Fundamentals of Success Mobility

A primary health-care provider prescribes crutches for a person who has a left lower leg injury. The nurse is teaching the person how to move from a standing to a sitting position in a chair. Place the following steps in the order in which they should be implemented. 1. While standing, back up so that the unaffected leg is against the edge of the center of the chair seat. 2. Hold the hand bars of both crutches with the left hand. 3. Lean forward slightly and flex the knees and hips. 4. Grasp the arm of the chair with the right hand. 5. Lower the body slowly into the chair.

Answer: 1, 2, 4, 3, 5 Rationale: 1. Being as close as possible to the chair allows a person to use the chair for support when sitting. Also, it supports sitting deeper into the seat of the chair, which is safer than sitting on the edge of the seat. 2. Holding the hand bars of both crutches with the left hand frees the right hand for the next step in the procedure. 3. Leaning forward slightly and flexing the knees and hips partially lowers the body and prepares it for the next step in the procedure. 4. Grasping the arm of the chair with the right hand allows the person to support body weight partially on the right arm and the right leg. 5. Lowering the body slowly into the chair protects the body from injury.

A nurse is to transfer a client from a bed to a chair. After washing the hands, providing privacy, and explaining the transfer to the client, the nurse ensures that the wheels on the bed are locked and moves the bed to the lowest position. Place the following steps in the order in which they should be implemented. 1. Verify if the client feels dizzy. 2. Assess the client's vital signs and strength while in the supine position. 3. Assist the client to a sitting position on the side of the bed, with the feet on the floor. 4. Elevate the head of the bed to the high-Fowler position and put footwear on the client's feet. 5. Support the client sitting on the side of the bed for several minutes before transferring to a chair.

Answer: 2, 4, 3, 1, 5 Rationale: 1. Verifying if the client feels dizzy evaluates tolerance to the activity and is the fourth step in the transfer procedure. Dizziness indicates orthostatic hypotension. If dizziness occurs, the nurse should support the client in the sitting position for a few minutes. if dizziness does not resolve, then return the client to a semi-Fowler position to provide for the safety of the client. 2. Assessing vital signs is the first step in the procedure because results provide baseline data against which to compare outcomes when evaluating activity tolerance. 3. Assisting the client to a sitting position on the side of the bed, with the client's feet on the floor, facilitates pivoting of the trunk of the body perpendicular to the length of the bed. This prepares the body eventually to assume a wide base of support, with the greatest mass between the feet. 4. Elevating the head of the bed is the second step in the procedure. It minimize the effort required by the client to move to a sitting position in the bed as well as minimizes lifting by the nurse. Footwear protects the client's feet from physical injury and contamination from pathogens that may be on the floor. 5. Supporting the client in the sitting position for several minutes before transferring to a chair is the fifth step in the transfer procedure. This reduces the possibility of orthostatic hypotension and allows more time for an evaluation of the client's response to the change in position.

A nurse is evaluating an ambulating client's balance. Which factor about the client is most important for the nurse to assess? A. Posture B. Strength C. Energy level D. Respiratory rate

Answer: A Rationale: A. Assessing posture will identify whether the client's center of gravity is in the midline from the middle of the forehead to a midpoint between the feet and therefore balanced within the client's base of support. B. Strength has more to do with the exertion of power, not balance. C. Energy has more to do with endurance, not balance. D. Assessing the respiratory rate before activity establishes a baseline against which to compare the respiratory rate after activity to determine tolerance for activity, not balance.

A nurse places a client with a sacral pressure ulcer in the left-Sims position. How should the nurse position the client's right arm? Select all that apply. A. On a pillow B. Behind the back C. With the palm up D. In internal rotation E. With the elbow extended

Answer: A Rationale: A. In the left-Sims position, the client's right arm and leg are supported on pillows to prevent internal rotation of the shoulder and hip. B. The right arm is positioned in front of, not behind, the back. C. The right hand is positioned in pronation, not supination. D. The right arm is positioned to maintain the shoulder in functional alignment, not internal rotation. E. The right arm should be flexed slightly at the elbow; this supports comfort and functional alignment.

A nurse turns a client's ankle so that the sole of the foot moves medially toward the midline. Which word should the nurse use when documenting exactly what was done during range-of-motion exercises? A. Inversion B. Adduction C. Plantar flexion D. Internal rotation

Answer: A Rationale: A. Inversion, a gliding movement of the foot, occurs by turning the sole of the foot medially toward the midline of the body. B. Adduction occurs when an arm or leg moves toward or beyond the midline of the body (or both). C. Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg. D. Internal rotation of a leg occurs by turning the foot and leg inward so that the toes point toward the other leg.

