ATI - Mobility Assessment Quiz

Cardiac deconditioning

Atrophy of the heart muscle which results in a decreased amount of blood being ejected from the heart during contraction

Movement

Bones work with the muscular attachments to create motion

Damage with skin intact

Can present as: Persistent redness or discoloration Temperature difference compared to the surrounding skin Firmness in the area

Promotion

Comfort, safety, dignity, privacy, participation, frequent position changes

Generate body heat

Contracting muscles generate heat that assists in maintaining body temperature. Shivering is an example of the muscles working to produce heat

A nurse is caring for a client who had a stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions? DVT Asthema Hernia Hypertension

DVT

Produce

Red bone marrow in the center of the bones, produces red blood cells, white blood cells, platelets, and macrophages

reverse Trendelenburg

-entire bed is tilted with the foot of the bed lower than the head -position promotes gastric emptying and prevents esophageal reflux

A nurse is preparing to lift a heavy object off of the floor. In which order should the nurse perform the following steps to demonstrate the proper use of the body mechanics?

1. Stand as close to the object as possible 2. Keep Abdominal muscles contracted and lower back straight 3. Look straight ahead with shoulders raised up 4. Bend hips slightly and squat 5. Push up from the knees when lifting the object

Using proper body mechanis

1.) Stand as close to the oject as possible 2.) Keep the abdominal muscles contracted and the lower back in its normal position 3.) Maintain the head upright with shoulders raised up 4.) Bow the hips slightly and squat 5.) Do not twist the torso. Always pivot or side-step 6.) Push up from the knees and use that momentum to lift the object

Deep Vein Thrombosis (DVT)

A condition that results a blood clot inside a deep vein, usually within the extremities.

Orthostatic hypotension

A significant drop in BP caused by a change in position

Tendons

Nonflexible fibrous connective tissue that attaches muscle to bone

A nurse is caring for a client who is prescribed bed rest. The nurse should recognize that which of the following are complications of bed rest?

Reddened areas of the skin Reports of heartburn Manifestations of a blood clot in an extremity Rapid, shallow breathing Resistance to extension of an extremity

Correct Body Mechanics

Stand close to the client when lifting Raise the client's bed when positioning Pivot or sidestep when moving client

Body mechanics

The combined effort from the musculoskeletal and nervous systems to maintain the body's posture, alignment, and balance

Gross motor skills

The use of large muscle groups to perform whole body movements

Pneumonia

an infection that often occurs in clients with limited mobility as a result of shallow breathing, thickened mucus, and decreased ability to cough

Flexion

bend; reduce the angle between the bones

Cerebrovascular accident

blood is prevented from reaching areas of the cerebrum, usually due to a clot or a rupture of a blood vessel within the brain, and brain cells die; also called a stroke

adduction

bring closer to baseline

circumduction

circular motion

Clients who are unable to independently change positions should be repositioned every 2 hours, with attention paid to their....

comfort and body alignment

Nurses caring for clients who have mobility deficits must plan assessments and interventions to minimize the impact of...

complications from altered mobility

Immobility

inability to reposition or move self

Join contractures intervention

inspect the client's position for proper body alignment every 2 hours Ensure ROM exercises are performed every shift

Sarcopenia

loss of lean muscle caused by immobility

Ergonomics

Study of body mechanics in relation to the demand and design of the work environment and equipment used.

A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include? Cartilage is always remodeling and changing Tendons connect muscle to bone Ligaments are flexible connective tissue that coat bony areas Synovial joints attach to the skeleton to maintain posture

Tendons connect muscle to bone

Dangling

The act of having a client sit on the edge of the bed before moving to a standing position

Self-concept

The beliefs one holds regarding their qualities and attributes formed through experiences..

