Unit 6-Mobility

The nurse is assisting a client who has had a spinal fusion apply a back brace. In which order of priority should the nurse assist the client applying the brace? All options must be used.

Verify the prescriptions for the settings for the brace. Have the client in a side-lying position. Assist the client to log roll and rise to a sitting position. Ask the client to stand with arms held away from the body. The nurse should first verify the settings for the brace and activity prescriptions. Next, the client should be in a side-lying position; explain that the spine should be kept aligned and in a neutral position, and the client should not pull on objects with arms. For getting out of bed, log roll client to side, splint back, and rise to a sitting position by pushing against the mattress while swinging legs over the side of the bed. Finally, the client should stand with the arms outstretched so the nurse can apply the brace.

To promote early and efficient ambulation for a client after an above-the-knee amputation, the nurse is aware that the leg will need to be positioned in which way?

in functional alignment Muscles that originate at the vertebrae or pelvic girdle and insert on the femur act to abduct, adduct, flex, extend, and rotate the femur. Normal body alignment should be maintained because it facilitates the safe and efficient use of muscle groups for balance and stability. Functional alignment is essential for all bone repair.

Using the Morse Fall Scale (see chart), place the clients in order from lowest to highest fall risk. All options must be used.

a 50-year-old client admitted for chest pain while running. The client has been healthy and has no history of falling; the client is alert and oriented, has IV access, and has been cleared to ambulate independently. a 38-year-old client who has been blind since birth, admitted for abdominal pain and nausea with IV in place. The client has steady gait and no history of falling and requires cuing and assistance due to unfamiliar surroundings. a 56-year-old client with diabetes admitted with osteomyelitis of right ankle, receiving IV antibiotics per peripherally inserted central catheter. The client is alert and cooperative, is non-weight bearing on the right lower extremity but may stand pivot into a wheelchair. The client has no history of falling. an elderly client admitted from assisted-living facility with new-onset confusion secondary to urinary tract infection. The client has a history of hypertension and diabetes; gait is weak due to illness, but the client has no known history of falling. The client may be up with assistance using a walker and is receiving IV antibiotics. The 50-year-old client has the lowest risk for falling with points assigned for IV access only (20); this client should be monitored regularly for changes that would increase the client's risk, and interventions should be instituted if they become necessary to ensure safety. The 38-year-old blind client is medium risk for falling with 35 points (secondary diagnosis and IV access); due to unfamiliar surroundings, the nurse may need to provide extra attention to cuing and providing assistance to keep this client safe. The client admitted with osteomyelitis is a high fall risk with points assigned for secondary diagnosis of diabetes (15), impaired gait (20), and IV access (20) to a total of 55; the nurse should institute high fall precautions and reassess need regularly. The elderly client with new-onset confusion is at highest risk for falling, acquiring points for a history of falling (25), secondary diagnosis (15), IV access (20), weak gait (10), and confusion (15) to a total of 85 points; the nurse should institute fall precautions, taking care to identify this client to all health care team members as high fall risk.

The nurse is caring for an elderly client with a fractured hip who is on bed rest. Which nursing interventions would be included on the plan of care?

Turn the client every 2 hours, and encourage coughing and deep breathing. Appropriate interventions for a bedridden client include turning every 2 hours, providing adequate nutrition, and encouraging coughing and deep breathing. Hydration, active and passive ROM, and adequate pain medication are also appropriate nursing measures. To prevent contractures, the client would not limit fluid intake or lie as still as possible.

The nurse advises the client who has had a femoral head prosthesis placement on the type of chair to sit in during the first 6 to 8 weeks after surgery. Which chair would be the correct type to recommend?

a high-backed chair with armrests A high-backed straight chair with armrests is recommended to help keep the client in the best possible alignment after surgery for a femoral head prosthesis placement. Use of this type of chair helps to prevent dislocation of the prosthesis from the socket. A desk-type swivel chair, padded upholstered chair, or recliner should be avoided because it does not provide for good body alignment and can cause the overly flexed femoral head to dislocate.

