Chapter 33 Mobility PrepU

The nurse is caring for a client who works in a warehouse and has been having low-back pain. Which statement by the client indicates the need for more education regarding safe lifting? "I stand with my feet apart so I have a better stance when I lift." "I bend with my knees when I pick up boxes." "I try to rest between periods of lifting." "I hold the boxes away from my body so I do not drop them on my feet."

"I hold the boxes away from my body so I don't drop them on my feet." Heavy objects should be held close to the body to distribute the weight evenly and prevent muscle strain. Other options are correct lifting techniques.

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. "Don't fully relax the muscle between episode of tightening." "Do not hold your breath while tightening the muscle." "Repeat this exercise until your muscle is tired." "Do these exercises once in the morning and once in the evening." "The muscle you are tightening is the one on the front of the thigh."

"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.

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response? "To help client to turn independently." "To preserve the client's functional ability to grasp and pick up objects." "To prevent foot drop." "To prevent the legs from rotating outward."

"To preserve the client's functional ability to grasp and pick up objects." Trochanter rolls prevent the legs from rotating outward. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop. Side rails help a weak client turn independently and protect the client from falling out of bed.

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

- 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 nurse is providing care for a client recovering from a stroke and teaches the spouse about caring for the client. Which strategy(ies) does the nurse include about how the spouse can maintain proper body mechanics and prevent injury to oneself? Select all that apply.

- When supporting your spouse during dangling, tighten your gluteal and abdominal muscles to avoid back strain or self-injury. - Grip the gait belt as your spouse walks so that you can provide aid if your spouse begins to fall. - Use a gait belt to help your spouse transfer from bed to chair. - Always keep your spouse close to your body during the transfer. - Use the muscles in your legs to lift and/or pull. When teaching the spouse about his or her safety while providing care for the client who had a stroke, the nurse will explain that when the caregiver supports the spouse during dangling, the caregiver should tighten the gluteal and abdominal muscles to avoid back strain or self-injury. In addition, the nurse will tell the caregiver to use a gait belt to help the spouse transfer from bed to chair to prevent the caregiver injuring one's own shoulders and back. The caregiver will also be advised to always keep the spouse close to one's body to prevent shoulder and back strain to self. The caregiver will be told to use the muscles in the legs to lift and/or pull rather than using the shoulders and back. When transferring a client, the body should turn with the client and there should not be a rotation movement as this will cause back injury.

The nurse is caring for a client who is on bed rest. After revieiwng the image above, which is the most appropriate reason for the nurse to observe this client perform the activity? "This physical exercise only helps to promote blood flow to the extremities." "A client can perform this activity to prevent a permanent condition in the feet caused by bed rest." "It is important for the client to perform this exercise so the gluteal muscles do not shorten and cause one leg to be longer than the other." "The activity will help the client to build muscle mass in the calves."

A client can perform this activity to prevent a permanent condition in the feet caused by bed rest." Assisting and observing the client perform dorsiflexion of the feet helps to reduce the risk of foot drop. Foot drop can occur if the toes of the feet are dropped downward for extended periods of time resulting in plantar flexion caused by changing the length of the muscles. Due to the gravitational pull, this position of the feet occurs naturally when the body is at rest and the toes are placed in a perpendicular position making heel-toe gait impossible. This results in altered mobility. Wearing shoes such as a high-top canvas sneaker could assist to minimize this complication of prolonged bed rest.

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

A client's body is in correct body alignment while standing when the weight of the body is distributed on the soles and heels. The chest is held upward and forward. The abdominal muscles are held upward and the buttocks downward. The line of gravity goes midline through the center of the knees and in front of the ankle joints.

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 stumbling gait unequal pupil size reports of pain in the lower back

A decrease in the flexibility of joints is a normal age-related finding. Pain in the lower back, stumbling gait, and unequal pupil can be indicators of pathology and are not normal age-related findings.

Which client would the nurse place in a protective prone position?

A nurse would place a client prone to hyperextension of the spine in a protective prone position. A nurse would place a client prone to edema of the hand in Fowler's position. A nurse would place a client prone to internal shoulder rotation and adduction in protective supine position. A nurse would place a client prone to flexion contracture of the neck in protective supine position.

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? mechanical lift transfer boards transfer belt roller sheet

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 has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: uses the sides of the walker to rise from a chair. leans over the walker when walking. places the walker far in front when walking. steps into the walker when walking.

A walker is mechanical aid that enhances the client's balance and ability to bear weight. Education is usually done by physical medicine or physical therapy, but the nurse should continue to assess the client's ability to use the walker properly. The client should step into the walker when walking rather than walking behind it. When the client is rising from a seated position, the arms of the chair, not the walker, should be used for support. The client should be cautioned to avoid pushing the walker out too far in front. Also, the client should avoid leaning over the walker but should instead stay upright while moving.