Which is the earliest nursing assessment that indicates damage to tissue because of compression of soft tissue between a bony prominence and a mattress? A. Nonblanchable erythema B. Circumoral cyanosis C. Tissue necrosis D. Skin abrasion

Answer: A Rationale: A. Nonblanchable erythema refers to redness of intact skin that persists when finger pressure is applied. This is the classic sign of a stage I pressure ulcer. B. Circumoral cyanosis (slightly bluish, graying, slatelike, or dark purpose discoloration of the skin around the mouth) is an indication of hypoxia, not pressure ulcers. C. With necrosis, death of cells has occurred. Necrosis occurs in stage III and stage IV pressure ulcers. D. With an abrasion, the superficial layers of the skin are scraped away. This stage II, not stage I, pressure ulcer appears reddened and may exhibit localized serous weeping or bleeding.

A nurse turns the palm of a client's hand downward when performing range-of-motion exercises. Which word should the nurse use when documenting exactly what was done? A. Pronation B. Lateral flexion C. Circumduction D. External rotation

Answer: A Rationale: A. Pronation of the hand occurs by rotating the hand and arm so that the palm of the hand is facing down toward the floor. B. Lateral flexion of the hand occurs with both abduction (radial flexion) and adduction (ulnar flexion). With the hand supinated, radial flexion occurs by bending the wrist laterally toward the thumb, and ulnar flexion occurs by bending the wrist laterally toward the fifth finger. C. Circumduction, associated with a ball-and-socket joint, occurs when an extended extremity moves forward, up, back, and down in a full circle. D. External rotation is associated with ball-and-socket joints. External rotation of a shoulder occurs when the upper arm is held parallel to the floor, the elbow is at a 90-degree angle, the fingers are pointing toward the floor, and the person moves the arm upward so that the fingers point toward the ceiling. External rotation of the hip occurs when a leg in extension is turned so that the foot points outward from the midline of the body.

A nurse places a client in the orthopneic position. Which is the primary reason for the use of this position? A. Facilitates breathing B. Supports hip extension C. Prevents pressure ulcers D. Promotes urinary elimination

Answer: A Rationale: A. Sitting in the high-Fowler position and leaning forward (orthopneic position) allow the abdominal organs to drop by gravity, which promotes contraction of the diaphragm. The arms resting on an over-bed table increase thoracic excursion. This position promotes breathing. B. The hips will be in extreme flexion, not extension. C. Pressure ulcers can still occur on the ischial tuberosities. D. Standing (for men) and sitting on a toilet/commode (for women) are superior to any position for promoting urinary elimination.

A nurse raises a client's arm forward and upward over the head during range-of-motion exercises. Which word should the nurse use when documenting exactly what was done during this range-of-motion exercise? A. Flexion B. Supination C. Opposition D. Hyperextension

Answer: A Rationale: A. The shoulder, a ball-and-socket joint, flexes by raising the arm from a position by the side of the body forward and upward to a position beside the head. B. Supination occurs when the hand and forearm rotate so that the palm of the hand is facing upward. C. Opposition is the touching of the thumb of the hand to each fingertip of the same hand. D. Hyperextension of the arm occurs by moving an arm form a resting position at the side of the body to a position behind the body.

A nurse is teaching a class to nursing assistants about how to care for clients who are immobile. Which should the nurse include about why immobilized people develop contractures? A. Muscles that flex, adduct, and internally rotate are stronger than weaker opposing muscles. B. Muscular contractures occur because of excessive muscle flaccidity. C. Muscle mass and strength decline at a progressive rate weekly. D. Muscle catabolism exceeds muscle anabolism.

Answer: A Rationale: A. The state of balance between muscles that serve to contract in opposite directions is impaired with immobility. The fibers of the stronger muscles contract for longer periods than do those of the weaker, opposing muscles. This results in a change in the loose connective tissue to a denser connective tissue and to fibrotic changes that limit range of motion. B. Contractures occur because of muscle spasticity and shortening, not muscle flaccidity. C. Disuse and muscle wasting cause a reduction in muscle strength at the rate of 5% to 10% a week, so that within 2 months more than 50% of a muscle's strength can be lost. This results in muscle atrophy, not contractures. D. Muscle catabolism exceeding muscle anabolism is unrelated to contractures. In unused muscles, catabolism exceeds anabolism, and the muscles decrease in size (disuse atrophy).