A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?

shearing forces Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) can occur as clients slide down in bed or are pulled up in bed. Subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy?

raising all side rails while the client is in bed Raising all side rails on the bed would be a restraint and may increase the client's risk of a falling if the client climbs out of bed. All the other options would comply with a least restraint policy.

While assessing a client's spine for abnormal curvatures, the nurse notes lordosis. Identify the area of the spine that is affected by lordosis.

Lordosis is characterized by an accentuated curve of the lumbar area of the spine.

When the nurse is conducting a preoperative interview with a client who is having a vaginal hysterectomy, the client states that she forgot to tell her surgeon that she had a total hip replacement 3 years ago. Why should the nurse communicate this information to the perioperative nurse?

The client should not have her hip externally rotated when she is positioned for the procedure. The nurse should notify the surgery department and document the past surgery in the medical record in the preoperative notes so that the client's hip is not externally rotated and the hip dislocated while she is in the lithotomy position. The prosthesis should not be a problem as long as the perioperative nurse places the return electrode away from the prosthesis site. The perioperative nurse will inform the rest of the team, but the primary reason to inform the perioperative nurse is related to safe positioning of the client. The surgeon should enter this information on the client's medical record at this time.

A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital?

conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. When walking with crutches, the client engages the triceps, trapezius, and latissimus muscles. A client who has been immobilized may need to implement an exercise program to strengthen these shoulder and upper arm muscles before initiating crutch walking. The other choices are incorrect based on functionality and muscle use.

An older adult is admitted with a fracture of the femur. What should the nurse assess first about this client?

mechanism of injury The nurse first assesses the mechanism of injury to help determine related injuries, tests needed, and potential treatment options. The next step is to assess the location, type, quality, and intensity of the pain. Neurovascular stasis of the injured site is assessed after pain; therefore, the nurse checks for functional ability or changing positions. Although the nurse can also determine the extent of anxiety while assessing the injury and can use communication strategies to minimize anxiety, it is not the first priority for assessing this client.

Which cells are involved in bone resorption?

osteoclasts Osteoclasts carry out bone resorption by removing unwanted bone while new bone is forming in other areas. Chondrocytes are responsible for forming new cartilage. Osteoblasts are bone-forming cells that secrete collagen and other substances. Osteocytes, derived from osteoblasts, are the chief cells in bone tissue.

The nurse is aware that frequent repositioning in bed will assist in the prevention of which condition for a client?

pneumonia By frequently changing positions in bed, the client can prevent the development of pneumonia, urinary stasis, and deep vein thrombosis. These movements promote blood, oxygen, and fluid circulation throughout the body systems and prevent stasis. Postural hypotension can often be associated with medications and no information is given about this in the question. Arterial thrombosis is incorrect because decreased movement would more likely result in a venous thrombosis.

A client in the postoperative setting asks the nurse if he or she will have compression stockings like after the last surgery. What is the next action by the nurse?

Check the medical record for a provider's prescription for compression stockings. The application of compression stockings for a client in the postoperative period requires a healthcare provider's prescription. The nurse should check the medical record for the given prescription before proceeding with the placement of the compression stockings. Placement of compression stockings may be delegated to unlicensed assistive personnel (NAP) after properly measuring the client for the appropriate size. It is important to measure the client for the appropriate size stocking before retrieving the compression stockings from the supply room.

Following a client's total hip replacement, what should the nurse do? Select all that apply.

Encourage the client to use the overhead trapeze to assist with position changes. Use a fracture bedpan when needed by the client. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises. Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement.

The nurse is caring for an adult with a grade III compound fracture of the right femur; the client has been placed in skeletal traction. What is the intended outcome of the traction?

Reduce and immobilize the fracture. Skeletal traction is often used to regain normal length of the bone, but in this situation the main purpose of the traction is to reduce and immobilize the fracture. This type of traction allows the client to move in bed without dislocating the fracture. This client has an open fracture, but skeletal traction will not prevent further skin breakdown.