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?

Activity Intolerance may result from any condition that interferes with the transport of oxygenated blood to tissue. The altered response to activity includes exertional dyspnea, shortness of breath. Shortness of breath after walking up five stairs would be included in this nursing diagnosis. Another altered response would be excessive increase in pulse rate. After walking up 20 stairs, a change in pulse of 4 points is not excessive. Joint stiffness is a defining characteristic of the nursing diagnosis Impaired Physical Mobility. Walking with a slow and uncoordinated movement is another defining characteristic of Impaired Physical Mobility.

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?

Adduction is a lateral movement of a body part toward the midline of the body. An example of adduction is when a person's arm is moved from an outstretched position to a position alongside the body. Abduction is a lateral movement of a body part away from the midline of the body. An example of abduction is when a person's arm is moved away from the body. Circumduction is turning in a circular motion. This motion combines abduction, adduction, extension, and flexion. An example of this movement is the circling of the arm at the shoulder, as in bowling or a serve in tennis. Extension is the state of being in a straight line. An example of extension is when a person's cervical spine is extended, the head is held straight on the spinal column.

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?

Adequate skeletal muscle mass, tone, and strength are prerequisites to appropriate body movement and work performance. Spasticity, or hypertonicity, is defined as increased tone that interferes with movement. Spasticity is caused by neurologic impairments, and is often described as a stiffness, tightness, or pulling of the muscle. Hypertrophy refers to increased muscle mass resulting from exercise or training. Atrophy describes muscle mass that is decreased through disuse or neurologic impairment. Flaccidity, or hypotonicity, results from disuse or neurologic impairments, and is described as a weakness of paralysis

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?

Adequate skeletal muscle mass, tone, and strength are prerequisites to appropriate body movement and work performance. Spasticity, or hypertonicity, is defined as increased tone that interferes with movement. Spasticity is caused by neurologic impairments, and is often described as a stiffness, tightness, or pulling of the muscle. Hypertrophy refers to increased muscle mass resulting from exercise or training. Atrophy describes muscle mass that is decreased through disuse or neurologic impairment. Flaccidity, or hypotonicity, results from disuse or neurologic impairments, and is described as a weakness of paralysis.

When assessing the physical activity of clients, the nurse would be most concerned about which client?

Although further assessments should be done to avoid making assumptions and imposing stereotypes, there are many variables that may contribute to a sedentary lifestyle, such as occupations. A computer programmer has a job that is inactive. The nurse would be concerned about this client and would need to do further assessments to determine activity, frequency, and intensity that occur outside of work. The mother of small children would be involved in housecleaning and chasing after the children. Walking is a commonly prescribed exercise, and going to the mall provides a safe environment where walking would be possible. A Native American who hunts is engaging in culturally related physical activity.

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

At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raise the head, but this is not expected at this age. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month-old infants. Stacking blocks is accomplished by most 3-year-olds, but doing so at 18 months is considered early.

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 refers to a lack of muscle coordination. Tremors are rhythmic, repetitive movements. Chorea is spontaneous, brief, involuntary muscle twitching of the limbs or facial muscles. Athetosis refers to movement characterized by slow, irregular, twisting motions.

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 refers to a lack of muscle coordination. Tremors are rhythmic, repetitive movements. Chorea is spontaneous, brief, involuntary muscle twitching of the limbs or facial muscles. Athetosis refers to movement characterized by slow, irregular, twisting motions.

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?

Be prepared to apply the stockings in the morning before the client is out of bed. Assist the client to a supine position. If the client has been sitting or walking, have him or her lie down with legs and feet well elevated for at least 15 minutes before applying the stockings. Powder the leg lightly unless client has a breathing problem, dry skin, or sensitivity to the powder. If the skin is dry, a lotion may be used. Powders and lotions are not recommended by some manufacturers; check the package material for manufacturer specifications.

Which exercises would the nurse recommend when planning isometric exercise for a client? Select all that apply.

Contracting the quadriceps, Kegel exercises, and contracting and releasing the gluteal muscles are isometric exercises that the nurse might recommend to a client. Jogging, range-of-motion exercises, and bicycling are isotonic exercises.

A client who has an immobilizer on the arm reports shortness of breath following ambulation to the bathroom. The nurse notes the client's pulse increased from 82 to 124 beats/min, respirations increased from 16 to 24 breaths/min, and blood pressure is 90/50 mmHg. The nurse makes the nursing diagnosis of Activity Intolerance. What are the client's defining characteristics for this diagnosis? Select all that apply.

Defining characteristics for the nursing diagnosis Activity Intolerance include the client's report of shortness of breath with activity, increased pulse rate, increased respiratory rate, and decrease in blood pressure. Limited range of motion is a defining characteristic for the nursing diagnosis Impaired Physical Mobility.