No assistance

The client can stand, march or step in place, and walk without any help

Risk factors in the workplace: Environmental hazards

mental stress, physical stress, workload hours (shift, overtime), falls, slips, exposure to hazards

Older adults typically experience age-related changes to their musculoskeletal and nervous systems and vision, which can negatively impact these clients'....

mobility

current exercise recommendations

moderate-intensity aerobic activities at least 150 minutes per week (30minutes per day, 5 days per week)

Examples of ergonomic practices and equipment in health care

modifiable workstations and chairs, keyboards with wrist support, adjustable IV Stands and poles, height adjustable beds, two person lifts/transfers, client transfer devices, shower chairs, toilet seat risers, side-opening garbage and linen containers, elimination of uneven floor surfaces.

Mental vuntion

oriented verses confused

Range of Motion

The manipulation of a joint within its range of flexion and extension

Body Alignment

The positioning held by the various parts of the body while performing activities or during a test

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include? The use of ergonomics improves blood circulation in the body The use of ergonomics eliminates costs related to workers' compensation The use of ergonomics increases job satisfaction The use of ergonomics maintains the body's balance and lower center of gravity

The use of ergonomics increases job satisfaction

Active range of motion

Voluntary movement of a joint

Malnutrition intervention

Weight the client daily Assist the client with meals, if needed

Gait belt

a belt made of canvas or other heavy material used to help people who are weak, unsteady, or uncoordinated to stand, sit, or walk; also called a transfer belt

myocardial infarction

a condition in which arterial blood flow to the heart muscle is blocked resulting in death of cardiac muscle cells

Fecal impaction

a hardened mass of stool which creates a blockage in the intestines

Fowler's position

a semi-sitting position; the head of the bed is raised between 45 and 60 degrees

Joint contractures

abnormal fixations of the joints that occur as a result of changes to muscles and connective tissue

Slide or transfer board

allows the lateral transfer of a client without imposing the physical exertion of lifting on the staff member

atrophy

become smaller and weaker often from disuse

Fragility fractures

fractures that occur following stress on a bone that would not typically result in a break

Variations and differences in body size and shape

height and weight

prone

lying face down

abduction

move away from baseline

Atelectasis

partial or complete collaspe of the lung, including airways and small sections of lung tissue

Rotation

side-to-side

Ergonomics is a field that designs, adjusts, and arranges items so that individuals can work....

safely and efficiently

extension

straighten the limb

Prevention

strain, injury, and skin breakdown

Inversion

turn inward

Gastroesophageal reflux

A backflow of gastric fluids into the esophagus which can result in irritation of the tissue

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include? A stable center of gravity increases stability and balance A wide base lowers the center of gravity Proper body alignment involves tightening the abdomen Leaning slightly back while carrying an object equalizes the center of gravity Bending at the waist when picking up objects stabilizes the spine

A stable center of gravity increases stability and balance A wide base lowers the center of gravity Proper body alignment involves tightening the abdomen

Atelectasis intervention

Encourage the frequent use of an inventive spirometer Elevate the head of the bed at least 30-45 degrees

A nurse is assessing a client's ability and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing? Atrophy Foot drop Join contracture Disuse osteoporosis

Foot drop

Musculoskeletal

General term used when referring to the muscles and the skeleton

Malnutrition

Imbalance in a client's intake which can include deficiencies or excesses in nutrients, vitamins, or calories

Activity intolerance

Inadequate amount of physical or psychological energy to undergo or complete a necessary activity

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should should include that which of the following is responsible for body posture? Center of gravity Bones Muscles Synovial joints

Muscles

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include? Muscles store calcium and magnesium Muscles produce red blood cells and platelets Muscles assist with thermoregulation in the body Muscles provide protection of internal organs

Muscles assist with thermoregulation in the body

support

provide a solid and stable framework

lateral

side

pronation

turning to face backward

supination

turning to face forward

foot drop

type of joint contracture that results in a partial or total inability to pull the toes up toward the head (dorsiflexion)

Level of cooperation

willing versus combative

A walker should be used on stairs or an escalator T F

F

Proprioception

Feedback from sensory receptors to coordinate, balance, and fine-tune body positioning and movement

