Ch.33 Activity PrepU

The nurse has asked the client to grasp his overbed trapeze and pull his torso up off the surface of the bed. What movement will the client perform with his arms?

Flexion

You are providing step-by-step instructions to a patient who is learning how to climb stairs while using crutches. Arrange the following instructions in the correct order.

"Place both crutches under your left arm." "Grasp the stair railing with your right arm." "Place your unaffected leg on the first stair tread." "Transfer your weight to the unaffected leg." "Move up onto the stair tread." "Move your crutches and the affected leg up onto the stair tread."

A patient 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 patient to ambulate with her crutches?

"Try to avoid putting too much pressure on your armpits with the tops of the crutches."

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that he is able to move onto the stretcher without her help. What is the nurse's best response?

"You are free to move onto the stretcher without assistance, but I will supervise for your safety."

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?

Supporting the client's back.

Which type of mobility aids would be most appropriate for a client who has poor balance?

A cane with four prongs on the end (quad cane)

When teaching range-of-motion exercises to a caregiver, a nurse moves the arm of the patient laterally to an upright position above the head, and then returns it to the original position. What term is used to describe this body movement?

Abduction

A client with asthma tries to jog a mile but cannot finish and complains of fatigue. An appropriate nursing diagnosis would be

Activity intolerance related to fatigue

The nurse and an assistant are preparing to move a client up in bed. Arrange the following steps in the correct order.

Adjust the head of the bed to a flat position. Remove all pillows from under the client. Position the assistant on the side opposite you. Place a friction-reducing sheet under the client. Ask the client to bend legs and place the chin on the chest. Grasp the sheet and move the client on the count of 3.

When the client restricts use of her dominant arm because of pain and the nurse notes that the measurement of the circumference of the client's nondominant arm is greater than her dominant arm, the nurse determines that the lack of use has resulted in the dominant arm's

Atrophy

The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client data would the nurse check to see if the assistance of another nurse is needed?

Client restrictions

While performing passive range-of-motion exercises on the lower extremities of a patient with a spinal cord injury, the nurse assesses permanent flexion of the muscles. What term will the nurse use to document this finding related to the muscles?

Contractures

A group of nursing students are reviewing the aspects of motor function control by the nervous system. The students demonstrate understanding of this information when they identify which of the following as a function of the cerebellum?

Coordination of movement motor activities

When turning a patient in bed, what positioning instructions would the nurse give the patient before using the friction-reducing sheet to turn the patient?

Cross the arms across the chest and cross the legs.

When the home care nurse notes that a widow of 3 months is not sleeping well, has no appetite, and does not attend activities outside the home, the nurse suspects the client is experiencing

Depression

A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed?

Every two hours

An obstetrical nurse is preparing to help a client up from her bed and to the bathroom three hours after the woman delivered her baby. Which of the following actions should the nurse perform first?

Explain to the client how the nurse will assist her.

A nurse uses proper body mechanics to move a client up in bed. Which of the following is a guideline for using these techniques properly?

Face the direction of movement.

Once applied, antiembolism stockings should not be removed until the primary care provider writes an order to discontinue them.

False

The nurse is helping a patient perform range-of-motion exercises on the hand and fingers. Which of the following exercises would be performed first?

Flex the hand down and backward and relax.

The nurse is teaching a patient how to perform range-of-motion exercises on the toes. What motions would be accomplished by curling the toes downward, spreading the toes apart, and then bringing them together?

Flexion, extension, abduction, and adduction

A nurse applies padded boots to maintain the foot in dorsiflexion on a client who is comatose. The nurse is protecting the client from what?

Foot drop

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Fowler's

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following actions will be most effective to transfer the client safely into the chair?

Have the client sit on the side of the bed for several minutes before moving to the chair.

A client is discharged to his daughter's home. He weighs 250 pounds and is immobile. The nurse should instruct the daughter on the use of a

Hydraulic lift

A nurse teaches a student nurse the importance of ambulating patients to prevent the effects of immobility on body systems. Which of the following is one of these effects?