The nurse is caring for an 84-year-old client. While assessing the client, the nurse notes that the client has an unsteady gait and weak muscle strength and tires easily with physical exertion. How will the nurse document this finding?

Disuse syndrome is the appropriate documentation of this client finding. Energy is the capacity to do work. Alignment is the part of an object in proper relationship to others. Functional position is the position in which an activity is properly and normally performed. Therefore low energy, poor alignment, and functional position are not how the nurse would document this finding.

A client has been prescribed graduated compression stockings to wear for the next three weeks. The nurse will implement which interventions? Select all that apply. Remove the stockings and massage the legs once each day. Measure each leg and take an average to determine size to order. Order at least two pairs of stockings. Plan to put the stockings on the client right before bedtime. Launder the stockings at least every three days.

Each leg should be measured, and stockings ordered to fit. If there is difference between the size of the legs, the nurse should order two sizes of stockings. At least two pairs of stockings must be ordered so that the client has a pair to wear while the other pair is being laundered. The stockings should be put on for the first time in the morning before the client gets out of bed. The stockings should be removed each day, but the legs should not be massaged. The stockings should be laundered regularly, at least every three days.

On a previous clinic visit a month ago, an overweight client reported shortness of breath with activity and constipation. The client was diagnosed as having osteoporosis and noted to have an elevated triglyceride level. The primary care provider prescribed an exercise program. The nurse is assessing for the effects of exercise. What are the expected outcomes for this client? Select all that apply.

Effects of an exercise program include improved work of breathing (no shortness of breath with activity), improved bowel elimination (regular and formed bowel movements), and weight controlled at the current weight, or ideally lessened. The client's blood triglyceride level should decrease with an effective exercise program. The client should experience increased joint mobility and less joint pain.

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?

Exercising 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 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 Hyperextension of fingers Adduction of fingers Abduction of fingers Flexion of fingers

Extension of fingers Flexion of fingers Adduction of fingers Abduction of fingers The standard range-of-motion exercises for the fingers of the left hand that will assist the client are extension, flexion, adduction, and abduction of the fingers. Hyperextension of the fingers is not appropriate and may cause injury to the client.

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 is achieved when a body part is bent, as when the elbow is bent and the upper arm and forearm are brought together. Adduction and abduction denote lateral movement to and from the body, and dorsiflexion is backward bending of the hand or foot.

The nurse is assisting the client who has dementia from the bed to the chair for mealtime. What actions by the nurse would facilitate cooperation from the client? Select all that apply.

For the client who has dementia, the nurse would facilitate cooperation by calling the client by the preferred name, facing the client when speaking, and providing instructions one at a time. The nurse would use a calm and reassuring tone with the voice, not a forceful tone. Clients with dementia respond better to statements that are positive, rather than those statements that have a negative connotation or the word "don't."

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

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.

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. You may switch hands with your cane if you become tired. Hold the cane 6 in (15 cm) in front of you. Lean into the cane as it supports you.

Hold your cane on the right side. Explanation: Because this client is using the cane due to weakness, it should be placed on the "strong" side, in this case the right side. The client should stand tall and not lean into the cane. The cane should be 4 in (10 cm) outside the stronger foot. This client should not switch hands with the cane.

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 the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response?

If the client is fully able to assist in the transfer, the nurse should allow the client to complete the movement independently, with supervision for safety. A physician order is not necessary for a transfer from a stretcher to a bed. The client can move independently and therefore does not need a friction-reducing device. A nurse should remain at the bedside to monitor the transfer.

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?

If the pain is unexpected, notify the primary care provider because the client may be developing a deep vein thrombosis. Applying padding would be an insufficient response, and it would be dangerous to proceed with applying the stocking.

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 increased metabolic rate increase in circulating fibrinolysin increase in the movement of secretions in the respiratory tract

In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.

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? isotonic isometric aerobic anaerobic

Isometric exercise isolates a specific muscle or muscle group and exercises it by holding the muscle steady and maintaining tension. Both squat holds and lateral arm holds involve maintaining a position, in this case, for 10 minutes each.

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 exercise involves muscle shortening and active movement. Examples include carrying out ADLs, independently performing range-of-motion exercises, and swimming, walking, jogging, and bicycling. Isometric exercise involves muscle contraction without shortening (i.e., there is no movement or only a minimal shortening of muscle fibers). Examples include contractions of the quadriceps and gluteal muscles, such as that which occurs when someone holds a yoga pose. Isokinetic exercise involves muscle contractions with resistance. The resistance is provided at a constant rate by an external device that has a capacity for variable resistance. Examples include rehabilitative exercises for knee and elbow injuries and lifting weights. Range-of-motion exercise refers to the maximum degree of movement of which a joint is normally capable.

