Mobility

Prone

- Lying on abdomen with head turned to the one side; hips are unflexed - Advantages: Allows for full extension of the hip and knee joints to prevent contractures and promotes drainage of secretion

Fowler

- Semi-seated or reclined position with the head of the bed elevated 45 degrees; knees may be flexed - Semi-Fowler: Head of the bed is elevated 15-30 degrees -High Fowler: Head of the bed is elevated 60-90 degrees - Advantages: Promote lung expansion

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? a. Lateral b. Supine c. Prone d. Fowler's

c. Prone

Damage into the skin layer

- An area of the skin that is lighter in color than the usual skin tone - Open or intact blister - Shallow wound with pink or red bed

Kyphosis

- An outward curvature of the thoracic area of the spine - most commonly occurs in older adult females due to weakening and breakage of vertebra - Posture change can impact a client's ability to ambulate and rise from a seated position

Activities of Daily Living (ADLs)

- Basic essential skills that a person does independently everyday and that are usually related to personal care - Bathing, dressing, toileting, and feeing oneself

Deep damage through the skin and tissue layer

- Deep wound with exposed muscle, ligaments, or bone and dead tissue

Pneumonia

- Is an infection that often occurs in clients with limited mobility as a result of shallow breathing, thickened mucus, and decreased ability to cough

Trendelenburg

- Lying flat on back, with the foot of the bed above the head of the bed - Reverse Trendelenburg: The foot of the bed is lower than the head of the bead - Advantages: Promotes venous return and promotes drainage of the lower lobes of the lungs

Supine or dorsal recumbent

- Lying flat on the back, possibly with knees bent - Advantages: Enables visualization of the client for examination

Mobility Assessment

- Normal mobility status - Ability to sit - Ability to stand - Ability to walk - Use or need for assistance - Degree of mobility and immobility - Condition of the skin - Presence of any manifestations during activity

Deep vein thrombosis (DVT)

- Occurs when a thrombus or blood clot develops in one or more of the deep veins, typically in the arms, pelvis, thighs, or lower legs - Most serious complication of DVT is a pulmonary embolism

Damage beyond the skin layer

- Open wound, possibly with adipose tissue or granulation tissue visible

Damage with Skin Intact

- Persistent redness or discoloration - Temperature difference compared to the surrounding skin - Firmness in the area

Later semi-prone recumbent

- Placed between the prone and lateral position, with the top leg flexed up toward the chest and support with a pillow; bottom arm is place to the side of the torso, not underneath - Advantages: Reduces pressure on the sacrum and hips and promotes drainage of secretions

Lateral

- Side-lying; the hips and knees are flexed with a pillow separating the knees/legs - Designated as left lateral or right lateral depending on which side of the client is in contact with the bed - Advantages: Promotes spinal alignment and reduces pressure on the sacrum and heels

Atelectasis

- The partial or complete collapse of the lung, including airways and small sections of lung tissue. - It occurs as a result of shallow breathing and this collapse decreases the number of alveoli that are available to exchange oxygen and carbon dioxide.

Pulmonary Embolism

- occurs when part of the thrombus breaks off and travels into the lungs via the bloodstream. - The clot could travel to the brain and result in a stroke, or the hear and cause a heart attack

A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Look Straight ahead with shoulders raised up Keep abdominal muscles contracted and the lower back straight Stand as close to the object as possible Bend hips slightly and squat Push up from the knees when lifting the object

1. Stand as close to the object as possible 2. Keep abdominal muscles contracted and the lower back straight 3. Look straight ahead with shoulders raised up 4. Bend hips slightly and squat 5. Push up from the knees when lifting the object

Foot Drop

A type of joint contracture that result in a partial or total inability to pull the toes up toward the head (dorsiflexion)

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take? a. Reposition the client every 2 hours while in bed b. Remind the client to use the incentive spirometer c. Obtain the client's weight daily d. Encourage the client to eat foods that are high in fiber

b. Remind the client to use the incentive spirometer

Disuse Osteoporosis

Occurs when bones have become thinner and weaker as a result of prolonged bed rest. This demineralization results in fragile bones, which are prone to breaking even under minor stress

Sarcopenia

The loss of lean muscle mass. It is caused by the deterioration of the twitch fibers in voluntary muscles

Atrophy

When muscles are not used and become smaller and weaker. The more developed that muscle is, the fastest that it will atrophy. Occurs with both prolonged bed rest and immobilization off a limb

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instruction should the nurse include? a. "The top of the walker should be at the level of your wrist." b. "When using the stairs, place the walker before taking a step." c. "When holding the walker, bend your elbows 30 degrees." d. "Take a step first before moving the walker."

