Chapter 33: Activity

The nurse has been educating a client about health promotion and exercise. What statement made by the client demonstrates that the education has been successful?

"I will invite a friend to exercise with me." xercising with a friend will add the support of a buddy. Joining a spa, health club, or exercise group is also recommended to provide support to exercise. Exercise sessions should be introduced gradually to prevent overexertion and injury to muscles. Clients should be encouraged to exercise for 30 to 45 minutes 3 or 4 times per week. Alternating types of exercise will help prevent boredom.

The nurse is encouraging the client to use hand rolls to prevent contractures. Which statement by the client indicates that further teaching is necessary?

"The hand rolls help me develop strength in my grip." Hand rolls prevent contractures (permanently shortened muscles that resist stretching) of the fingers. They keep the thumb positioned slightly away from the hand and at a moderate angle to the fingers. The fingers are kept in a slightly neutral position rather than a tight fist. A rolled-up washcloth or a ball can be used as an alternative to commercial hand rolls. Hand rolls are removed regularly to facilitate movement and exercise. Hand rolls are not used to strengthen the grip.

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

A client who has leg strength and can cooperate with the movement

The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason?

Acts to prevent injury to the client and/or nurse

Which nursing actions would the nurse perform when assisting clients with passive ROM exercises? Select all that apply

Adjust the bed to the flat position or as low as the client can tolerate. Begin ROM exercises at the client's head and move down one side of the body at a time. Move each joint in a smooth, rhythmic manner.

The nurse is preparing to reposition an older adult client. Which action(s) will the nurse take prior to moving the client to ensure client safety? Select all that apply.

Assess the client's blood pressure. Explain each step in the process. Allocate extra time to each step of the process.

The nurse is applying graduated compression stockings to the legs of a postsurgical client. The client suddenly complains of sharp pain to his left leg as the nurse is unrolling the stockings. What is the nurse's most appropriate action?

Assess the client's leg for signs and symptoms of deep vein thrombosis and inform the primary care provider.

The nurse is assessing a client's ability to use a walker. The nurse would provide additional information if which behavior were observed?

Correct response: The client pushes the walker ahead, following behind it.

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?

Equipment is positioned to the side, 50 degrees away. Proper ergonomics promote comfort, performance, and health in the workplace. All findings support proper ergonomics, with the exception of equipment positioning. Equipment should be positioned 20 to 30 degrees away, in front, not off to the side, to avoid turning or twisting of the head, neck, and shoulders.

The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply.

Fowler Semi-Fowler Upright

The nurse is orienting a new unlicensed assistive personnel (UAP) to hospital policies. While a client is participating in physical therapy the UAP decides to make the bed. What are appropriate action(s) by the nurse after entering a hospital room and observing the UAP in the image? Select all that apply.

Inform the UAP the linens should not be placed on the floor for any reason Communicate the importance of using proper body mechanics to avoid straining the back

The nurse is assisting with client transfer. Which guideline(s) will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply.

Lower the bed to the lowest position allowing the client's soles to contact the floor. Provide the client with nonskid slippers to put on prior to standing up. Provide step-by-step instructions to the client before the transfer begins.

A nurse is providing care for a frail older adult client with chronic obstructive pulmonary disease (COPD). The client always remains in a sitting position, leaning forward to improve oxygenation. Which assessment(s) provide data of possible impaired tissue integrity? Select all that apply.

Monitor skin integrity of heels. Monitor ischial tuberosities for pressure injury. Evaluate the client's awareness of pressure sensation. Assess for edema.

The nurse directs the unlicensed assistive personnel (UAP) to help a partially blind older adult client with meals. Which information is appropriate for the nurse to provide the UAP to facilitate the client's comfort and safety during mealtime? Select all that apply.

Place client in upright position at a 45- to 90-degree angle in the bed or chair Provide verbal cues regarding location of food on plate Cut food into small pieces Ensure that the temperature of food is safe

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body?

Short bones contribute to movement.

The nurse is preparing the client for the administration of an enema. The nurse will place the client into which position?

Sims

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

Sims'

A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take?