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. Ensure that the client's bedrails are up prior to transfer. Lower the bed to the lowest position allowing the client's soles to contact the floor. Make sure the client's weaker leg is nearest to the chair. Provide step-by-step instructions to the client before the transfer begins. Provide the client with nonskid slippers to put on prior to standing up.]

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. Lowering the bed to the point where the client is able to touch the ground allows the client to be as stable as possible prior to standing up. Having the client wear nonskid slippers prevents the client from slipping and falling during the transfer. Providing step-by-step instructions to the client allows the nurse to solicit the client's help as much as possible. This action informs the client, encourages self-help, and reduces the workload/burden on the nurse. The nurse should ensure the bedrails are down prior to starting the transfer. Having these up will obstruct movement and make the transfer more difficult. Since the client is not lying in bed, the bedrails do not need to be up for client safety. The client's strongest leg should be positioned closest to the chair to provide stability and prevent a fall as the client moves to lower oneself into the chair.

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 stand-assist device lateral assist device powered full-body lift friction-reducing device

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 teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when the graduate states that back injuries:

Many nurses believe that back pain is a routine consequence of the job, but it need not be. Employing principles of body mechanics, use of algorithms, and guidelines for transferring or lifting clients contributes to the prevention of back injuries and pain. Back injuries can occur when uncooperative clients are being repositioned. Back injuries cannot be prevented with the use of a gait belt. Inappropriate use of the gait belt and other factors can contribute to back injuries. Standing, not sitting, for long periods can contribute to back injuries.

The nurse observes an older adult client walks walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating? should have an orthopedic consultation. requires a better walking shoe. is demonstrating a common gait for the older adult. requires crutches for mobility.

Many older people have more difficulty overcoming inertia and using gravity efficiently. One contributing factor is the shift in the center of gravity. To compensate for this shift, the knees flex slightly for support.

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. Full range of motion with each joint Able to lift head from pillow No swelling, heat, tenderness, pain, nodules, or crepitation Walks 20 feet No masses, deformities, or muscle atrophy

No masses, deformities, or muscle atrophyFull range of motion with each jointNo swelling, heat, tenderness, pain, nodules, or crepitation The nurse should document the size, shape, color, and symmetry of joints: note any masses, deformities, or muscle atrophy. Range of motion of each joint. Any limitation in the normal range of motion or any unusual increase in the mobility of a joint (instability); range of motion varies among people and decreases with aging. Muscle strength when performing range-of-motion exercises against resistance. Any swelling, heat, tenderness, pain, nodules, or crepitation (palpable or audible crunching or grating sensation produced by motion of the joint). Comparison of findings in one joint with those of the opposite joint.

A nurse is assessing a client's mobility status. What data would the nurse document as normal findings? Select all that apply.

Normal findings that the nurse would document regarding a client's mobility would include independent maintenance of correct alignment, full range of motion, and the alignment of the client's head, shoulders, and hips in bed. A fasciculation is a muscle twitch, which would not be a normal finding regarding a client's mobility. The documentation of a client having a scissors gait would not be a normal finding. Increased joint mobility would not be a normal finding regarding the client's mobility.

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group? kyphosis shifted center of gravity scoliosis increased need for calcium and vitamin D

Numerous factors, including growth and development, influence a person's posture, movement, and daily activity level. The adolescent should be assessed for scoliosis (curvature of the spine). Kyphosis is increased convexity in the thoracic spine from disk shrinkage and decreased height, common in older adults. A shifted center of gravity occurs during pregnancy (in the adult) because of the developing fetus. Older adults have an increased need for calcium and vitamin D related to the risk for osteoporosis.

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

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 Appropriate information for the nurse to provide the UAP includes placing the client in an upright position in the bed or chair, providing verbal cues regarding location of food on plate, cutting food into small pieces, and ensuring that the temperature of the food is safe. It is not appropriate to place a pillow behind the neck as this could cause difficulty swallowing. The bed should be at least a 45-degree, preferably at a 90-degree, angle to prevent aspiration while eating.

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?

Placing a client in slight Trendelenburg position may help keep the client from sliding down toward the foot of the bed. Placement into the other position choices does not accomplish the same purpose.

When moving a client up in bed with the assistance of another caregiver, the nurse should: maintain a pillow under the client's head. have the client fold the arms across the chest. ask another nurse about the plan of care. elevate the head of the bed.

Positioning the arms across the chest improves assistance, reduces friction, and prevents hyperextension of the neck. Before attempting to move a client up in bed, the nurse should review the medical record and the nursing plan of care. This validates the correct client and correct procedure, identification of limitation, and ability. Reviewing the medical record and plan of care also identifies use of an algorithm to prevent injury and assists in determining the best plan for client movement. The head of the bed should be flat or as low as the client can tolerate; this will help to decrease the gravitational pull of the upper body. If tolerated, a slight Trendelenburg position aids in movement. Pillows should be removed from under the client's head; this facilitates movement.

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?

