elastic stockings so I don't faint."

Which teaching will the nurse include when educating a client with a below-the-knee amputation about stump socks?

"If stump socks get holes in them, purchase new ones."

The nurse is caring for an older adult client who has difficulty walking. The client states, "I hate that I can barely walk. I'm such a burden to my family." What is the appropriate nursing response?

"Let's talk about how mobility can increase your independence."

Before assisting a client from lying in the supine position to standing using an assistive device, the nurse applies elastic stockings on the client. The client asks why these are necessary. Which response from the nurse is accurate?

"The stockings help compress vein walls, preventing blood from pooling in extremities, which can cause fainting."

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."

A client's plan of care specifies the goal that the client perform quadriceps setting four times daily. The nurse has explained the rationale for this exercise to the client and is now teaching the client to perform the exercises safely and effectively. What instructions should the nurse provide to the client?

'Slowly alternate between tightening the muscles in your thighs and then relaxing them."

The nurse is providing instruction to a client on moving from a standing to sitting position using a cane Place the steps the client will take in the correct sequence. Use all options.

-Back up to the chair until the seat is against the back of the legs. -Rest the cane close by. -Grip the armrests with both hands. -Lower down onto the chair seat.

The nurse is providing care to a client with right-sided weakness due to a recent cerebrovascular accident. The nurse is preparing the client to use a cane as an assistive mobility device. Which action(s) will the nurse take to ensure the client can use the cane effectively? Select all that apply.

-Ensure all measurements are taken on the right side of the client's body. -Take an accurate measurement from the client's right wrist to the floor. -Instruct the client to avoid leaning forward or elevating the shoulders during measurement.

A nurse is assisting a client with dangling. Place the steps in the correct sequence. Use all options.

-Place the client in Fowler position for a few minutes. -Lower the height of the bed. -Provide a footstool if the client's feet do not reach the floor. -Fold back the top linen and provide the client with a robe and slippers. -Help the client pivot a quarter of a turn to swing the legs over the side and sit on the edge of the bed. -Stay with the client until the client no longer feels dizzy or light-headed.

A 60-year-old client who uses a walker to aid ambulation is being discharged from the health care facility. Which change should be made to the homes of older adults to increase safety? Select all that apply.

-Replace scatter rugs with secure mats. -Ensure that there are no electric cords in the passageway. -Ensure that all the rooms in the house are adequately lit. -Add railings and grab bars to the bathrooms and entrance.

An older adult has developed flexion of the spine. For which related complication will the nurse be alert?

Falls

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

The client's strength and type of disability are guides to the best possible crutch-walking gait or style of walking. The client is using each crutch and each leg separately. What would be the best description of this type of crutch-walking gait to include in the documentation in the electronic medical record?

Four-point gait

A client with a right lower limb prosthesis uses a cane for additional stability. Which behavior demonstrates to the nurse that the client is ambulating appropriately?

Holds cane in left hand

A client has been diagnosed with multiple sclerosis and will permanently require crutches. Which type of crutch would be most appropriate for this client?

Lofstrand

The nurse is caring for a client post-left hip surgery. What intervention should the nurse provide?

Maintain hip abduction

The nurse is fitting a client for forearm crutches. Which nursing action is appropriate?

Measure the forearm from 3 inches below the elbow to the wrist, and add the distance between the wrist and floor.

A nurse is ambulating a client who has had a cerebrovascular accident (CA). The client has paresis on the right side of the upper body. Where would the nurse stand to walk the client?

On the weak side

The nurse is assisting a client to use a double row of stationary bars as handrails to gain practice in ambulating. What is the name for the device the client is using?

Parallel bars

A client that is being ambulated in the hallway by the nurse reports dizziness and proceeds to begin falling. Which nursing action is appropriate?

Place nurse's foot to the side, and slide arm under client's axilla.

A client requires crutches but cannot bear any weight with the hands or wrists. What type of crutches would the nurse prepare to assist this client with?

Platform crutch

A nurse is educating an older adult client on how to use a walker. Which instructions to the client ensure accurate use of this device? Select all that apply.

Stand between the back legs of the walker. Keep arms relaxed at the side. Line up the top of the walker with the crease on the inside of your wrist.

The nurse is planning to teach a client about crutch-walking. Which is the priority nursing action?

Review the health care order

The nurse is planning to teach a client about crutch-walking. Which is the priority nursing action?

Review the health care provider's order.

A male client with a history of type 1 diabetes has had a below-the-knee (BK) amputation. The client states that he is eager to be fitted for his prosthesis and to resume activities of daily living. When assisting the client with his adjustment to using his prosthesis, the nurse should prioritize what nursing diagnosis?

Risk for impaired skin integrity

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.

A nurse is walking with a client, who stops walking and states, "I am suddenly feeling very lightheaded." What action would the nurse take next?

Slide an arm under the client's axilla and place the nurse's foot to the side.