Cartilage

Flexible connective tissue that coats bony areas, allowing them to glide over each other and absorb shock

Ligaments

Flexible fibrous connective tissue that attaches bone to bone

Pressure injury

Keep the client's skin free from moisture due to incontinence, perspiration, or wound drainage Reposition the client every 2 hours

Gait

Manner or style of ambulation

Risk factors in the workplace

Practice controls, physical characteristics, and environmental hazards

Moderate assistance

The client can maintain a seated position and has some upper extremity strength but lacks enough lower extremity strength to transfer safely. Use sit-to-stand powered lifts and assistive devices

Physical disabilities

Health related conditions and equipment

Sarcopenia

Loss of lean muscle caused by immobility

Mobility

Moving from one position to another

A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client? Speech therapist Physical therapist Respiratory therapist Occupational therapist

Occupational therapist

Damage beyond the skin layer

Open wound possible with adipose tissue or granulation tissue visible

Lateral, semi-prone

Side-lying, bottom arm behind or in front of client, not as extreme as Sims.

Remodeling

The process of bone breakdown and replacement that occurs throughout a lifespan

Prior to emulating or transferring a client, a mobility assessment should be performed to determine the client's abilities and the level of aid needed from staff members and....

assistive devices

Cardiac deconditioning

atrophy of the heart muscle which results in a decreased amount of blood being ejected from the heart during contraction

recumbant

in a reclining position, lying down, in the posture of one sleeping or resting

supine

lying on the back

Assistive devices should be selected based on the individual client needs and evaluated to ensure....

proper fit and usage

Protect

provide mechanical protection for the internal organs such as the brain, spinal cord, heart, and lungs

Physical exercise improves health outcomes and quality of life, and....

reduces the risk of falls

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include? "The top of the walker should be at the level of your wrist" "When using the stairs, place the walker before taking a step." "When holding the walker, bend your elbows 30 degrees" "Take a step first before moving the walker"

"The top of the walker should be at the level of your wrist"

When a client is gripping a cane the elbow should be bent at approximately a.... 10-20 degree angle 15-30 degree angle 12-30 degree angle 20-30 degree angle

15-30 degree angle

When using crutches the elbows should have a.... 10-20 degree angle 15-30 degree angle 12-30 degree angle 20-30 degree angle

15-30 degree angle

Urinary retention

A condition in which the bladder does not completely empty with urination

Renal calculi

A condition in which the bladder does not completely empty with urination.

Orthostatic hypotension

A decrease in blood pressure and a sensation of dizziness that occurs when a client sits or stands up. Occurs because gravity pulls body fluids to the lower extremities. Reduced blood volume and cardiac deconditioning increase this effect, especially in older adult clients or those that have long periods of immobility.

Orthostatic hypotension guidelines

A decrease in systolic blood pressure of 20 mmHg or more OR A decrease in diastolic blood pressure of 10 mmHg or more within 3 minutes of changing to a sitting or standing position

Mobility assessment

An objective assessment to determine the amount of assistance required for ambulation and transfers based upon the client's ability to move.

Pulmonary embolism

An obstruction of blood flow in a pulmonary artery due to the movement of blood clot from an extremity to the lungs.

Mechanical sit-to-stand lift

Appropriate for a client who possesses the lower extremity strength and balance required to maintain an upright position.

A nurse in a long-term facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing? Sarcopenia Disuse of osteoporosis Atrophy Joint contracture

Atrophy

Damage into the skin layer

Can appear as: An area of skin that is lighter in color than the usual skin tone Open or intact blister Shallow wound with a pink or red bed

Timed Up & Go (TUG) Assessment

Client is instructed to stand up from a seated position, abulate 10 feet, turn and ambulate back to the chair, and become seated During the assessment the nurse should observe the client's balance, stride, posture, and gait. If an older patient takes longer than 12 seconds they are at risk of falling

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage? Deep damage through the skin and tissue Damage beyond the skin layer Damage into the skin layer Damage with the skin intact