Positioning the shoulder blade in this manner removes pressure from the bony prominence and thus helps decrease the risk of impaired skin integrity. The other actions should also be performed but do not decrease the risk of impaired skin integrity.

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?

Prolonged sitting can increase a client's risk for thrombus formation. The nurse will emphasize this and teach stretching exercises. Skeletal contractures, pooling of secretions, and oliguria are not risk factors associated with flying (prolonged sitting).

The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care? pull sheets trochanter rolls trapeze bar log rolling

Promoting client independence with movement and activity is an important intervention for clients with musculoskeletal problems. Unlike log rolling and pull sheets, which are nurse-initiated methods, the overhead trapeze is used by the client.

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

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 occupational nurse is teaching an administrative assistant about proper posture when sitting. Which teaching will the nurse include?

Proper sitting posture includes using the buttocks and upper thighs as the base of support, keeping both feet resting on the floor and the knees bent, with the backs of the knees away from the chair to avoid distal circulation concerns. The other choices are unsafe practices.

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? Make sure the bed brakes are unlocked. Raise the head of the bed to a sitting position. Put the chair at the foot of the bed. Place the bed in the highest position

Raise the head of the bed to a sitting position. When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair.

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

Regardless of the type of walker used, the client stands between the back legs of the walker with arms relaxed at the side, the top of the walker should line up with the crease on the inside of the client's wrist. When the client's hands are placed on the grips, elbows should be flexed about 30 degrees. Have the client move the walker forward 6 to 8 in (15 to 20 cm) and set it down, making sure all four feet of the walker stay on the floor. Then, tell the client to step forward with either foot into the walker, supporting himself or herself on his or her arms. Follow through with the other leg.

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 installing hardwood floors removing clutter from the floor moving the bedroom to the ground floor

Removing clutter from the floor, placing nightlights in the bathroom and hallways, and moving the bedroom to the ground floor will reduce the risk of falling and encourage the client to increase his mobility. Installing hardwood floors may induce falls due to the smooth surface; wall-to-wall carpeting would provide traction.

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body? Long bones are relatively thin and contribute to shape. The wrist is classified as an irregular bone. Short bones contribute to movement. Flat bones are found in the spinal column.

Short bones contribute to movement and are located in the wrist and ankle. The wrist is classified as a short bone. Long bones, such as the femur and humerus, are located in the upper and lower extremities and contribute to height and length. The flat bones are relatively thin and contribute to shape. The flat bones are found in the ribs and several of the skull bones and contribute to shape (structural contour).

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

Sims' position is used for the procedures involving the rectum and vagina. The other options are incorrect for this client.

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep? prone lateral supine Sims

Supine position is recommended as a way to reduce the incidence of sudden infant death syndrome (SIDS) among newborns. The other positions are inappropriate for placing an infant to sleep.

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. Upright Supine Fowler Semi-Fowler Modified supine

The Fowler position is a sitting position, also known as upright, that raises the client's head 80 to 90 degrees and benefits the client by preventing aspiration, promoting ventilation, facilitating eating, and improving cardiac output. The semi-Fowler position is a 45-degree angle, which also allows for ventilation without aspiration. The supine and modified supine (pillow under knees) would not be appropriate for facilitation ventilation and preventing aspiration.

The nurse recognizes that which organization requires that employers comply with ergonomic recommendations?

The National Institute for Occupational Safety and Health (NIOSH) requires compliance with ergonomic recommendations. The Joint Commission (TJC) is an accrediting body for healthcare organizations. The American Nurses Association (ANA) is directed toward nursing professionals. The National League for Nursing (NLN) promotes excellence in nursing education.

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. Instruct the UAP to leave the linens on the floor for now and suggest a meeting to discuss the actions being performed 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 Assist the UAP to pick up the linens and place them in the linen basket Avoid confronting the UAP until there is a more appropriate time

The UAP is at risk for back injury or straining due to lifting the linens using the back muscles and the shift in gravity beyond the base of support. The UAP should move close to and work as closely as possible to an object that is to be lifted or moved to avoid injury. The linens should not be placed on the floor for any length of time due to the increase risk for transmission of microorganisms from the hospital room to other areas of the hospital. It is important to educate all health care personnel when a potential risk to safety or possible harm is occurring. This will help minimize possible injury. Avoiding the conversation with the UAP until there is a more appropriate time is not an appropriate action.

When assessing correct body alignment when the client is standing, the nurse would document which abnormal findings? Select all that apply. The chest is held upward and forward. The head is held erect. The arms are bent at the elbows. The feet are at right angles to the lower legs. The knees are bent.

