ATI: Custom: Mobility

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as the indication that the client understands the discharge instructions? a. "I'll apply ice to my ankle today and tomorrow." b. "I'll rewrap my ankle starting from the knee down." c. "I'll bear weight on my ankle for 10 minutes every hour." d. "I'll put a heating pad on my ankle at bedtime tonight."

a. "I'll apply ice to my ankle today and tomorrow." -The RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation. The client should apply ice for the first 24 to 48 hr after the injury.

A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the interprofessional health care team? a. OT b. Social worker c. Registered dietician d. Speech pathologist

a. OT -An occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding.

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching? a. Buck's extension traction will reduce the fracture. b. Buck's extension will relieve muscle spasms. c. Buck's extension will maintain alignment of the pins. d. Buck's extension traction will allow supported movement of the extremity.

b. Buck's extension will relieve muscle spasms. -Buck's extension traction immobilizes the fractured bone to relieve associated muscle spasms and thereby relieve pain. Any movement of the fractured extremity will aggravate severe muscle spasm and trigger pain.

A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur. Which of the following interventions should the nurse include in the plan? a. Instruct the client to flex and extend ankle twice daily. b. Monitor the client's pedal pulses every hour. c. Remove the weights every 4 hours. d. Evaluate pressure points daily.

b. Monitor the client's pedal pulses every hour. -The nurse should assess the neurovascular status of the client's affected extremity including assessing pulses, color, and capillary refill hourly for the first 24 hours following the placement of skeletal traction to prevent complications such as compartment syndrome or circulatory compromise.

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching? a. "I will keep spare crutch tips handy." b. "I will bear the weight of my body on my hands." c. "I will inspect my crutches every day for signs of wear." d. "I have a set of my brother's crutches in my basement I can also use."

d. "I have a set of my brother's crutches in my basement I can also use." -The client should not use crutches that belong to someone else. The client's crutches must fit his body dimensions, not someone else's.

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I will keep my walker at the end of my bed." b. "I will keep the fluorescent ceiling light on in my room at night." c. "I will place an area rug at the entry of my bathroom." d. "I will place a bath seat in my shower to use when I bathe."

d. "I will place a bath seat in my shower to use when I bathe." -A bath seat can help reducing slipping and falling in the bathtub or shower.

A nurse is providing discharge teaching to a client who has a plaster of paris walking cast on his left lower leg. Which of the following instructions should the nurse include? a. Apply ice to your foot after walking. b. A must odor is normal as the cast ages. c. There is no need to cover the cast when showering. d. Report any numbness or pain in your tootsies.

d. Report any numbness or pain in your tootsies. -The client should be taught to check circulation, mobility, and sensation (perform CMS checks) daily and to inform the provider of any coolness, pallor, immobility, or diminished sensation.

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? a. One nurse lifting as the client pushes with his feet. b. Two nurses lifting the client under the shoulders. c. One nurse lifting the client's legs as the client uses a trapeze bar. d. Two nurses using a friction-reducing device.

d. Two nurses using a friction-reducing device. -This method reduces the risk of injury to the nurses and to the client. The nurses can use a draw sheet as a friction-reducing device.

A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include? a. Relax her abdominal muscles when she lifts an object. b. Twist at the waist when she moves an object to one side. c. Hold an object away from her body as she lifts it. d. Bend at the knees when picking up an object.

d. Bend at the knees when picking up an object. -Bending at the knees can help the client maintain her center of gravity. Then when she lifts the object, she should use her leg muscles, not her back muscles, to lift it.

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? a. Trochanter roll b. Sheepskin heel pad c. Abduction pillow d. Footboard

d. Footboard -Plantar flexion contractures, or foot drop, develop when a client's unsupported feet are constantly in plantar flexion. The nurse should place the soles of the client's feet against a footboard, a flat wooden or plastic panel perpendicular to the bed, to keep them dorsiflexed and, therefore, prevent foot drop.

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? a. Measure the circumference of the thigh. b. Palpate the femoral pulse. c. Monitor the client's calf for edema. d. Instruct the client to wiggle his tootsies.

d. Instruct the client to wiggle his tootsies. -The nurse should observe the client's ability to move his toes when collecting data regarding neurovascular status distal to the fracture. Other means of evaluating neurovascular status include assessing skin color and temperature, sensation, pain, and capillary refill.

