Chapter 16

Dorsiflexion

Ankles flexed at 90 degrees so the toes point to the ceiling when the patient is in a supine position

A patient is returning to your unit from surgery. What assistive device would you place in the room prior to the patient's return?

A slide board or slide sheet to facilitate transfer of patient from the stretcher to the bed.

To perform perineal care, you will place the patient in which position? A. Dorsal Recumbent B. Trendelenburg C. Reverse Trendelenburg D. Sims'

A. Dorsal recumbent

When you prepare to turn a patient who has had a spinal surgery, you will plan to... A. Have a total of three health-care staff assist with the turn B. Have the patient assist by using a trapeze bar C. Have each person turn a section of the patients body at a separate time D. Logroll the patient E. Have one person at the patient's head to direct the turn

A. Have the total number of health-care staff assist with the turn D. Logroll the patient E. Have one person at the patients head to direct the turn

Why is it important to explain what you will be doing when you assist a patient with position changes? A. The patient may be sedated or have an impaired level of consciousness B. The patient may have a preference about who performs repositioning C. The patient will be more cooperative with the position change D. The patient will be less likely to resist during the position change E. The patient can more easily assist with the position change

A. The patient may be sedated or have an impaired level of consciousness C. The patient will be more cooperative with the position change D. The patient will be less likely to resist during the position change E. The patient can more easily assist with the position change

Which assistive device will you use to assist a patient with mild-right sided weakness as he moves from the bed to the wheelchair? A. Transfer belt B. Slide sheet C. Slide board D. Transfer board

A. Transfer belt

When you assist a patient to a left lateral position, where will you place the additional pillows? A. Under the knees B. Between the knees and ankles and at the back C. At the right lateral thigh D. At the soles of the feet and at the back

B. Between the knees and ankles and at the back

A patient you are caring for has been on bed rest for 4 days and is having difficulty with gas and constipation. What nursing interventions will you use to help prevent further gastrointestinal complications? A. Encourage fluid intake of 6 ounces Q4 hours to prevent further constipation B. Help the patient choose well-balanced meals, keeping in mind the patient's food preferences C. Assess bowel sounds and the frequency of bowel movements, document D. Serve preferred liquids with a straw to provide continuous access to fluids E. Encourage fresh fruits and vegetable intake, raw if possible, to add fiber

B. Help the patient choose well-balanced meals, keeping in mind the patients food preferences C. Assess bowel sounds and the frequencies of bowel movements, document E. Encourage fresh fruits and vegetable intake, raw if possible, to add fiber

When you care for your assigned patient with paralysis of both legs, you are concerned about skin breakdown. Which nursing interventions would you use? A. Reposition him every 4 hours while he is in bed B. Inspect bony prominences for redness every two hours. If found, massage around the area but not on it C. Dry skin thoroughly but gently after cleansing it with mild soap D. Pat bony prominences with fluffy towels to relieve pressure points E. Provide adequate nutrition so that the tissue can repair itself

B. Inspect bony prominences for redness Q2 hours. If found, massage around the area but not on it C. Dry skin thoroughly but gently after cleansing it with mild soap E. Provide adequate nutrition so that the tissue can repair itself

How can you be certain that the wheels of a stretcher are locked before transferring a patient? A. Press the foot lock and announce loudly that the wheels are locked B. Physically attempt to move the stretcher, even when you lock the wheels C. Bend down on one knee to ensure that the red lever is up and the green one is down D. Assign one person to hold the stretcher in place while the patient is transferred

B. Physically attempt to move the stretcher, even when the wheels are locked

How will you provide stability as you assist a patient to stand before you begin ambulation? A. Place a gait belt around the patient's shoulders B. Place your feet in front of the patient's feet and your knees against the patient's knees C. Have the patient use a walker to stand but not while he or she ambulates D. Place a rolled blanket in front of the patient's feet to prevent slipping

B. Place your feet in front of the patients feet and your knees against the patient's knees

What is the purpose of assisting a patient to dangle? A. To increase blood flow to the feet and legs B. To determine if the patient can tolerate changing positions C. To allow time to assist the patient to put on a robe and slippers D. To evaluate circulation to all extremities

B. To determine if the patient can tolerate changing positions

What common linen item might you use to manually transfer a weak patient who is unable to help move himself from a bed to a stretcher if no assistive devices are available?