The arms are bent at the elbows. The knees are bent. Correct alignment permits optimal musculoskeletal balance and operation and promotes optimal physiologic function. With the client standing, the nurse would be concerned if the arms were bent at the elbows. The arms should hang comfortably at the sides. Also, the nurse would be concerned if the knees were bent. The knees should be in a slightly flexed position, not bent and not in the knee-locked position. It is a normal finding for the head to be held erect and in the midline position. It is also a normal finding for the feet to be at right angles to the lower legs. It is a normal finding for the chest to be held upward and forward.

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.

The benefits of exercise include: increasing intestinal tone, increasing efficiency of the metabolic system, and increasing blood flow to the kidneys. Exercise decreases resting heart and blood pressure. Exercise increases appetite. Exercise increases the rate of carbon dioxide excretion.

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." "Your feet should be at 45-degree angles from the legs." "Sleep with your head tilted to one side to take pressure off your neck." "Keep knees and legs very straight."

The best posture lying down will be the same as standing posture, except the client is horizontal. Knees should be slightly flexed; feet should be at a right angle from the legs; the head and neck muscles should be in a neutral position, centered between the shoulders. It is not correct to say to keep the knees and legs very straight, to position feet at a 45-degree angle from the legs, or to sleep with the head tilted to one side.

The nurse is positioning a client with limited mobility who is lying down to go to sleep. Which positioning technique is most appropriate?

The best posture lying down will be the same as that for standing posture, except the client is horizontal. Knees should be slightly flexed; feet should be at a right angle from the legs; the head and neck muscles should be in a neutral position, centered between the shoulders.

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 has awareness of spatial relationships (where objects are located in space). This ability comes from the visual or optic reflexes. The labyrinthine sense relates to the sensory organs in the inner ear and provides a sense of position, orientation, and movement. It does not contribute to where objects are in space. When the extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture (e.g., when the knee buckles under, the reflex contraction aids the person to straighten the knee). This does not contribute to perception of where objects are in space.

The nurse is considering the use of a power stand-assist machine with a client who has difficulty getting out of bed. The nurse will choose a different assistive device if which assessments are present? Select all that apply. The client makes no attempt to help with transfers. The client has an above-the-knee amputation of the right leg. The client has an abdominal hernia. The client weighs 200 lb (91 kg). The client is oriented to self, but not time or place

The client is oriented to self, but not time or place.The client makes no attempt to help with transfers. In order to safely use a power stand-assist machine, the client must be able to bear weight on at least one leg, follow directions, and be cooperative. A client who is not oriented to time or place and a client who does not attempt to help with transfers do not meet these criteria.

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

The inactive client should be repositioned every 2 hours with the use of a low-friction fabric or gel-filled plastic sheet and then placed in good alignment with joints slightly flexed. Skin care should be provided after repositioning.

The nurse is observing an unlicensed assistive personnel (UAP) transferring a client with left-sided weakness from the bed to the chair. What observations made by the nurse require immediate intervention to prevent injury to the client? Select all that apply.

The nurse keeps the client in good body alignment and protects the client from injury while being moved. Safety and comfort are key concerns when assisting a client out of bed. The side rails should be down when transferring a client out of bed. The client should be instructed to use an arm on the arm of the chair for support and stability when getting out of bed. The nurse should stand in front of, not next to, the client as the client sits on the side of the bed; this will prevent falls or injuries from orthostatic hypotension. When assisting the client to sit up on the side of the bed, the nurse should stand near the client's hips. The nurse's center of gravity is placed near the client's greatest weight to assist the client to a sitting position safely. The head of the bed should be elevated to place the client in a sitting position or as high as the client can tolerate. The amount of energy needed to move from a sitting position or elevated position to a sitting position is decreased. Bracing the nurse's knee against the client's weak knee will help prevent it from buckling and the client from falling.

A 59-year old female client reports to the nurse that she recently began taking alendronate and has been having stomach cramping, nausea, and diarrhea. How will the nurse educate the client?

The nurse will educate the client to drink 8 ounces of water when taking the medication and remind the client to take it on an empty stomach. The nurse should not recommend discontinuation or a dosage change. Although some side effects are normal, telling the client to not worry about them does not reflect proper teaching.

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

The nurse would adjust the bed to the flat position or as low as the client can tolerate. The nurse would begin ROM exercises at the client's head and move down one side of the body at a time. The nurse would move each joint in a smooth, rhythmic manner. The nurse would not raise the bed to the highest position, but to a position that is waist-high to the nurse. The nurse would not perform each exercise 10 to 15 times, rather 2 to 5 times. The nurse would not use a flat palm, rather a cupping hold to support joints during ROM exercises.

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? under the client's feet in front of the client's abdomen under the client's head supporting the client's back

The nurse would place the pillow under the client's back to provide support and help maintain the proper position. A pillow can also be placed between the knees. More than one pillow under the client's head is not necessary. Placing a pillow in front of the client's abdomen would be helpful for a client who has undergone abdominal surgery. Placing a pillow under the client's feet is not helpful for the side lying position.