Tell the client he can remove them for 20 or 30 minutes during this shift.

The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table?

The client is aware of spatial relationships to avoid the table.

A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall?

The nurse should gently slide the client down his or her body to the floor.

Using proper body mechanics, which motions would the nurse make to move an object?

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

In an assessment for proper body alignment of a standing client, which finding is normal?

The weight of the body is distributed on the soles and heels.

A nurse is assisting in the transfer of a client with a diagnosis of Alzheimer's disease to a stretcher. The client experiences frequent periods of agitation and is unable to follow cues or directions. Which device would be the best choice for transferring this client?

Transfer chair Chairs that can convert into stretchers are available. These are useful with clients who have no weight-bearing capacity, cannot follow directions, and/or cannot cooperate. The back of the chair bends back and the leg supports elevate to form a stretcher configuration, eliminating the need for lifting the client. Powered stand-assist and repositioning devices require the client to have weight-bearing capacity in one leg. Gait belts are used to assist clients to ambulate safely.

The nurse is performing an admission for a client determined to be a high fall risk. What interventions should be a priority for the nurse to employ to provide a safe environment for the client? Select all that apply.

Use a chair alarm when the client is out of the bed. Use a bed alarm to signal when the client gets up

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?

When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.

A nurse is teaching a client who has unilateral weakness how to walk with a cane. Which guideline promotes safe use of this device?

When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane. When stepping forward, the heel should be slightly beyond the tip of the cane. The client should hold the cane on the opposite side of the foot with the deficit and evenly distribute weight between the feet and the cane. The client should step first with the weaker leg.

The nurse is caring for a client who is postoperative from a hip fracture repair. The nurse must be careful to avoid:

adduction of the affected leg. For some types of hip surgery, dislocation can result from movement of the leg toward or past the midline of the body (adduction). Thus, to prevent injury, it is important to avoid hip adduction on clients who have had hip replacement surgery.

The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply.

adjust the height of the work area face in the direction of the activity he is performing use a wide stance and lift with the large leg muscles

The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher?

alongside the bed at the same height

The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse correctly documents the presence of:

ataxia.

A nurse is promoting body movements for a client during range-of-motion exercises. Which movement(s) provide for flexion? Select all that apply.

bending the hand or foot backward and forward bending the leg and bringing the heel toward the back of the leg, then returning the leg to the straight position curling the toes downward and then straightening them out extending the leg and lifting the thigh toward the abdomen, then returning the leg to the original position

A nurse is conducting an in-service education program for a group of staff nurses about ways to reduce their risk for injuries incurred while working with clients. Which action(s) would contribute to this risk? Select all that apply.

engaging in repetitive movements lifting when tired using uncoordinated lifts standing for long periods

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

foot drop.

When moving a client up in bed with the assistance of another caregiver, the nurse should:

have the client fold the arms across the chest.

The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?

placing the client in good alignment with joints slightly flexed

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

predisposition to renal calculi

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group?

scoliosis

An 85-year-old white woman walks 1 mile (1.6 km) every morning and every evening. She continues to smoke but has cut back to half a pack per day. She had a total oophorectomy at age 45 secondary to stage I ovarian cancer. This client is currently not on any medications. Which is not a primary risk factor for osteoporosis for this client?

sedentary lifestyle

An older adult client is transferring from a supine position to a sitting position in a chair. The client reports dizziness when transferring. Which teaching by the nurse is most appropriate?

"Move slowly and sit on the edge of the bed before transferring to the chair."

The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include?

"Picture yourself with good posture standing; that is how good lying posture works."

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?

"Put your arm in this sleeve." When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions.

A nurse is teaching a client how to use a walker. Which instructions should the nurse provide? Select all that apply.

"Stand centered between the back legs of the walker." "Keep your arms relaxed at the side of the walker." "Line up the top of the walker with the crease on the inside of your wrist."

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response?

"To preserve the client's functional ability to grasp and pick up objects."

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

"To prevent your legs from rotating outward."

The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response?

"You have lost the padding in your joints and the friction causes pain."

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?

"Your elbows will be slightly bent when you are using your crutches."