The nurse is to apply a sequential compression device (intermittent pneumatic compression). Identify the area of the compression device that is placed on the client's calf.

The air cell should be centered on the back of the client's calf.

The neck of the femur is a flattened pyramidal process of bone connecting the femoral head with the femoral shaft just below the ball and socket. When a femoral neck fracture occurs, the ball is disconnected from the rest of the thigh bone.

When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight. To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the walker should be level with the client's waist, not below it. If one leg is weaker than the other, the walker and the weak leg move together while the stronger leg bears the client's weight. To use a standard walker correctly, a client should pick it up to move it. However, some walkers have wheels and can glide across the floor.

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?

ring or donut The nurse should not use rings or donuts with any client because this equipment restricts circulation. Specialty mattresses evenly distribute pressure. Gel pads redistribute the client's weight, and water beds distribute pressure over the entire surface.

Which is not a typical clinical manifestation of multiple sclerosis (MS)?

sudden bursts of energy With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS.

What factor has the potential to lead to chronic respiratory acidosis in older adults?

thoracic skeletal changes Poor respiratory exchange as the result of chronic lung disease, inactivity, or thoracic skeletal changes may lead to chronic respiratory acidosis. Decreased renal function in older adults can cause an inability to concentrate urine and is usually associated with fluid and electrolyte imbalance. A poor appetite, erratic meal patterns, inability to prepare nutritious meals, or financial circumstances may influence nutritional status, resulting in imbalances of electrolytes. Overuse of sodium bicarbonate may lead to metabolic alkalosis.

When teaching the child with scoliosis being treated with a Boston brace about exercises, the nurse explains that the exercises are performed primarily for what reason?

to strengthen the back and abdominal muscles Exercises are prescribed for the child with scoliosis wearing a Boston brace to help strengthen spinal and abdominal muscles and provide support. Typically, children wearing a Boston brace do not have muscle spasms. Performing exercises provides no effect on the brace's traction ability. Spinal contractures do not occur when a Boston brace is worn.

A client recovering from surgery needs to be ambulated in the room twice a day. For which reason should the nurse question the use of a gait belt when ambulating this client?

Client is recovering from abdominal surgery. A gait belt is used to transfer and assist a client with ambulation. A gait belt should not be used on a client with an abdominal incision that would be present after abdominal surgery. A gait belt would not necessarily be required for a client with mild cognitive impairment. A gait belt would not be required for a wound infection. A client needing minimal assistance would be a reason to use a gait belt.

The client has been diagnosed with septic arthritis in a hip joint. Which outcomes are desired from a client-focused teaching plan? Select all that apply.

Report pain that is severe enough to limit activities. Discuss how to take prescribed medications. Describe the septic arthritis physiologic process. Explain the importance of supporting the affected joint. Describe how to use ambulatory aids and assistive devices. The nurse should determine that a client with rheumatoid arthritis can describe the septic arthritis physiologic process and knows how to relieve pain using pharmacologic and nonpharmacologic interventions. Prolonged immobility and limited activity may promote formation of a deep vein thrombosis and possibly subsequent pulmonary emboli. The client should also understand the importance of supporting the affected joint, weight-bearing and activity restrictions, and how to use ambulatory aids and assistive devices safely to promote recovery of normal function. The local application of heat and cold to an injured body part can provide therapeutic benefits; however, "high" heat may cause a thermal injury and further promote edema formation. The client should inform the health care provider (HCP) about pain that is not relieved by the current management plan.

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?

The nurse uses a rocking motion while helping the client to stand. Rocking provides extra force when pushing or pulling. The nurse should keep any weight as close to the nurse's body as possible when lifting — not at arm's length. The nurse should keep knees slightly bent and feet spread apart to provide a wide base of support. Keeping the knees straight and stiff and bending at the waist and keeping the feet close together aren't examples of safe body mechanics. These positions could result in injury to the nurse or to the client.