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

The nurse would position the bed so that the client is lying flat on the back and then raise the bed to a comfortable working height. This facilitates moving the client to the side in order to perform the turn in bed. If the client was prone, the client will need to be moved to the client's back. Sitting up is another position a client can be moved into.

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

The nurse would tighten gluteal and abdominal muscles, flex the knees, and use the leg muscles to do the pulling. This saves strain on the nurse's lower back. The arms and chest are part of the accessory muscle groups used in pulling a client.

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

Trochanter rolls prevent the client's legs from rotating outward. The other statements do not describe trochanter rolls. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop.

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

Trochanter rolls prevent the legs from rotating outward. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop. Side rails help a weak client turn independently and protect the client from falling out of bed.

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

Trochanter rolls prevent the legs from rotating outward. The other statements do not describe trochanter rolls. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop.

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 prevent the legs from turning outward. The trochanters are the bony protrusions at the heads of the femurs, near the hip. Placing positioning devices at the trochanters helps prevent the legs from rotating outward. Other devices are inappropriate for this client.

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 can be performed by one experienced nurse. It is acceptable to twist the client's head, but not the hips, while logrolling. Logrolling will maintain straight alignment when the client is sitting in a chair.

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.

Using proper body mechanics, which motions would the nurse make to move an object? The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity. The nurse uses the muscles of the back to help provide the power needed in strenuous activities. 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.

Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The internal girdle is made by contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward. It is helped further by making a long midriff by stretching the muscles in the waist. The nurse would not relax the stomach muscles or use the muscles of the back when moving an object. The nurse would not lift an object when it can be safely slid, rolled, pushed, or pulled.

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. The nurse teaching a group of UAPs about proper body mechanics recognizes the need for additional education when a class participant states that, when lifting and carrying a heavy box of supplies, the UAP will keep it at an arm's length from body. This motion will result in injury and the UAP should be instructed to keep items close to the body. The UAPs should lift an object with feet shoulder width apart by bending at the knees instead of the waist and getting close to the object being lifted. These actions reflect the correct understanding of proper body mechanics.

A nurse is logrolling a client who has a spinal injury. Which nursing action follows the recommended guidelines for this procedure?

When a client has a spinal injury or is recovering from neck, back, or spinal surgery, it is often necessary to keep the body in straight alignment when turning the client. Two or three nurses can accomplish this safely by logrolling a client. Do not try to logroll the client without enough help. Do not twist the client's head, spine, shoulders, knees, or hips while logrolling. A friction-reducing sheet is used for other transfers, but not with the logrolling technique. The nurse would have a client cross the arms on the chest with other transfers, but not with the logrolling technique. A nurse should be on both sides of the bed of a client who is being logrolled, not just on the side that the client is being turned.

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 together to the nondominant side of the client, with legs together and one foot near the head of the bed. to the dominant side of the client, with legs together and one foot near the head of the bed near the client's hip, with legs shoulder width apart and one foot near the head of the bed

When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight to assist the client to a sitting position safely. The dominant or nondominant side is not relevant when moving a client with equal strength but would be helpful with a client who has had a stroke.

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 pants on and zip the zipper." "Don't put on your shoes yet." "Put your arm in this sleeve." "Put on your shirt."

When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions. "Put your arm in this sleeve" gives one step in the process of getting dressed. "Put on your shirt" involves many steps and should be broken down into the steps of putting on a shirt. "Put your pants on and zip the zipper" should be broken down into steps and given in clear, short sentences. Furthermore, putting on pants and zipping a zipper involves many steps and may be too complicated for the client with dementia to follow. Instructions should be phrased positively as the client may not register the "Don't"; the client may put the shoes on if the nurse states "Don't put on your shoes yet."

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

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.

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? "We'll have the nursing assistant watch you while you walk around the unit the first time." "When your crutches fit right, most of your body weight will be supported by your armpits." "Your elbows will be slightly bent when you are using your crutches." "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly."

When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down, if fatigued.

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 hold his breath only when lifting heavy objects face in the direction of the activity he is performing use a wide stance and lift with the large leg muscles

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 Explanation: Breath holding is a sign of muscle strain and an inefficient use of body mechanics.

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 Explanation: By placing the bed and the stretcher at the exact same height, it makes for easier transfer and decreases risk of potential injury. If the stretcher were lower or higher, it would not make for a smoother transfer and the client could be injured during transfer.

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 cradle - to keep the foot off the blanket trochanter roll- to prevent the client from rotating footboard - the feet rest firmly against it and are at right angles to the legs (for proper positioning) ***bed trapeze- a grab bar, providing leverage for patients with upper body strength to position themselves without help.

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. Estimate the size of the client's legs, and obtain the stockings. Have the client lie down with legs and feet elevated for at least 15 minutes before applying. Apply the stockings in the evening. Massage the client's legs before applying.

deep vein thrombosis- blood clot forms in a large vein, usually in a lower limb

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

footdrop A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Footdrop is a contracture in which the foot is fixed in plantar flexion.