Impaired circulation

The cardiac response to exercise is well-researched and documented. Which of the following is a cardiovascular response to regular exercise?

Increased efficiency of the heart

A client who is immobile complains of severe pain in the right flank. The physician diagnoses the client with renal calculi. This condition often results from

Increased serum calcium

A nurse is providing care to a client who has a cast on his leg. While teaching the client how to perform quadriceps setting exercises to strengthen the quadriceps muscle, he asks, "what kind of exercise is this?" The nurse identifies this type of exercise as which of the following?

Isometric

An orthopedic client is instructed to tighten the gluteus muscles and relax. This is an example of an

Isometric exercise

The nurse is preparing to move a patient using a powered full-body sling lift. Which of the following is a recommended action in this procedure?

Lower the side rail on the side of the bed being worked on.

The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure?

Lying flat

The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action?

Move the client to edge of the bed opposite the side that client will be turning.

The nurse is caring for a patient who is on strict bedrest. Her medical history includes partial paralysis from a stroke suffered several years ago. There is also evidence of early dementia. The nurse correctly recognizes the patient is at an increased risk for which of the following complications?

Muscle atrophy

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed?

Near the client's hip, with legs shoulder-width apart and one foot near the head of the bed

A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes that which of the following conditions is likely affecting the client?

Orthostatic hypotension

While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has which of the following?

Paralysis of the legs

A nurse is preparing to turn a hospitalized client age 65 years. Which of the following is a recommended guideline for performing this skill?

Position a friction-reducing sheet under the client.

A client 86 years of age with a diagnosis of late-stage Alzheimer's disease requires full assistance with transfers to and from his bed. Which of the following nursing actions is most likely to promote safe handling of this client?

Provide to the client brief, clear instructions that are phrased positively.

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which of the following actions should you take next to decrease the risk of impaired skin integrity?

Pull the shoulder blade forward and out from under the client.

The nurse is assisting a patient from the bed into a wheelchair. Which of the following is a recommended guideline for this procedure?

Raise the head of the bed to a sitting position.

Assessment of a client who is bedridden due to hip fracture reveals atrophy of the leg muscles due to immobility. The nurse demonstrates understanding of muscle atrophy, identify which of the following as a characteristic?

Reduction in muscle cell size

When assisting a client from the bed into a wheelchair, the nurse assesses the client standing up and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation?

Return the client to the bed.

A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease. The client always remains in a sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client?

Sacrum

The nurse is assisting a client to ambulate following knee surgery. What is a key concern when assisting clients with activity?

Safety

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

Shift their weight back and forth, from back leg to front leg.

A staff development nurse is discussing techniques to prevent back injury with a group of nursing assistants. The nurse informs the group that back stress and injury can be prevented by doing which of the following?

Spreading feet shoulder-width apart to broaden the base of support

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which of the following initial actions by the nurse is appropriate?

Support the client's body against yours and gently slide the client onto the floor.

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client?

The client's ability to assist

Which of the following phrases best explains the purpose of antiembolism stockings?

They promote venous blood return to the heart.

When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the patient. What is the rationale for using a transfer board in this procedure?

To reduce friction as the client is pulled laterally onto the stretcher.

A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as which of the following?

Tremor

When a patient independently moves all of the joints through their normal motions, it is referred to as active range of motion (AROM).

True

The nurse is assisting with range-of-motion exercises for a patient who is on bed rest following surgery. How often would the nurse perform each range-of-motion exercise?

Two to five times

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. What statement is correct regarding logrolling?

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.

When a client is lifted or held by a nurse, the additional weight becomes a part of the nurse's weight and should be ...

balanced over the center of gravity

When an older adult client walks with her knees slightly flexed and body leaning, the nurse determines that the client ...

is demonstrating a common gait for the older adult

Logrolling requires the nurse to use supportive devices in turning the client, in order to ...

maintain the natural alignment of the body

Which of the following are effects of immobility on the body? Select all that apply.

• Decreased muscle strength • Urinary stasis, infection • Impaired circulation and skin breakdown

A nurse is teaching an elderly patient how to use a walker. Which of the following instructions ensures 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