The nurse is preparing to apply compression stockings for a client that is at risk for the development of deep vein thrombosis. What action(s) by the nurse demonstrate to the client the appropriate way to apply the stockings? Select all that apply.

Assess the skin and neurovascular status of the legs and feet before applying. Have the client lie down with legs and feet elevated for at least 15 minutes before applying. The nurse needs to measure the client's legs to determine the proper size of stocking. Each leg should have a correct fitting stocking; if measurements are different, then two different sizes of stocking need to be ordered to ensure correct fitting on each leg. The size should not be estimated. The nurse will apply the stockings in the morning before the client is out of bed and while the client is supine. If the client is sitting or has been up and about, the nurse will have the client lie down with legs and feet elevated for at least 15 minutes before applying the stockings. Otherwise, the leg vessels are congested with blood, reducing the effectiveness of the stockings. The nurse will not massage the client's legs before applying the stockings. If a clot is present, massaging the leg may break it away from the vessel wall and it can circulate in the bloodstream.

A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply.

Exercise increases intestinal tone. Exercise increases efficiency of the metabolic system. Exercise increases blood flow to kidneys.

The nurse assists a client who has had a stroke affecting the left side causing difficulty moving the hand and fingers. Which range-of-motion exercise(s) will the nurse use? Select all that apply.

Extension of fingers Flexion of fingers Adduction of fingers Abduction of fingers

A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction?

Hold your cane on the right side.

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.

The nurse assesses a 68-year-old client being treated for heart failure who reports dyspnea with mild activity, sitting at a desk most of the day while working, and preferring an orthopneic position. Recognizing that the client is at risk for disuse syndrome, which intervention(s) will the nurse initiate? Select all that apply.

Instruct the client to sit upright to prevent dyspnea. Offer activity options and their benefits that match the client's interests and address the client's needs. Collaborate with physical, occupational, and recreational therapists to implement an individually tailored exercise program. Encourage active range-of-motion exercises.

The nurse is performing an assessment of a client's joint mobility. What documentation should the nurse provide related to this assessment if joint function is considered normal? Select all that apply.

No masses, deformities, or muscle atrophy Full range of motion with each joint No swelling, heat, tenderness, pain, nodules, or crepitation

The nurse is preparing to reposition a client on bedrest to the left side. Which action should the nurse prioritize?

Seek assistance from another health care worker.

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.

At a well-child visit, the nurse is observing siblings at play. Which observed behaviors would be of concern to the nurse and would require additional assessment? Select all that apply.

The 3-year-old sits by as the 5-year-old stacks a tower of blocks. The 3-year-old does not join the 5-year-old in the jumping game.

When assessing correct body alignment when the client is standing, the nurse would document which abnormal findings? Select all that apply.

The arms are bent at the elbows. The knees are bent.

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

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight alignment when the client is being turned. The nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement. The nurse should avoid twisting the client's head, spine, shoulders, knees, or hips while logrolling. A chair is not used with logrolling.

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

a cane with four prongs on the end (quad cane) Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold but are not recommended for clients with poor balance. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.

A 45-year-old man is interested in starting an exercise program. The nurse informs him that exercise does not:

decrease appetite.

The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change?

decrease in flexibility

Which body system effects would the nurse state as occurring due to immobility? Select all that apply.

increased cardiac workload increased risk for renal calculi Increased risk for electrolyte imbalance

The nurse observes an older adult client walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating?

is demonstrating a common gait for the older adult.

As a part of his workout regimen, a 21-year-old college football player often engages in both a 10-minute squat hold and 10-minute lateral arm hold. These are examples of what type of exercise?

isometric

A nurse is interviewing a client about the client's usual activity level. The client states, "I swim laps 2 to 3 times a week and walk 1 to 2 miles twice a week. The nurse interprets this activity as which type of exercise?

isotonic

The nurse is preparing to transfer a client from the bed to a stretcher. What action should the nurse take to prevent injury to the client and nurse?

leave the friction-reducing sheet in place once the client is transferred

When turning a client in bed, what muscle groups would the nurse use to pull the client to the opposite side of the bed?

leg

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene?

lowering the height of the bed prior to moving the client Lowering the height of the bed is an incorrect action that would require the nurse to intervene. The bed should be raised to the height of the caregiver's elbow, or to a comfortable working height before the client is positioned. All other options are appropriate positioning techniques.