Damage into the skin layer

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse plans to assess the client for which of the following? Restricted movement due to abnormal fixation of a joint A drop in blood pressure that occurs with a change in position Altered gait with dragging of the toes while ambulating Diminished awareness of body position and balance

Diminished awareness of body position and balance

Constipation

Encourage the consumption of high-fiber foods and fluids Evaluate the client for the presence of nausea, vomiting, or abdominal pain

Kyphosis

Excessive outward curvature of the upper area of the spine

Mobility Assessment Steps in the correct order

Extend arm to shake hands with client's father upper extremity Instruct client to sit on edge of bed for at least 2 minutes Instruct client to extend one leg, flex ankle, and point toes Request client to stand at the bedside for at least 5 seconds Request client to walk in place Ask client to take a few steps forward and then backwards

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis? Fowler's Lateral Prone Supine

Fowler's

Risk Sites for Pressure Injuries: Supine

Head, Shoulder, Elbow, Buttocks, Toes, and Heel

Risk Sites for Pressure Injuries: Fowler's Position

Head, Shoulder, Sacrum, Ischion, and Heel

A nurse is performing a focused assessment on an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing an age-related change to their musculoskeletal system? Increased curvature of the thoracic spine Reduced depth perception Narrower stance when standing Quick steps when ambulating

Increased curvature of the thoracic spine

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include? Kyphosis is when the upper back extends posteriorly to the lower back Kyphosis is an inward curvature of the lower back Kyphosis is a sideways curvature of the spine Kyphosis is a rounded upper back with the pelvis tilted forward

Kyphosis is a rounded upper back with the pelvis tilted forward

Incorrect Body Mechanics

Lift from the large back muscles Place feel close together Bend slightly at the waist

A nurse is preparing to transfer a client from a bed to a wheelchair. Which of the following actions by the nurse demonstrates proper use of body mechanics? Twisting the torso when transferring the client Bending at the waist when transferring the client Placing the bed in the high position before transferring the client Looking at the client face-to-face when transferring the client

Looking at the client face-to-face when transferring the client

A nurse is caring for a client who is prescribed bed rest. The nurse should recognize that which of the following are NOT complications of bed rest?

Loose, frequent stools Increased muscle mass Inability to flex the foot downward Elevated blood pressure when sitting

Disure osteoporosis

Loss of skeletal mss, density, and strength caused by immobility

A nurse is caring for a client who requires maximum assistance to transfer from the bed to the chair. Which of the following pieces of equipment should the nurse use? Pivot disc Machanical lift Sit-to-stand lift Gait belt

Machanical lift

A nurse is caring for a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client? Gait belt Mechanical lift Cane Sit-to-stand lift

Mechanical lift

Mobility Assessment

Mobility Assessment Tool (MAT) 4 step process test's client's abilities and then assigns a recommended level of assistance for the client to be mobile Ranges from maximum assistance to requiring two or more, to no assistance. Focuses on the ability to move, stand, walk, and step. Evaluates balance, strength, posture, and any activity tolerance

Peripheral nervous system

Nervous system outside of the brain and spinal cord that regulates the responses of the body to external stimuli

Tendon

Nonflexible fibrous connective tissue that attaches muscle to bone

A nurse is assessing the competency of a new assistive personnel (AP) as they assist in moving a client up in bed. Which of the following actions by the AP demonstrates competence? Lifts with arms fully extended Places feet shoulder width apart Maintains client's bed in a low position during move Twists at the waist during the move

Place feet shoulder width apart

Risk factors in the workplace: Physical characteristics

Posture, duration, force, velocity, heavy exertion, repetition, time, lunch/rest breaks, recovery time

Goals for client position and alignment consist of the two P's Posture and promotion Prevention and posture Promotion and prevention Procedure and promotion

Promotion and prevention

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage? Lateral Supine Prone Fowler's

Prone

....exercises promote mobility by presenting the flexibility of the joints

Range of motion

Splints

Rigid or semirigid device designed to support or stretch an injured or altered part of the body