Bath Blanket

A newly admitted patient with a diagnosis of right-sided weakness resulting from cerebrovascular attack puts on her light and asks for assistance to the bathroom. You have not yet assessed her transfer abilities. What will you do? A. Ask the CNA assigned to patient to carefully assist her to the commode B. Tell the CNA that the patient has right-sided weakness but can transfer with minimal assistance C. Ask the CNA to accompany you and together transfer the patient to the bedside commode D. Ask the CNA to assist the patient with a bed pan until you have time to get an order for a lift for her

C. Ask the CNA to accompany you and together transfer the patient to the bedside commode

Slide sheets are different from draw sheets because they are: A. Placed beneath the patient B. Used to move the patient up in bed C. Made of thin webbed nylon D. Used to turn the patient from back to side

C. Made of thin webbed nylon

You and a UAP are preparing to turn an immobile patient from her back to her right side. Which of the following actions will you take first? A. Place a pillow between her knees and ankles B. Cross the patient's left leg over her right leg C. Move the patient to the left side of the bed D. Externally rotate the patients right shoulder

C. Move the patient to the left side of the bed

Which position do you use for a patient in sever respiratory distress? A. Lithotomy B. Dorsal recumbent C. Orthopneic D. Semi-Fowler's

C. Orthopneic

Which assistive device would you use after a patient had fallen to help him or her return to the bed? A. A slide board B. A slide sheet C. A transfer belt D. A battery-operated lift

D. A battery-operated lift

When performing range of motion exercises, which action will you take first? A. Cover the patient with a bath blanket to preserve dignity and keep the patient warm B. Wash your hands to prevent cross-contamination C. Exercise the patient's neck by moving it from side to side D. Check the patient's chart for any contraindications to full range of motion exercises

D. Check the patient's chart for any contraindications to full range of motion exercises

You are concerned about the psychological effects of immobility on the patient you are caring for during your clinical experience. To help prevent psychological complications, you would avoid which of these interventions? A. Encourage the patient to stay awake during the day and allow natural light into the room B. Encourage the patient to read, watch tv, solve puzzles, and interact with family and friends C. Encourage the patient to do as much as possible during his personal care D. Encourage the patient to look on the bright side and be glad that he is alive, even though he is paralyzed

D. Encourage the patient to look on the bright side and be glad that he is alive, even though he is paralyzed

Syncope

Fainting

Plantar flexion

Foot pointing in a downward direction

Lateral position

Lying on the right or left side with the back supported, pillow between knees and ankles

Transfer

Move a patient from one place to another

Footdrop

Permanent plantar flexion of the foot

Trochanter Roll

Placed at the lateral aspect of the patient's thigh to prevent outward rotation of the leg

Supine

Position described as lying on the back with the arms at the sides

Prone

Position described as lying on the stomach with the head turned to the side

Fowler's position

Semi-sitting position with HOB elevated and knees slightly elevated

Contractures

Shortening or tightening of muscles as a result of disuse

If a patient is able to bear partial weight but not full weight, which type fo assistive device would you select to transfer him from the bed to the wheelchair?

Sit to stand lift

Semi-fowler's position

Sitting position with the HOB elevated 45 degrees

Orthopedic position

The position used to assist patients in severe respiratory distress, allowing maximum expansion fo the chest for moving air in and out of the lungs

Shearing

This occurs when the skin layer is pulled across the muscle and bone in one direction, while the skin slides over the bedsheet in the opposite direction

Logroll

Turn the patient with the body as one unit

Orthostatic hypotension

When a patient's blood pressure decreased with a change in position it is referred to as...

Position of function

When you position a patient so that his or her extremities are in alignment to maintain the potential for their use and movement

Sim's

When you prepare to administer an enema, you will place the patient in this position