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate? positioning the client on the stomach contacting the primary care physician placing a small towel under the neck administering a muscle relaxer

kyphosis - hunch back placing a small towel under the neck Kyphotic changes can cause pressure on cervical vertebrae when someone is in a supine position. Effects of this can be minimized by placing a small towel or cervical pillow under the neck. Placing the client on the stomach is incorrect, and a muscle relaxer will not help reduce the pressure caused by the kyphosis. Contacting the physician is unnecessary.

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 choose a specific single-exercise activity pick an activity the client enjoys to promote adherence understand that the activity will have positive benefits.

obtain a pre-exercise medical examination for clearance Explanation: The client has underlying medical conditions and should obtain a pre-exercise medical examination before beginning any exercise program. Picking an enjoyable activity and understanding that the activity will have positive benefits will help promote success. Variety is preferable to a single-exercise activity to promote success.

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness. For what adverse condition is the nurse assessing in the client? hypertension deep vein thrombosis orthostatic hypotension circulatory alterations

orthostatic hypotension The nurse would stand in front of the client and assess for any balance problems or reports of dizziness upon standing due to orthostatic hypotension. Orthostatic hypotension occurs when the blood pressure drops when standing from the sitting or lying position. Standing in front of the client prevents falls or injuries. Hypertension or high blood pressure is a condition in which the force of the blood against the artery walls is too high. Hypertension needs to be treated with medications to lower the blood pressure. Deep vein thrombosis is a thrombosis or blood clot in a vein lying deep below the skin, especially in the legs. Treatment is by medications, compression stockings, and filters. There are other circulatory alterations, like peripheral artery disease, which is caused by narrowed blood vessels that reduce blood flow to the limbs.

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 trochanter roll under the arms place a small pillow under each arm elevate the head of the bed instruct the client to place arms on the side rails

place a small pillow under each arm Explanation: A small pillow may be used to elevate the extremities, shoulders, or incisional wounds. Instructing the client to place the arms on the side rails will place pressure on the arms and affect circulation to the extremity. Elevating the head of the bed (Fowler) will not elevate the arms. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward. trochanter roll - looks like rolls on the side of the hips. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward. Pillows are used primarily to provide support or to elevate a body part.

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 It is important to be aware of client positioning and nursing actions required to prevent complications. The client who is in the prone position is at risk for foot drop (plantar flexion of the feet) because of the pull of gravity on the feet—unless the legs and feet are positioned carefully. The client in the prone position is not at risk for flexion contracture of the neck, because the body is straight—the shoulders, head, and neck are in an erect position. The client would be at risk for flexion contractures of the hips when in the supine or Fowler position. The client in the prone position is lying on his abdomen and therefore would be at risk for skin breakdown of the sacrum. The client in the Fowler position would be at risk for skin breakdown of the sacrum. When in the prone position, the hips are prevented from flexing or hyperextending.

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 Positioning the shoulder blade in this manner removes pressure from the bony prominence and thus helps decrease the risk of impaired skin integrity. The other actions should also be performed but do not decrease the risk of impaired skin integrity.

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? turning the client as a complete unit to avoid twisting the spine lowering the height of the bed prior to moving the client replacing pillows and positioning devices placing the client in good alignment with joints slightly flexedraising the height of the bed to the waist level prior to moving the client

raising the height of the bed to the waist level 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 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. Explanation: Spasticity refers to stiff or awkward muscle movements. Hemiparesis refers to weakness on one side of the body. Ataxia refers to impaired muscle coordination. Disequilibrium would lead to balance problems.

A nurse is caring for clients with alterations in mobility. Which nursing interventions are recommended for these clients? Select all that apply. For constipation, increase fluid intake and roughage. For orthostatic hypotension, have the client sleep sitting up or in an elevated position. For impaired physical mobility, perform ROM exercises every 2 hours. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours. For increased cardiac workload, instruct the client to lie in the prone position. For ineffective breathing patterns, encourage shallow breathing and coughing

• For orthostatic hypotension, have the client sleep sitting up or in an elevated position. • For constipation, increase fluid intake and roughage. • For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours. The nurse would implement the following nursing interventions when caring for clients with alterations in mobility: Have the client sleep sitting up or in an elevated position for orthostatic hypotension; have the client increase fluid intake and roughage (if not contraindicated) to address constipation concerns; reposition the client in correct alignment at least every 1 to 2 hours to address impaired skin integrity issues. The client would decrease the cardiac workload if lying in the prone position. Shallow breathing would not be encouraged with a client with ineffective breathing patterns. Range of motion (ROM) exercises would not be performed as often as every 2 hours for a client with impaired physical mobility.