Which action employed by the nurse indicates acceptable body mechanics to avoid self-injury? Select all that apply. A. Keep back, neck, pelvis, and feet aligned. B. Position oneself close to the client. C. Keep knees and hips slightly flexed. D. Arrange for adequate help. E. Keep feet close together.

Answer: A, B, C, D Rationale: A. Alignment reduces the risk of lumbar vertebrae and muscle group injury resulting from torquing (twisting). B. Positioning oneself close to the client keeps the client closer to your center of gravity. Increased stability reduces strain on back muscles. C. Keeping knees and hips slightly flexed facilitates using the large muscles of the legs, rather than the back, to move the client. D. Multiple caregivers share the load of moving a client safely. E. Feet should be positioned wide apart, not close together, to provide a wide base of support, which increases stability.

A nurse is planning to help move a client up in bed. Which of the following can the nurse implement to reduce the risk of self-strain when performing this action? Select all that apply. A. Use the force of gravity to facilitate the move. B. Keep the upper and lower body in alignment. C. Use the large muscles of the legs. D. Keep the knees slightly bent. E. Raise the bed to waist level.

Answer: A, B, C, D, E Rationale: A. Muscle strain is reduced when clients are moved by using gravity, not with the added effort needed to move clients against gravity. B. Keeping the upper and lower body in alignment decreases strain on the sacrospinal muscles and intervertebral disks. C. To exert an upward lift, the gluteal and leg muscles should be used, rather than the sacrospinal muscles of the back. The gluteal and leg muscles are larger than the sacrospinal muscles and therefore fatigue less quickly, and their use protects the intervertebral disks. D. The muscles of the legs are most efficient when the knees and hips are slightly bent. This reduces strain on the muscles being used. E. Positioning the bed at waist height avoids the need to reach and stretch, which may strain a caregiver's muscles, bones, joints, tendons, or ligaments.

An emaciated client is at risk for developing a pressure ulcer. In which position should the nurse avoid placing the client? A. Thirty-degree lateral position B. Side-lying position C. Supine position D. Prone position

Answer: B Rationale: A. The 30-degree lateral position is the preferred position to prevent pressure ulcers because it limits body weight directly over bony prominences, versus other positions. B. In the side-lying position, the majority of the body weight is borne by the greater trochanter. The bone is close to the surface of the skin, with minimal overlying protective tissue. C. In the supine position, the occiput, scapulae, spine, elbows, sacrum, and heels are at risk for pressure; however, the body weight is distributed more evenly than in some other positions. D. In the prone position, the ears, cheeks, acromion process, anterior-superior spinous process, knees, toes, male genitalia, and female breasts are at risk for pressure; however, the body weight is distributed more evenly than in some other positions.

A primary health-care provider prescribes a standard walker for a client who has left-sided weakness and requires some assistance with balance but can bear weight on both legs. Which should the nurse teach the client about how to use the walker safely? Select all that apply. A. Advance the strong leg last by itself. B. Lift the walker before moving it forward twelve inches. C. Advance the walker and the weak leg ahead together first. D. Adjust the height of the walker so that it is equal with the hip joint. E. Roll the walker a comfortable distance ahead before stepping forward.

Answer: A, C Rationale: A. Advancing the unaffected leg last by itself allows weight to be borne by the affected leg while both arms are supported on the walker. B. Six, not 12, inches is the proper distance to advance a walker. Twelve inches will require the client to reach too far forward, moving beyond a stable center of gravity. C. Advancing the walker and the affected leg together ensures that weight is borne by the unaffected leg. D. Adjusting the height of the walker so that it is equal with the hip joint is too low and will require the client to stoop to each the hand bar. The hand bar should be at a height just below the client's waist, allowing the elbows to be slightly flexed. A walker that is the correct height allows a client to assume a more functional posture. E. A standard walker does not have wheels. Directing a person to advance a walker a comfortable distance is unsafe. The word "comfortable" is subjective and unclear. Walkers should be advanced 6 inches at a time to ensure that a person's weight does not extend beyond the center of gravity.