A nurse is working with a client who is learning to use a walker. Place in the correct order the steps the nurse would advise the client to take in using this device.

Stand within the walker. © Hold on to the walker at the padded handgrips. • Pick up the walker and advance it 6 to 8 in (15 to 20 cm). © Take a step forward. Support the body weight on the handgrips when moving the weaker leg.

The nurse is teaching a client who has been on prolonged bed rest about using a walker. Which teaching will the nurse include?

Strand within the walker

The nurse is caring for a client with a below-the-knee amputation who has not yet been fitted for a prosthesis. Which crutch-walking gait will the nurse teach?

Swing-through

An older adult client with weakness on one side of the body needs to use a cane for walking. How should the nurse determine the correct height of the cane to be used by the client?

The cane's handle should be parallel with the hip.

A client is to begin ambulating with the use of a T-handle cane. The nurse determines that the cane is at the proper height based on which observation?

The handle is parallel with the client's hip.

A client is beginning to ambulate with crutches after surgery on his right leg. He is allowed to bear weight only on his left leg. The nurse would work with the client to use which gait?

Three-point

The nurse is providing client education on crutch-walking. Into which shape should the client place the feet and crutches to provide balance and support?

Triangle

The client's strength and type of disability are guides to the best possible crutch-walking gait or style of walking. The client is partially able to bear weight on both legs. What would be the best type of crutch-walking gait to recommend to the client?

Two point

The nurse is caring for an older adult client who had a stroke and has regained ambulatory function. As the client is being discharged to home, which safety education will the nurse provide regarding use of stairs?

Use a stair rail when going up or down.

The nurse is observing an unlicensed assistive personnel (UP) ambulate a client. Which UAP behavior requires nursing intervention?

Walks slightly ahead of the client to clear pathway

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)

The nurse is caring for a client with impaired physical mobility related to a hip replacement surgery. Which joint position of the operative hip will the nurse maintain?

abduction

The nurse is preparing to help a client ambulate after hip surgery. Which nursing action promotes client autonomy?

allowing client to select time of day to ambulate

The nurse is assessing a client for proper crutch size. The nurse would begin the measurement from which area?

anterior axillary fold

The nurse is preparing to assist the client from a supine to a standing position using a tilt table. What action by the nurse will prevent the client from fainting when using the table?

apply elastic stockings to both lower extremities

The nurse is caring for a client with postural hypotension. Which nursing intervention is appropriate?

asking the client to dangle before moving from a reclining position

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 caring for a client who has had a total knee replacement. Which nursing action would be most important postoperatively to prevent deep vein thrombosis for this client?

assisting the client with early ambulation

A nurse is caring for a client whose fractured leg is in a cast, Which ambulatory device could the nurse suggest for the client to use at the health care facility?

axillary crutch

A nurse is caring for a client whose fractured leg is in a cast. Which ambulatory device could the nurse suggest for the client to use at the health care facility?

axillary crutch

A client with an above-the knee amputation has been prescribed three-point non-weight bearing crutch-walking. Which teaching regarding gait pattern will the nurse provide?

both crutches move forward, followed by the weight-bearing leg

The nurse observes a client picking up the walker and packing it when rushing to the bathroom. Which is the best nursing response?

change client to a walker with wheels

The nurse is meeting a new client who appears to be having difficulty with the use of a cane. The client remarks, "My grandpa made and used this cane, so it should work for me." Which action will be most important for the nurse?

check the cane's size

Which client would benefit the most from the use of a walker to assist in ambulation?

client who requires considerable assistance with balance

The nurse is reading documentation that indicates that a client has a Syme's amputation. Which client does the nurse associate with this condition?

client with amputation at the foot

A nurse is assisting a client to apply his leg prosthesis. The nurse should first:

cover the prosthetic foot with a stocking and shoe of choice.

The nurse is educating a client who will be using crutches for approximately 6 weeks. Which exercise would be beneficial to help with crutch use?

flexion and extension of the arms and the wrists

A nurse is evaluating an older adult client's functional ability. What factor will the nurse include in this evaluation?

mobility and ability to compensate for age-related changes

The nurse is caring for a client who will be using forearm crutches after having spinal surgery. To improve upper body strength for crutch-walking, the nurse will instruct the client to regularly perform which type of exercise?

performing modified push-ups in an armchair

The home health nurse is conducting the initial visit with a client who now needs to use a walker to ambulate. Which action should the nurse prioritize after walking up the front steps to meet the client for the first time to help ensure safety?

provide information on resources which can help put a ramp up the steps

When preparing to teach a client about quadriceps setting, the nurse recognizes that which muscles will be involved? Select all that apply.

rectus femoris vastus intermedius vastus medialis vastus lateralis

After teaching a client how to perform a four-point crutch gait, the nurse determines that the teaching was successful when the client first moves the left crutch and then follows with:

right foot

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