A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification? a. "I'll sit with my knees lower than my hips." b. "I'll do exercises that strengthen my abdominal muscles." c. "I'll wear low-heeled shoes from now on." d. "I'll carry heavy objects close to my body."

a. "I'll sit with my knees lower than my hips." -To prevent back injuries, the clients should sit with their knees slightly higher than their hips.

A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is true regarding the postoperative placement of a prosthesis? a. "You will do special exercises in advance of getting your prosthesis." b. "You will be fitted for your prosthesis at the time of your surgery." c. "A special pressure dressing will remain on to cushion your prosthesis." d. "The prosthesis will be adjustable depending on what shoe you are wearing."

a. "You will do special exercises in advance of getting your prosthesis." -The physical therapist will teach muscle strengthening exercises to prepare the client for prosthesis use.

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? a. Place the wheelchair at a 90 degree angle to the bed. b. Lock the wheels of the bed and the wheelchair. c. Acquire the help of several people to lift the client. d. Elevate the bed to a position of comfort for the nurse.

b. Lock the wheels of the bed and the wheelchair. -The nurse should keep the wheels of the bed and the wheelchair in the locked position to prevent them from moving when transferring a client.

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first? a. Change in temperate of the toes. b. Pallor of the toes. c. Edema of the toes. d. Inability to move tootises.

b. Pallor of the toes. -If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider.

A nurse is caring for a client who is 4 hr postop following a hip replacement. The nurse should isntruct the client to avoid which of the following activities? a. Placing a large pillow between legs when turning. b. Putting on shoes/socks. c. Using a raised toilet seat. d. Using a walker.

b. Putting on shoes/socks. -The client should not bend over to put on shoes and socks. It increases the risk of dislocation of the prosthesis to create more than 90° of flexion at the hip.

A nurse is caring for a client who has a prescription for balanced skeletal traction with a Thomas splint for the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint? a. Apply lotion to the skin under the edges of the splint. b. Reposition the client to keep him from staying in the same position in bed. c. Remove the weights for a few minutes each hour. d. Apply a foot plate to the bed.

b. Reposition the client to keep him from staying in the same position in bed. -The nurse should assist in the prevention of pressure points by keeping the client properly and frequently positioned in bed. Balanced suspension traction with a Thomas splint allows for increased movement.

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? a. Electrical cords are placed along the walls. b. Scatter rugs are present in the kitchen. c. Handrails are present in the bathroom. d. Uses a microwave for cooking

b. Scatter rugs are present in the kitchen. -Scatter rugs in the kitchen are a safety hazard. The client could trip on one of the rugs and fall due to impaired vision.

A nurse is teaching a client who has a prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching? a. Expect ringing in your ears. b. Take the medication with food. c. Store the medication in the refrigerator. d. Monitor for weight loss.

b. Take the medication with food. -To minimize gastric irritation, the client should take ibuprofen with food or immediately after a meal.

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? a. The client complains of pain. b. The client develops a life-threatening situation. c. The client needs to have a x-ray of the femur performed. d. The client has to be repositioned in the bed.

b. The client develops a life-threatening situation. -Traction weights, which are to hang freely at all times, are never to be removed without a specific provider prescription unless there is a life-threatening situation.

The nurse is teaching a client about crutch walking using the 3-point gait. Which of the following statements by the nurse should be included in the teaching? a. "Look down at your feet before moving the crutches." b. "Place one crutch forward with the opposite foot and then place the second crutch forward followed by the second foot." c. "Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches." d. "Support your body weight on the underarm crutch pads."

c. "Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches." -The nurse should instruct the client to use this method of crutch walking for a three-point gait.

A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching? a. Remain on bedrest for the first 24 hr. b. Keep the leg in a dependent position. c. Apply ice to the affected area. d. Begin active ROM.

c. Apply ice to the affected area. -Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems inside a joint. Applying ice to the affected area in the immediate postoperative period (first 24 hr) reduces pain and swelling.

A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching? a. Keep the prosthesis in direct contact with the residual limb. b. Apply a moisturizing lotion or oil to the stump daily. c. Dry the prosthesis socket completely before applying it to the limb. d. Expect some skin irritation from the prosthesis.

c. Dry the prosthesis socket completely before applying it to the limb. -The client should dry the prosthesis socket thoroughly with a clean cloth. Moisture between the socket and the stump can put the client at risk for fungal or bacterial infection and skin breakdown

A nurse is providing discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. Which of the following instructions should the nurse include in the teaching? a. Use a blow dryer on a moderate heat setting to dry the cast after showering. b. Use a cotton swab to relieve itching under the cast. c. Report any worsening or unrelieved pain. d. Avoid moving the affected leg.

c. Report any worsening or unrelieved pain. -Pain can be a sign of complications such as compartment syndrome or skin breakdown. The client should report it to the provider.