A nurse concludes that a client has the potential for impaired mobility. Which of the following reflect risk factors that support this conclusion? Select all that apply. A. Joint pain B. Exertional fatigue C. Sedentary lifestyle D. Limited range of motion E. Increased respiratory rate

Answer: A, D Rationale: A. Joint pain may prevent the client from moving about, leading to contractures that result in impaired mobility. B. Exertional fatigue is associated with activity intolerance. People who are fatigued are still able to move. C. People who are sedentary are still able to move. D. Limited range of motion is associated with contracture formation and impaired mobility. E. An increased respiratory rate is a response to activity, not impaired mobility.

A nurse is caring for a variety of clients, each experiencing one of the following problems. Which health problem places a client at the highest risk for complications associated with immobility? A. Incontinence B Quadriplegia C. Hemiparesis D. Confusion

Answer: B Rationale: A. Clients who are incontinent are not necessarily immobile. B. Quadriplegia, paralysis of all four extremities, places the client at highest risk for pressure ulcers because the client has no ability to shift body weight off of bony prominences or change position without total assistance. C. Hemiparesis, muscle weakness on one side of the body, does not prevent a person from shifting or changing position to relive pressure on the skin. D. Confused clients can move independently when uncomfortable or when encouraged and assisted to move by the nurse.

A client has hemiplegia as a result of a brain attack (cerebrovascular accident). Which complication of immobility that may be associated with this client is a concern for the nurse? A. Dehydration B. Contractures C. Incontinence D. Hypertension

Answer: B Rationale: A. Dehydration is not a response to immobility. B. Contractures can result from permanent shortening of muscles, tendons, and ligaments and are a complication associated with a brain attack if routine range-of-motion exercises and maintaining the body in functional alignment are not provided. C. The decreased tone of the urinary bladder and the inability to assume the usual voiding position in bed promote urinary retention, rather than urinary incontinence. D. With immobility, the increased heart rate reduces the diastolic pressure. In addition, there is a decrease in blood pressure related to postural changes from lying to sitting or standing (orthostatic hypotension). This situation is manageable with a priority on maintaining client safety.

A nurse identifies that a client's pressure ulcer has just partial-thickness skin loss involving the epidermis and dermis. Which stage pressure ulcer should the nurse document based on this assessment? A. Stage I B. Stage II C. Stage III D. Stage IV

Answer: B Rationale: A. In a stage I pressure ulcer, the skin is still intact and manifests clinically as reactive hyperemia. B. In a stage II pressure ulcer, the partial-thickness skin loss manifests clinically as an abrasion, blister, or shallow crater. C. In a stage III pressure ulcer, there is full-thickness skin loss involving the subcutaneous tissue that may extend to the underlying fascia. The ulcer manifests clinically as a deep crater with or without undermining. D. In a stage IV pressure ulcer, there is full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

A nurse is caring for a client with impaired mobility. Which position contributes most to the formation of a hip flexion contracture? A. Low-Fowler B. Orthopneic C. Supine D. Sims

Answer: B Rationale: A. In the low-Fowler position, the hips are slightly flexed. B. While in the high-Fowler position, the client is then positioned leaning forward with the arms resting on an over-bed table (orthopneic position). In the orthopneic position, the hips are extensively flexed, creating an angle of less than 90 degrees. C. In the supine position, the hips are extended (180 degrees), not flexed. D. In the Sims position, the hip and the knee of the upper leg are just slightly flexed.

A client has a cast from the hand to above the elbow because of a fractured ulna and radius. After the cast is removed, the nurse teaches the client active range-of-motion exercises. Which client action indicates that further teaching is necessary? A. Moves the elbow to the point of resistance B. Keeps 90° elbow flexion after the prcoedure C. Assesses the elbow's response after this procedure D. Puts the elbow through its full range at least 3 times

Answer: B Rationale: A. Moving the elbow to the point of resistance is desirable. Performing range-of-motion exercises beyond resistance may injure muscles and joints and should be avoided. B. Keeping the elbow flexed after the procedures is undesirable because it contributes to a flexion contracture. Slight flexion to maintain functional alignment is preferred because it minimizes stress and strain on muscle, tendons, ligaments, and joints. C. Responses to range-of-motion exercises must be evaluated and compared with the assessment performed before the procedure. D. Sequential flexion and extension of a hinge joint are efficient in facilitating full range of motion of the joint.