A nurse is completing the Mobility Assessment Tool (MAT) for client and determines that the client is at Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks? Sit on the edge of the bed for 1 min Stand in place for 5 seconds Walk in place Step forward and backward

Sit on the edge of the bed for 1 min

Minimum assistance

The client can rise from a seated position and sustain a steady stand. Use a gait belt and ambulation assistive devices as indicated

Maximum assistance

The client cannot bear weight, assist, or maintain a seated position. Use a total mechanical lift or sling

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the cruches? The hand grips of the crutches are at the level of the client's umbilicus The client's elbows are bent 45 degrees when holding the crutches The client places their weight on their axilla when using the crutches The client has the crutches resting 5 cm (2in) below their axilla

The client has the crutches resting 5 cm (2in) below their axilla

A nurse is preparing a presentation for a group of clients who are scheduled for a joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a join? Synovial joints contain sensory receptors that trigger flexion The contraction of a muscle results in flexion of a join Neurotransmitters coordinate with cartilage to initiate flexion Ligaments extend to enable flexion of a joint

The contraction of a muscle results in flexion of a join

Posture and positioning

The skeletal muscles maintain posture and body positioning without a person's conscious control. The cause motion through a series of contraction and relaxations, or contract to hold the body in a certain position such as sitting or standing.

Movement (main function)

The skeleton muscles work with the skeleton to create body movements such as texting, sitting, standing, walking, running, and dancing

A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as ADL? Toileting Writing Ambulating Talking

Toileting

Body mechanics

involves the combined effort of the musculoskeletal nervous systems to maintain posture, alignment, and balance

Risk factors in the workplace: Practice controls

lighting, noise, transfer lifts, carts, furniture, whole-body vibrations, exposure to heat/cold

Disuse osteoporosis

loss of skeletal mass, density, and strength caused by immobility

Trendenlenburg

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

The musculoskeletal and nervous systems work together to coordinate....

movement, positioning, and balance

Immobility can have widespread negative impacts on clients'....

musculoskeletal, cardiac, respiratory, gastrointestinal, genitourinary, and integumentary systems as well as their psyche

Constipation

occurs 16 times more often in clients who are prescribed bed rest than those who are active.

Using the principles of proper body mechanics, a stable center of gravity, a wide base, and proper body alignment can reduce the risk of injury due to...

physical strain

Eversion

turn outward

Pivot Disc

used for sitting or standing transfers for clients who are cooperative and have weight bearing capabilities. This tool is used for clients who can stand but have difficulty moving their feet. Enable the health care personnel to easily rotate the client to the desired position.

A mobility assessment should be performed prior to initially mobilizing a client and repeated every _____-

24 hours

Risk Sites for Pressure Injuries: Lateral Position

Ear, Shoulder, Elbow Hip, Thigh (external and internal), Ankle, and Heel

Synovial joints

Fluid-filled capsules that connect bones and enable movement

Passive range of motion

Movement of a joint by another individual

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take? Reposition the client every 2 hr while in bed Remind the client to use the incentive spirometer Obtain the client's weight daily Encourage the client to eat foods that are high in fiber

Remind the client to use the incentive spirometer

Mechanical Lift

Required for clients who are unable to support their own weight

Normal mobility status

Ability to sit Ability to stand Ability to walk Use or need for assistance Degree of mobility and immobility Condition of the skin Presence of any manifestations during activity

Steps for moving a client up in bed in the correct order

Assess the client's level of mobility Get lift assistance Lock the wheels of the bed Raise the client's bed Position the client's arms across their chest Use the draw sheet to move client Lower the client's bed to the lowest position

Contracture

An abnormal fixation of a joint

Activities of daily living (ADLs)

Basic essential skills, usually related to personal care, that a person performs every day.

Deep damage through the skin and tissue layer

Deep wound with exposed muscle, ligaments, or bone, and dead tissue

Storage

Provide storage for calcium, phosphorus, magnesium, iron, and lipids