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

move the client to edge of the bed opposite the side that client will be turning When turning a client in bed, the nurse would use a friction-reducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Pushing the client to the opposite side of the bed is not good for back safety. Consult a Safe Patient Handling algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client.

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client 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 nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program?

obtain a pre-exercise medical examination for clearance

The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement?

place a small pillow under each arm

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate?

placing a small towel under the neck

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.

placing nightlights in the bathroom and hallways removing clutter from the floor moving the bedroom to the ground floor

The nurse is developing a plan of care for a client who has been in the (protective) prone position. What should the nurse be sure to monitor the client for, related to the positioning?

plantar flexion of the feet

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse?

positioning a friction-reducing sheet under the client to facilitate movement

The nurse is caring for a client who has a lower-body injury and who is able to partially assist with transfers. The nurse should:

provide the client with an overhead trapeze.

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

pull the shoulder blade forward and out from under the client

The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select?

risk for impaired skin integrity

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?

trochanter rolls

A client is to do quadriceps drills as an isometric exercise after surgery. The nurse provides which information about this exercise? Select all that apply.

"The muscle you are tightening is the one on the front of the thigh." "Do not hold your breath while tightening the muscle." The quadriceps muscle is on the front of the thigh. The exercise is done by tightening the muscle for the count of four, relaxing fully for the count of four, and then retightening the muscle. Holding the breath while doing these exercises can cause strain on the heart. The exercises should generally be done three or four times per hour and four to six times per day. The client should avoid tiring the muscle.

A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client?

Client is in supine position with arms in functional position and pillow support under the knees.

A client expresses concern that there is an increase in urine output after exercising. How would the nurse address the client's concern? Select all that apply.

Explain that urination after exercise is a result of increased circulation to the kidneys and is a normal function Assess cardiovascular function and blood pressure Ask the client to provide details of the exercise regimen including frequency and type Evaluate for diabetes mellitus

The nurse is providing discharge teaching to a family member of a client who has recently developed right sided weakness post-stroke. Which information will the nurse provide when educating the family member on how to assist the client to mobilize? Select all that apply.

Have the client dangle legs on the side of the bed before standing. Rock the client to standing position based on an agreed signal. Have the client stand for 1 minute before trying to take steps. Encourage the client to slowly take small steps.

Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer?

If the client is in pain, administer analgesics in advance of the transfer. If the client is in pain, administer the prescribed analgesic sufficiently in advance of the transfer to allow the client to participate in the move comfortably. Clients should be encouraged to assist in their own transfers. During any client-transferring task, if any caregiver is required to lift more than 35 lb (16 kg) of a client's weight, then the client should be considered to be fully dependent and assistive devices should be used for the transfer. Handling aids should be used whenever possible to help reduce the risk of injury to the nurse and client.

A nurse is caring for an older adult client who has osteoporosis. Upon further examination the client reports smoking one pack of cigarettes per day, social alcohol consumption, a low-fat low-carb diet, and walks for exercise at least once a week. What primary intervention would the nurse recommend to help the client prevent further bone loss?

Increase regular weight-bearing exercises such as brisk walking, dancing, and yoga to at least 3 times per week. Osteoporosis is a condition where bone destruction exceeds bone formation and in which the resultant thin, porous bones fracture easily. Bone loss can be decreased by smoking cessation, no or limited alcohol and caffeine consumption, and a diet rich in calcium and vitamin D. However, adding regular weight-bearing exercises and increasing the frequency would be the primary intervention as this has proven to prevent further bone density loss. A diet high beneficial fats would not affect bone density directly and weight-lifting exercises are not the recommendation for older adults with osteopenia or osteoporosis.

Which strategy(ies) does the nurse use to maintain proper body mechanics and prevent self-injury? Select all that apply.

