Vsims 1

1 The nurse is using the Morse Fall Scale to determine Mr. Russell's fall risk. What variable(s) will the nurse assess by using this tool?

:The Morse Fall Scale is widely used in hospital and long-term care settings and is used to assess six variables that put patients at a higher risk for falls. These include the following: history of falls, secondary diagnosis, ambulatory aid, IV or IV access, gait, and mental status. Although advanced age and female gender place a patient at risk for falls, they are not included in the Morse Fall Scale.

The nurse is completing passive range of motion on Mr. Russell. What movements would the nurse expect to complete at the elbow joint?

At the elbow joint, the nurse would expect to find flexion, extension, supination, and pronation of the forearm.

The nurse is educating Mr. Russell on the effects of prolonged immobility. What physiologic change(s) would the nurse describe to Mr. Russell?

Decreased muscle protein synthesis, increased muscle catabolism, decreased muscle mass, and bone demineralization are physiologic changes that result from prolonged immobility.

2 The nurse is reviewing Mr. Russell's medications. Which medication(s) would place Mr. Russell at a higher risk for falls?

Losartan (antihypertensive), metformin (antidiabetic), and chlorthalidone (diuretic) all place Mr. Russell at a higher risk for falls.

The nurse is educating Mr. Russell on how to prevent falls. Which statement, if made by the patient, indicates that he understood the teaching?

Mr. Russell has understood the teaching if he states he will use the call light if he wants to get out of bed. Mr. Russell should have non-skid socks on at all time while ambulating and should always use his walker—not just when feeling unsteady. He should keep the walker close to his bed rather than close to the door so that it is easily accessible.

The nurse is assessing flexion in Mr. Russell's hip. What instructions would the nurse give to Mr. Russell to complete this assessment?

Rationale:To assess flexion of the hip, the nurse would instruct Mr. Russell to bend his knee to his chest and then pull it against his abdomen. Instructing the patient to lie face down and then bend the knee and lift it up assesses extension. Asking the patient to lie flat and then move the lower leg away from the midline assesses abduction. Instructing the patient to lie flat and then bend the knee and move the lower leg toward the midline assesses adduction.

The nurse is caring for Mr. Russell, who is recovering from a stroke and has mild left-sided hemiplegia. What would the nurse include in the plan of care?

The nurse includes passive range-of-motion exercises in the plan of care and should encourage the patient to set realistic, short-term goals. The patient should call for assistance when ambulating rather than try to maintain independence. It is important for the patient to use assistive devices as long as necessary. The nurse should cluster care activities to allow the patient to rest rather than spread them throughout the day.

The nurse is assessing the muscle strength in Mr. Russell's left hand and notes active motion against some resistance. How would the nurse document this finding?

The nurse would document this finding as 4, slight weakness. Active motion against full resistance is 5, or normal strength. Active motion against gravity would be charted as 3, average weakness. Finally, a finding of 2 is passive range of motion (ROM) or poor ROM.

Mr. Russell asks the nurse, "What is the purpose of these passive range-of-motion (ROM) exercises? I can move my own arms and legs." What is the correct response by the nurse?

The nurse would explain to Mr. Russell that the passive range-of-motion exercises will help him to maintain mobility in his joints. The purpose of passive range-of-motion exercises is not to prevent clot formation or skin breakdown. Mr. Russell is not confined to bed and can ambulate with the help of a walker.