Week 3 safety,immobility, safe movement EAQ

The nurse is teaching an adolescent with a sprained ankle how to use one crutch when walking. Which statement indicates that no further teaching is necessary?

"I should use the crutch on the side of my good ankle"

Which interventions would the nurse manager include in a fall prevention program to decrease the number of falls on the unit

- apply fall wristband - install bed safety alarms - establish a toileting schedule

Which intervention would the nurse follow to prevent future falls in an older adult experiencing delirium who sustained a leg fracture caused by a fall

- min. Sedating medications - modifying the home environment - manage foot and footwear problems

Which instructions to minimize the risk of falls in the home would the nurse provide the caregiver Of an older client who requires the use of a walker with wheels

- remove cords - use bright lighting - get rid of throw rugs

Which instructions would the nurse give to an older adult with decreased perception of touch

-hold on handrails while ambulating -look where your feet are placed while walking -wear shoes that give good support while walking -if you are unable to change your position frequently, request assistance

Four-point gait

3 points of support not two at all times. Divides weight bearing equally among the limbs

Why is it beneficial to have a patient diagnosed with pheochromocytoma sit on the side of bed for a few minutes before transfer?

Allows time for blood pressure to adjust to vertical position;avoids dizziness & potential for fainting or falling

Asymmetric gait

Associated with weakness of or pain in lower extremity

Scissoring gait

Bilateral spastic paresis of legs

Which physiological change occurs in older adults and warrants the nurse teaching the client about safety tips to prevent falls

Decreased bone density

The nurse is preparing to teach a year-old child about crutch walking. Which would be included in the plan?

Exploring the Childs fear of falling

Which nursing intervention is appropriate to include in the plan of care when the nurse is transferring a client with a diagnosis of pheochromocytoma from bed to chair?

Having client sit on the side of bed for a few minutes before transfer

hemiparesis

It creates instability. It is a Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles.

A client who had a right total hip replacement is progressing from use of a walker to the use of a cane. In which hand would the nurse teach the client to hold the cane

Left hand

Which action by an adolescent after the nurse teaches crutch-walking indicates the need for more teaching?

Looks down when placing crutches

Which rationale would the nurse use to explain the canes purpose to a client with hemiparesis who voices a reluctance to use a cane.

Maintain balance to improve stability

Nurse has provided discharge instructions to a client who received a prescription for a walker. The nurse determines that the teaching has been effective when the client does which?

Moves the walker no more than 2 ft during use

Client with a left sided weakness is learning how to use a Cane. The nurse would demonstrate proper use of cane by holding it where?

On the right. By moving cane on stronger side & move cane forward first, followed by weaker leg & then stronger leg

The nurse is planning to teach the four point alternate crutch gait to a 9-year-old with cerebral palsy. How would the nurse explain this choice to the parent?

Provides for equal but partial weight bearing on each limb

Which instruction provides a client the best description of how to use a prescribed, stationary (nonrolling) walker?

Put the walker's front leg tips about an arms length ahead of the feet s shift the body weight to walker & step forward

What type of walker is most appropriate for a client with weak upper arm strength and impaired stamina who is less-able to lift up and move a walker with four rubber tips.

Rolling walker

Shuffling gait

Short and dragging ; seen with basal ganglia defects

Which term would the nurse use to document observing the characteristic gait associated with parkinson disease?

Shuffling

Which clinical finding demonstrates to the nurse that the client can use a Standard walker?

Strong upper arm strength & non weight bearing on affected extremity

Which intervention should the nurse classify as highest priority for an older client with lower-extremity ulcerations due to chronic venous insufficiency?

Teaching how to transfer from a bed to chair in the least painful manner.

Which condition would the nurse ensure when adjusting the crutches of an addescent who sustained an ankle injury while playing soccer and is prescribed crutches and no weight-bearing by the primary health care provider?

That they attend to six inches (15.2cm) from the side of each foot

Which action would the nurse take when using a mechanical lift device to transfer a client

fold clients arm across chest

Four-point alternate crutch gait

simple,slow, stable gait because there are always three points of support on the floor, with equal but partial weight bearing on each limb

ataxia gait

staggering, wide based gait - often associated with cerebral damage