Place feet shoulder width apart when lifting an object Plant feet firmly on the floor when supporting the client during dangling When lifting an object, the nurse will place the feet shoulder width apart with feet planted firmly to provide a stable base of support. When supporting the client during dangling, the nurse will tighten the gluteal and abdominal muscles to avoid back strain or injury. When lifting an object, the nurse will bend at the knees instead of the waist because the thigh muscles are larger in mass than either the buttocks or back muscles. The nurse will get close to the object to be lifted to prevent excess stress on arm and back muscles. The nurse does not hold heavy object away from the body nor lock the elbows during lifting and carrying objects. These actions put extra stress on the muscles of the back and this strain could lead to injury.

A nurse is explaining to a caregiver the value of nonpharmacologic methods of pain management. Which statement best describes the proper rationale for using nonpharmacologic methods to help manage pain?

Use of nonpharmacologic methods can diminish the emotional component of pain. Nonpharmacologic methods of pain management can diminish the emotional components of pain, strengthen coping abilities, give clients a sense of control, contribute to pain relief, decrease fatigue, and promote sleep. Although it is true that nonpharmacologic methods do not require a health care provider's prescription, it is not the best rationale for their use. Many nonpharmacologic methods are more expensive than pain medications, especially if nursing staff are needed to implement the methods. Nonpharmacologic interventions lessen the emotional impact of pain but may not diminish the sensation of pain. A combined approach is often most effective.

The nurse is caring for a client who is ordered to be in the Fowler position. When assessing the client's position in bed, the nurse will adjust the client in bed if what is observed? Select all that apply.

There is a large pillow under the client's head. The knee gatch on the bed is engaged. The client's foot is in the plantar flexion position. n the Fowler position, the client's head should be against the mattress or supported by a small pillow only. Using a large pillow may cause flexion contracture of the neck. The knee gatch should be avoided to prevent pressure on the popliteal artery that could compromise lower extremity circulation. When the client's foot is in the plantar flexion position, the client is at risk for foot drop. A foot board, high-top sneakers, or improvised firm foot support should be used. It is appropriate to place the client's forearms on pillows. This will prevent pull on the shoulders and help prevent dislocation of the shoulder. A rolled towel or trochanter roll will help prevent external rotation of the hips.

A client's job requires moving heavy objects from one surface to another. The nurse will provide which anticipatory guidance to help this client avoid a back injury? Select all that apply.

Work as closely to the objects you are moving as possible. Flex the knees to improve balance and strength. Face in the direction in which you are moving the load. Standing with the feet apart and knees flexed will improve balance. Objects should be pushed, not pulled, if possible. Working close to the object and facing in the direction of movement improve strength.

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?

bed trapeze

The nurse would like to assist a client out of bed and into a chair. The client is uncooperative, has a leg cast, and can bear weight on the unaffected leg. Which equipment or assistive device should the nurse use?

powered full-body lift Many devices are available to aid in transferring, repositioning, and lifting clients. It is important to choose the right equipment and appropriate device on the basis of client assessment and desired movement. Although this client can bear weight on the unaffected side, the client is uncooperative. A powered full-body lift device should be used. A lateral assist device is used during side-to-side transfers to make transfers safer and more comfortable for the client. A friction-reducing device can be used under clients to prevent skin shearing when moving clients in bed and when assisting with lateral transfers. A powered stand-assist device can be used with clients who can bear weight on at least one leg, can follow directions, and are cooperative.

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern?

shortness of breath after walking up five stairs

The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client?

slight Trendelenburg

The nurse is assessing an older adult client who is having difficulty with mobility. Assessment reveals that the client has stiff and awkward muscle movements. The nurse identifies this as:

spasticity.

The nurse is assessing the client for muscle mass, tone, and strength and determines that there is increased tone that interferes with movement. How does the nurse document this finding?

spasticity.

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:

steps into the walker when walking.

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

the 24-month-old child who is unable to walk unassisted

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?

transfer belt A transfer belt is designed for clients who can bear weight and help with the transfer but are unsteady. The other options are inappropriate for this client.

The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care?

trapeze bar

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:

tremor