A nurse is making an occupied bed. Which is the easiest way for the nurse to prevent plantar flexion? A. Tuck in the top linens on just the sides of the bed. B. Place a toe pleat in the top linens over the feet. C. Let the top linens hang off the end of the bed. D. Position the top linens over a bed cradle.

Answer: B Rationale: A. Top sheets tucked in along the sides of the bed still exert pressure on the upper surface of the feet, which may promote plantar flexion. The sides of top sheets, mitered at the foot of the bed, hang freely off the side of the bed. B. Making a vertical or horizontal toe pleat in the linen at the foot of the bed over the client's feet leaves room for the feet to move freely and avoids exerting pressure on the upper surface of the feet, thus minimizing plantar flexion. C. The weight of the top sheets still exerts pressure on the upper surface of the feet, promoting plantar flexion. D. Although the use of a bed cradle will hold the linen off the legs and feet of the client, it is not the easiest way for the nurse to prevent plantar flexion of the options presented.

Which systemic response in immobilized clients should nurses monitor for? Select all that apply. A. Pressure ulcer B. Dependent edema C. Hypostatic pneumonia D. Plantar flexion contracture E. Increased cardiac workload

Answer: B, C, E Rationale: A. Prolonged pressure on skin over a bony prominence interferes with capillary blood flow to the skin, which ultimately can result in a pressure ulcer. A pressure ulcer is a localized, not systemic, response to immobility. B. Decreased calf muscle activity and pressure of the bed on the legs allow blood to accumulate in the distal veins. The resulting increased hydrostatic pressure moves fluid out of the intravascular compartment and into the interstitial compartment, causing edema. Dependent edema is a systemic response to immobility. C. Static respiratory secretions provide an excellent media for bacterial growth that can result in hypostatic pneumonia, which is a systemic response to immobility. D. Plantar flexion contracture (footdrop) is a localized response to prolonged extension of the ankle. E. An increased cardiac workload results from a decrease in vessel resistance and redistribution of blood in the body, with blood pooling in the lower extremities. These are systemic responses to immobility.

A nurse is performing passive range-of-motion exercises for a client who is in the supine position. Which motion occurs when the nurse bends the client's ankle so that the toes are pointed toward the ceiling? A. Adduction B. Supination C. Dorsal flexion D. Plantar extension

Answer: C Rationale: A. Adduction occurs when an arm or leg moves toward or beyond the midline of the body (or both). B. Supination occurs when the hand and forearm rotate so that the palm of the hand is facing upward. C. Dorsal flexion (dorsiflexion) of the joint of the ankle occurs when the toes of the foot point upward and backward toward the anterior portion of the lower leg. D. There is no range of motion called plantar extension. Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg.

A nurse is transferring a client from a bed to a wheelchair. Which should the nurse do to quickly assess this client's tolerance to this activity? A. Obtain a blood pressure. B. Monitor for bradycardia. C. Determine if the client feels dizzy. D. Allow the client time to adjust to the change in position.

Answer: C Rationale: A. Although a blood pressure reading may indicate the presence of hypotension, the blood pressure should be obtained before and after a transfer to allow a comparison to conclude that the hypotension is orthostatic hypotension. B. If the client is experiencing orthostatic hypotension, the heart rate will increase, not decrease. C. Feeling dizzy is a subjective response or orthostatic hypotension. Obtaining feedback from the client provides a quick evaluation of the client's tolerance of the transfer. D. Allowing the client time to adjust to the change in position is not an assessment. This is a safe intervention for a client who is experiencing orthostatic hypotension.

An immobilized bedbound client is placed on a 2-hour turning and positioning program. Which should the nurse explain to the client is the primary reason why this program is important? A. Supports comfort B. Promotes elimination C. Maintains skin integrity D. Facilitates respiratory function

Answer: C Rationale: A. Although turning the client to a new position every 2 hours provides variety and increased comfort, these are not the primary reasons for this intervention. B. Although turning frequently promotes elimination, the upright positions, such as high-Fowler and sitting, have a greater influence on elimination because of the effect of gravity. C. Compression of soft tissue greater than 15 to 32 mm Hg interferes with capillary circulation and compromises tissue oxygenation in the compressed area. Turning the client relieves the compression of tissue in dependent areas, particularly those tissues overlying bony prominences. D. Although turning and positioning promote respiratory functioning, other interventions, such as sitting, deep breathing, coughing, and incentive spirometry, have a greater influence on respiratory status.