A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer? a. Enlist help from another staff member. b. Adjust the bed to an appropriate height. c. Use a powered standing-assist lift. d. Avoid movements that twist the spine.

c. Use a powered standing-assist lift. -Using a powered standing-assist lift will best ensure the safety of the client and the nurse.

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medication record? a. "There were no injuries sustained." b. "An incident report was completed." c. "An incident report was forwarded to risk management." d. "The provider was notified."

d. "The provider was notified." -Nursing interventions that support factual information should be documented in the health record.

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hrs. Which of the following actions should the nurse take as directed by the plan of care? a. Ask the client to move her arms and legs while applying slight resistance. b. Move the client's limbs through their complete ROM. c. Have the client move each limb independently through its complete ROM. d. Instruct the client to tighten muscle groups for a short period of time, and then relax.

d. Instruct the client to tighten muscle groups for a short period of time, and then relax. -Isometric exercises involves static (no movement) contraction of a muscle without any movement of the joint. Isometrics promote increased muscle mass, strength, and tone for clients who are on bedrest.

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate? a. Gait belt b. Jacket harness c. Four-wheel walker d. Cane

a. Gait belt -The nurse should use a gait belt to help support the client during ambulation. A gait belt helps keep the client's center of gravity stable and helps maintain balance and prevent falls.

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane? a. "When the client moves, he should move the cane forward first." b. "The client should hold the cane on the weak side of his body." c. "The grip should be level with the client's waist." d. "The client should first move the strong leg, then the weak one."

a. "When the client moves, he should move the cane forward first." -When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg.

A nurse is caring for a client following a right total hip arthroplasty. Postoperatively the nurse should maintain the right leg in which of the following positions? a. Adduction b. External rotation c. Internal rotation d. Abduction

a. Adduction -When caring for a client following a total hip arthroplasty, the nurse should abduct the affected extremity to prevent dislocation, positioning the legs away from the midline.

A nurse is caring for a client who requires cold applications with an ice bag to reduce swelling and pain of an ankle injury. Which of the following actions should the nurse take? a. Apply the bag for 30 min at a time. b. Reapply the bag 30 min after removing it. c. Allow room for some air inside the bag. d. Place the bag directly on the skin.

a. Apply the bag for 30 min at a time. -The nurse should leave the bag in place for 30 min, but should check the client's skin after 15 min to make sure there are no adverse effects.

A nurse is preparing to transfer a client from a bed to a chair. Which of teh following actions should the nurse take first? a. Determine if the client can bear weight. b. Place a transfer belt on the client. c. Position the bed at an appropriate height. d. Assist the client to a seated position.

a. Determine if the client can bear weight. -Using the nursing process, the nurse should first determine if the client can bear weight.

A nurse is assessing a client at a follow-up clinic visit for acute low back pain. A goal this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting their goal? a. The client faces the direction of movement when sliding an object across the floor. b. When pushing an object, the client moves his front foot backward. c. When moving an object to one side, the client puts his weight on his heels. d. The client stands with their feet close together when lifting an object.

a. The client faces the direction of movement when sliding an object across the floor. -Sliding an object across the floor rather than lifting it prevents strain on the lower back muscles. . Facing the direction of movement prevents twisting his back

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide? a. This service began with the client's admission to the hospital. b. This service focuses on teaching the primary caregiver to meet the client's needs. c. The emphasis is on the client's complete recovery from the illness/injury. d. Services are centered in LTC facilities.

a. This service began with the client's admission to the hospital. -Rehabilitation is a process that assists an ill person or a person with a disability or impairment to achieve the highest possible level of functioning. The process of rehabilitation begins with the client's admission to a health care facility for treatment.

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine? a. The client's ability to communicate. b. The client's current weight bearing status. c. The client's height. d. The type of equipment used in previous transfers.

b. The client's current weight bearing status. -The client's weight-bearing status is the most important information the nurse needs to know to identify the safest method of transfer.

A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings? a. The ropes are in the center of the wheel grooves. b. The weights rest against the foot of the bed. c. The weights are equal on each side. d. The ropes are securely attached to the pins.

b. The weights rest against the foot of the bed. -Weights that rest against the foot of the bed or on the floor do not apply the amount of traction essential for maintaining alignment and immobilizing the bone.