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

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include? (Select all that apply.) a. A stable center of gravity increases stability and balance b. A wide base lowers the center of gravity c. Proper body alignment involves tightening the abdomen d. Leaning slightly back while carrying an object equalizes the center of gravity e. Bending at the waist when picking up object stabilizes the spine

a. A stable center of gravity increases stability and balance b. A wide base lowers the center of gravity c. Proper body alignment involves tightening the abdomen d. Leaning slightly back while carrying an object equalizes the center of gravity e. Bending at the waist when picking up object stabilizes the spine

A nurse is caring for a client who had a stroke and is immobile. The nurse should identity that the client is at risk for which of the following conditions? a. Deep vein thrombosis b. Asthma c. Hernia d. Hypertension

a. Deep vein thrombosis

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis? a. Fowler's b. Lateral c. Prone d. Supine

a. Fowler's

A nurse is performing a focused assessment on an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing an age-related change to their musculoskeletal system? a. Increased curvature of the thoracic spine b. Reduced depth perception c. Narrower stance when standing d. Quick steps when ambulating

a. Increased curvature of the thoracic spine

A nurse is 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? a. Sit on the edge of the bed for 1 min b. Stand in place for 5 seconds c. Walk in place d. Step forward and backward

a. Sit on the edge of the bed for 1 min

A nurse is teaching 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? a. Toileting b. Writing c. Ambulating d. Talking

a. Toileting

A nurse is assessing 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? a. Atrophy b. Foot drop c. Joint contracture d. Disuse osteoporosis

b. Foot drop

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? a. Gait belt b. Mechanical lift c. Cane d. Sit-to-stand lift

b. Mechanical Lift

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use? a. Pivot disc b. Slide board c. Sit-to-stand lift d. Gait belt

b. Slide board

A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include? a. Cartilage is always remodeling and changing b. Tendons connect muscle to bone c. Ligaments are flexible connective tissue that coat bony areas d. Synovial joints attach to the skeleton to maintain posture

b. Tendons connect muscle to bone

A nurse is preparing a presentation for a group of client who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint? a. Synovial joints contain sensory receptor that trigger flexion b. The contraction of a muscle results in flexion of a joint c. Neurotransmitters coordinate with cartilage to initiate flexion d. Ligaments extend to enable flexion of a joint

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

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 the nurse suspect the client is experiencing? a. Sarcopenia b. Disuse osteoporosis c. Atrophy d. Joint Contracture

c. Atrophy

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage? a. Deep damage through the skin and tissues b. Damage beyond the skin layer c. Damage into the skin layer d. Damage with the skin intact

c. Damage into the skin layer

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture? a. Center of gravity b. Bones c. Muscles d. Synovial Joints

c. Muscles

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include? a. Muscles store calcium and magnesium b. Muscles produce red blood cells and platelets c. Muscles assist with thermoregulation in the body d. Muscles provide protein of internal organs

c. Muscles assist with thermoregulation in the body

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include? a. The use of ergonomics improves blood circulation in the body b. The use of ergonomics eliminates costs related to workers' compensation c. The use of ergonomics increases job satisfaction d. The use of ergonomics maintains the body's balance and a lower center of gravity

c. The use of ergonomics increases job satisfaction

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following? a. Restricted movement due to abnormal fixation of a joint b. A drop in blood pressure that occurs with a change in position c. Altered gait with dragging of the toes while ambulating d. Diminished awareness of body position and balance

d. Diminished awareness of body position and balance

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include? a. Kyphosis is when the upper back extend posteriorly to the lower back b. Kyphosis is an inward curvature of the lower back c. Kyphosis is a sideways curvature of the spine d. Kyphosis is rounded upper back with the pelvis tilted forward

d. Kyphosis is rounded upper back with the pelvis tilted forwarder

A nurse is preparing to transfer a client from a bed to a wheelchair. Which of the following actions by the nurse demonstrates proper use of body mechanics? a. Twisting the torso when transferring the client b. Bending at the waist when transferring the client c. Placing the bed in the high position before transferring the client d. Looking at the client face-to-face when transferring the client

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

A nurse is caring for a client who requires with ADLs. Which of the following referrals should the nurse recommend for this client? a. Speech therapist b. Physical therapist c. Respiratory therapist d. Occupational therapist

d. Occupational Therapist

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches? a. The hand grips of the crutches are at the level of the client's umbilicus b. The client's elbows are bent 45 degrees when folding the crutches c. The client places their weight on their axilla when using the crutches d. The client has the crutches resting 5 cm (2 in) below their axilla

d. The client has the crutches resting 5 cm (2 in) below their axilla

Level 4- No Assist

ENONE

Level 3- Minimal Assist

Equipment needed: Gait belt, ambulation assistive device

Level 1- Maximum Assist

Equipment needed: Mechanical lift, slide boards

Level 2- Moderate Assist

Equipment needed: Mechanical sit-to-stand lifts, Ambulation assortative devices

Level 4- Assist

Equipment needed: NONE