Which word is most closely associated with nursing care strategies to maintain functional alignment when clients are bedbound? A. Endurance B. Strength C. Support D. Balance

Answer: C Rationale: A. Endurance relates to aerobic exercise that improves the body's capacity to consume oxygen for producing energy at the cellular level. B. Strength relates to isometric and isotonic exercises, which contract muscles and promote their development. C. The line of gravity passes through the center of gravity when the body is correctly aligned; this results in the least amount of stress on the muscles, joints, and soft tissues. Bedbound clients often need assistive devices such as pillows, sandbags, bed cradles, wedges, rolls, and splints to support and maintain the vertebral column and extremities in functional alignment. D. Balance relates to body mechanics and is achieved through a wide base of support and a lowered center of gravity.

A client with a history of thrombophlebitis should not have pressure exerted on the popliteal space. In which position should the nurse avoid placing this client? A. Prone B. Supine C. Contour D. Trendelenburg

Answer: C Rationale: A. In the prone position, there is pressure in front of, not behind, the knees. B. In the supine position, the hips and legs are extended, which does not exert pressure on the popliteal spaces. C. In the contour position, the head of the bed and the knee gatch are slightly elevated. The elevated knee gatch pts pressure on the popliteal spaces. D. In the Trendelenburg position, the hips and knees are extended, which does not exert pressure on the popliteal spaces.

Which nursing action should be implemented when assisting a client to move from a bed to a wheelchair? A. Lowering the height of the bed to 2 inches below the height of the client's wheelchair B. Applying pressure under the client's axillae areas when assisting the client to stand C. Letting the client help as much as possible when transferring to the wheelchair D. Keeping the client's feet within 6 inches of each other

Answer: C Rationale: A. The bed should be higher, not lower, than the wheelchair so that gravity can facilitate the transfer. B. Applying pressure under the client's axillae areas when standing up should be avoided because it can injure local nerves and blood vessels. C. Encouraging the client to be as self-sufficient as possible ensures that the transfer is conducted as the client's pace, promotes self-esteem, and decreases the physical effort expended by the nurse. D. Keeping the client's feet within 6 inches of each other will provide a narrow base of support and is unsafe.

A nurse plans to teach a client with hemiparesis to use a cane. Which should the nurse teach the client to do? Select all that apply. A. Move forward 1 step with the weak leg first, followed by the strong leg and cane. B. Adjust the cane height 12 inches lower than the waist. C. Hold the cane in the strong hand when walking. D. Look at the feet when walking with the cane. E. Lean over onto the cane when walking.

Answer: C Rationale: A. The unaffected leg should be advanced first because the weight of the body is supported by the leg with the greatest strength. B. With the tip of the cane placed 6 inches lateral to the foot, the handle should be at the level of the client's greater trochanter to ensure that the elbow will be flexed 15 to 30 degrees when using the cane. C. A cane is a hand-gripped assistive device; therefore, the hand opposite the hemiparesis should hold the cane. Exercises can strengthen the flexor and extensor muscles of the arms and the muscles that dorsiflex the wrist. D. This action will cause flexion of the neck, hips, or waist that will move the center of gravity outside the base of support. Body alignment is essential for balance, stability, and safe ambulation. E. Leaning over onto the cane should be avoided. The client should distribute weight between the feet and the cane while standing in an upright posture. This is the most stable position when using a cane.

A client with impaired mobility is to be discharged from the hospital within a week. Which is an example of a discharge goal for this client? A. The client will understand range-of-motion exercises before they are initiated. B. The client will be taught range-of-motion exercises after they are prescribed. C. The client will transfer independently to a chair by discharge. D. The client will be kept clean and dry at all times.

Answer: C Rationale: A. This goal is not measurable as stated. Understanding is not measurable unless parameters are identified. B. This statement is a nursing intervention, not a client goal. C. This is a client-centered goal that is specific and measurable and has a time frame. D. This statement is a nursing goal, not a client goal.

