Chapter 8 ATI

The nurse explains to the patient that the log -rolling technique will be used to help the patient change positions the patient asks why this is necessary - which response is accurate.?

"It is important to keep your neck and spine in straight alignment while we hep you more onto your side."

The nurse is assigned to care for an 82 -year-old patient who weighs 252 pounds and has undergone a bilateral below the knee aputation. Which transfer method is the safest for the patient and the nurse?

A mechanical lift with a sling

A nurse is reinforcing teaching with a client who has kyphosis. Which of the following information should the nurse include?

Kyphosis is a rounded upper back with the pelvis tilted forward.

A nurse is reinforcing teaching with a client who injured their ankle. Which of the following information should the nurse include?

Tendons connect muscle to bone.

What is a necessary safety precaution when helping a patient who has an unsteady gait to ambulated?

Have patient wear well-fitting non skid shoes or slippers Have at least two people present to assist the patient Use a gait belt when assisting the patient to stand and to ambulate.

A nurse is assisting with performing the nurse that the client is experiencing an age-related a focused assessment on an older adult client's mobility. Which of the following findings should indicate to change to their musculoskeletal system?

Increased curvature of the thoracic spine

.When using a lift sheet to assist in moving a patient up in bed, what should the nurse ask the patient to do?

Maintain a straight body position

The student nurse demonstrated principles of good body mechanics with which activity?

Maintaining a wide base of support and bending at the knees

A nurse is caring for a client who requires maximum assistance from the bed to a chair, which of the following pieces of equipment should the nurse use?

Mechanical lift

A nurse is assisting with preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following i responsible for body posture?

Muscles

A nurse is assisting with preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?

Muscles assist with thermoregulation in the body

A nurse is caring for a client who requires assistance with ADLS. Which of the following referrals should the nurse recommend for this client?

Occupational therapist

A patient has been immobilized for 5 days because of extensive abdominal surgery. When this patient is helped out of bed for the first time, which patient problem related to safety applies to this patient?

Potential for inability to tolerate activity

What is a major benefit of active ROM exercises?

Preventing contractures Maintaining joint movement and mobility Preventing atrophy of muscle near the joints Increasing the patient's self-esteem and motivation

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

Prone

In which position is the patient lying face down or chest down?

Prone

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take?

Remind the client to use the incentive spirometer.

A nurse is assisting with completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks?

Sit on the edge of the bed for1 min.

The patient accidentally knocks the emesis basin to the floor. When picking up the emesis basin, which movement demonstrates proper body mechanics by the nurse?

The nurse lowers the body by flexing the knees and bending the hips

A nurse is reinforcing teaching with a client who has an unsteady gait about using a walker. Which of the following instructions should the nurse include?

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

A nurse is reinforcing teaching with a newly hired assistive personnel (AP) about working with clients who require assistance with ADLS. Which of the following activities should the nurse include as an ADL?

Toileting

Which assistive devices allows patients to pull with the upper extremities to raise their trunk off the bed, to assist in transfer from bed to wheelchair, and to perform upper arm excersices?

Trapeze bar

A 56 year old patient had an open cholecystectomy. The nurse is going to assist the patient with dangling on the side of the bed before ambulation. After sitting the patient on the edge of the bed. Which nursing intervention should the nurse perform before proceeding with the ambulation?

Assessment of the patient's pulse and respirations

A nurse is rinforcing teaching about placement of a prosthesis with a client who is'having a'below the knee amputaton. which of the foloning in fermation should the nuise include in the teaching?

"This will imprve your ability to ambulate Sooner,"

A nurse is discussing proper body mechanics with a group of assistive personnel which of the following should the nurse include?.

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

A nurse is preparing to transfer a client from a bed to a wheelchair which of the following actions by the nurse demostrates proper use of body mechanics?

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

The nurse is assigned to care for a patient who was admitted for exacerbation of chronic obstructive pulmonary disease and pneumonia. The patient is experiencing dysnea and is unable to rest in a supine position. The nurse elevates the head of the bed to 90 degrees, places a pillow on the overhead table, an assist the patient to lean forward, placing the patients head on the pillow - what position should the nurse document the patient as being in?

Orthopneic

A nurse is preparing to lift a heavy object off the floor. In which order should the nurseperform the following steps to demonstrate the proper of body mechanics? (Move the steps into the box on the right, placing them in the selected order of performance.Use all the steps.)

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

The nurse helps ambulated an 84 year old female patient who has peripheral vascular disease that caused a severe stasis ulcer. The patient becomes very weak, report feeling faint, and begins to fall. what is the most appropriate action to prevent injury to the patient?

Support her while she is falling and allow her to sit on the floor.

A nurse is assisting with preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the followinginformation should the nurse plan to include regarding flexion at the joint?

The contraction of a muscle results in flexion of a joint.

A older adult patient has been lying in the supine position for 3 hours and tells the nurse that she is too uncomfortable to move right now. What is the best response by the nurse?

The nurse should assess the patient's need for pain medication before helping her change position

A patient becomes faint and diaphoretic while sitting on the side of the bed in preparation to ambulated. To prevent injury to the patient and nurse which action should the nurse take?

The nurse should call for assistance. The nurse should not allow the patient to get out of bed at this time.

Anurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use ofthe crutchres?

The nurse should identify that the client is using the crutches properly when they rest the crutches 5 cm (2 in) below their axilla.

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

The nurse should identify that, according to the MAT, a client who requires total assistance requires the use of a mechanical it or slide board, along with assistance from one to two personnel, to transfer the client.

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

The nurse should suspect the client is experiencing atrophy of their muscles. Atrophy occurs when the muscles of the body become smaller and weaker. This can occur with prolonged immobility or disuse of a limb.

A nurse in a long-term care facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of thefollowing should the nurse suspect the client is experiencing?

The nurse should suspect the client is experiencing atrophy of their muscles. Atrophy occurs when the muscles of the body become smaller and weaker. This can occur with prolonged immobility or disuse of a limb.

A nurse is assisting with teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?

The use of ergonomics increases job satisfaction along with productivity of staff members. When staff members can work safely and effectively, they can perform at a higher level.

The nurse is receiving a report on a patient. The nurse giving the report states that the patient has a foot drop, the nurse receiving the report knows that which is the correct terminology for foot drop?

plantar flexion of foot

A nurse is caring for a client who had a stroke and reports difficulty with proprioception. The nurse should plan to collect data from the client for which of the following?

Diminished awareness of body position and balance

It is the patient's first night after an abdominal hysterectomy. She has not voided for 9 hours, and the nurse is to insert a 16Frch Foley catheter into her bladder. What patient position best allows insertion of the catheter?

Dorsal recumbent

The nurse and a UAP are to move a dependent patient from the supine to the lateral position. Which action should be performed first?

Ensure that the upper arm and leg are supported with pillows.

An 82 - year-old patient has had a cerebrovascular accident that affects her right The nurse repositions the patient to the left side placing a pillow between her legs and another behind her back. What is the primary purpose of this intervention?

Ensuring the patient's proper body alignment.

A patient who was admitted with the diagnosis of a stroke has slid to the foot of the bed .Which use of appropriate body mechanics the nurse maintains a wide base of support and faces the patient in the direction of movement what do these actions allow the nurse to do?

Exert less physical effort

A nurse is collecting data about a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?

Foot drop

A nurse is contributing to the plan of care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?

Fowler's

A nurse is collecting data from a client who had a stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions?

Deep vein thrombosis