A nurse is a community center is conversing with a group of older adults who voiced fears about falling. Which is the most common consequence associated with older adults' fear of falling that the nurse should discuss with them? A. Impaired skin integrity B. Occurrence of panic attacks C. Self-imposed social isolation D. Decreased physical conditioning

Answer: D Rationale: A. A person who chooses not to ambulate still has the ability to assume many different sitting or lying-down positions. B. The occurrence of panic attacks is not the most common consequence. Anxiety and ultimately panic that is precipitated by a situation can be prevented by avoiding the situation. C. A person who chooses not to ambulate because of a fear of falling still can socialize. D. Most falls occur when ambulating. Fear of falling results in the conscious choice not to place oneself in a position where a fall can occur. Disuse and muscle wasting cause a reduction of muscle strength at the rate of 5% to 10% per week, so that within 2 months of immobility more than 50% of a muscle's strength can be lost. In addition, there is a decreased cardiac reserve. These responses result in decreased physical conditioning.

Which nursing action is most effective in relation to the concept Immobility can lead to occlusion of blood vessels in areas where bony prominences rest on a mattress? A. Encouraging the client to breathe deeply 10 times per hour B. Performing range-of-motion exercises twice a day C. Placing a sheepish pad under the sacrum D. Repositioning the client every 2 hours

Answer: D Rationale: A. Deep breathing prevents atelectasis and hypostatic pneumonia, not pressure ulcers, which this question is about. B. Range-of-motion exercises help prevent contractures, not pressure ulcers. C. Although sheepskin reduces friction and limits pressure, its main purpose is to allow air to circulate under the client to minimize moisture and maceration of skin. D. Turning a client relives pressure on the capillary beds of the dependent areas of the body, particularly the skin overlying bony prominences, which reestablishes blood flow to the area. When pressure on a capillary exceeds 15 to 32 mm Hg, its lumen is occluded, depriving oxygen from local body cells.

A client is diagnosed with a stage IV pressure ulcer with eschar. Which medical treatment should the nurse anticipate the primary health-care provider will prescribe for this client? A. Heat lamp treatment three times a day B. Application of a topic antibiotic C. Cleansing irrigations twice daily D. Debridement of the wound

Answer: D Rationale: A. Heat lamp treatments will further dry out the wound and can cause burns. B. Topical antibiotics are used only when the ulcer is infected, not to treat eschar. C. Cleansing irrigations are ineffective in removing the thick, fibrin-containing cells of eschar covering the surface of the wound. D. Thick, leatherlike, necrotic, devitalized tissue (eschar) must be removed surgically or enzymatically before wound healing can occur.

Which do nurses sometimes do that increases their risk for injury when moving clients? A. Use longer, rather than shorter, muscles when moving clients B. Place their feet wide apart when transferring clients C. Pull rather than push when turning clients D. Rotate their backs when moving clients

Answer: D Rationale: A. Nurses should use the longer, stronger muscles of the thighs and buttocks when moving clients to protect their weaker back and arm muscles. B. Nurses should have a wide base of support when moving clients to provide better stability. C. Nurses should use a pulling motion to turn clients because the muscles that flex, rather than extend, the arm are stronger, and pulling, rather than pushing, creates less friction and therefore less effort. D. Twisting (rotation) of the thoracolumbar spine and flexion of the back place the line of gravity outside the base of support, which can cause muscle strain and disabling injuries. Misaligning the back when moving clients occurs most often when not facing the direction of the move.

Which stage pressure ulcer requires the nurse to measure the extent of undermining? A. Stage 0 B. Stage I C. Stage II D. Stage III

Answer: D Rationale: A. There is no stage 0 in the classification system for staging pressure ulcers. B. The skin is still intact and there is no undermining in a stage I pressure ulcer. C. Tissue damage is superficial and there is no undermining in a stage II pressure ulcer. D. In a stage III pressure ulcer, there is full-thickness skin loss involving damage to subcutaneous tissue that may extend to the fascia, and there may or may not be undermining, which is tissue destruction underneath intact skin along wound margins.

A nurse is placing a client in the left-lateral position. Which of the following should the nurse implement when positioning this client? Select all that apply. A. Maintain the left knee flexed at ninety degrees. B. Rest the right leg on top of the left leg. C. Place the ankles in plantar flexion. D. Align the shoulders with the hips. E. Protract the left shoulder.

Answer: D, E Rationale: A. This excessive flexion can result in contractures of the hip and knee. The left leg should be slightly flexed or extended. B. The right leg should be supported on a pillow in front of the left leg. C. The ankles should be maintained at 90 degrees. D. Maintaining alignment of the shoulders and hips avoids stress and strain on the bones, muscles, and joints. E. In the left-lateral (side-lying) position, the left arm is positioned in front of the body with the shoulder pulled forward (protracted). This position reduces pressure on the joint in the shoulder and acromial process.