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply.

a client who is on complete bed rest following extensive spinal surgery a client who has a large venous stasis ulcer on the right ankle area a client who has recently been admitted with a broken femur and is awaiting surgery a client who has undergone a total vaginal hysterectomy and is now on estrogen replacement Bed rest, poor venous circulation, fractures, and hormone replacement therapy can cause formation of a thromboembolus, placing these clients at risk for developing a PE. A deep vein thrombosis could break loose in the leg and travel to the lungs as a pulmonary embolus. The clot would then lodge in the pulmonary arteries or arterioles and impede blood flow. The client who is on complete bed rest is at risk for venous stasis, and the client who has a venous stasis ulcer is already demonstrating this condition. The client with a broken femur is at risk for a fat embolus, another form of PE. The client on estrogen replacement therapy is at increased risk for thromboembolic disorders. Pleural effusion and infection usually have no effect on thrombus formation, and oxygen therapy does not cause venous stasis or increase the risk of a pulmonary embolism.

Which statement would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment? The activity level is:

increased gradually; the client can resume usual activities in 5 to 6 weeks. The scarring of the retinal tear needs time to heal completely. Therefore, resumption of activity should be gradual; the client may resume usual activities in 5 to 6 weeks. Successful healing should allow the client to return to a previous level of functioning.

The nurse is teaching an older adult how to prevent falls. The nurse should tell the client to:

instruct the client to rise slowly from a supine position. Normal age-related changes can predispose older adults to falling and include vision, hearing, cardiovascular, musculoskeletal, and neurological changes. One of the most common problems facing older adults is the loss of tissue elasticity that affects the arteries. This loss of elasticity results in a decrease in tissue recoil and leads to changes in blood pressure with position changes. When they rise too quickly from a supine position, they feel light-headed and dizzy and can fall. The nurse should instruct clients to change positions slowly and to dangle the legs a few minutes when arising from a supine position. When aging, the lens of the eye becomes sensitive to very bright light which can causes a glare and visual disturbances that can lead to falls. Rooms should be well lit, but not with bright lights that cause a glare. Neurological changes are seen in impaired reflexes and thus postural instability. This loss of postural stability leads to falls. The need of assistive devices (hand rails, cane, walkers) helps reduce falls and promote independence. If joint pain develops and remains untreated, it can cause older adults to become sedentary or immobile. This disuse of muscles contributes to muscle weakness and falls. Nursing interventions should be directed at encouraging regular ambulation and joint movement (range of motion).

A 74-year-old client receiving fluphenazine decanoate therapy develops pseudoparkinsonism, and is ordered amantadine hydrochloride. With the addition of this medication, the client reports feeling dizzy when standing. Which response by the nurse is best?

"When you change positions, do so slowly." Both the fluphenazine decanoate and amantadine hydrochloride can have orthostatic hypotensive effects. Clients should be educated about this side effect especially in the elderly. Telling the client to change positions slowly will help ease the dizziness. If the dizziness is prolonged, the client should report those results to their practitioner. The client does not need a dose change or taken off the medication. The symptoms reported are orthostatic hypotensive effects not signs and symptoms of a stroke. The client could consider taking the medications at bedtime, but symptoms will likely persist. It would be safer to teach the client how to deal with symptoms as they occur.

The nurse is examining an older adult client with a fracture. What is the most common site of fractures in older adults?

Hip fracture is the most common injury in the elderly population, and has a high rate of mortality due to complications of surgery and prolonged immobility.

Which nursing goal should take priority when planning for the client's physical mobility immediately after amputation?

preventing contractures Preventing joint contractures is essential to future physical mobility and use of a prosthesis if needed. Joint contractures can begin to form within a few days after surgery, thus careful positioning of the limb and physical therapy will be an important part of postoperative care immediately after surgery.Promoting comfort and preventing edema are appropriate immediate postoperative nursing goals, but neither affects physical mobility in the extended postoperative periods.Phantom-limb pain can begin as early as several days after surgery. It occurs briefly in about 30% of clients, but only about 2% experience persistent pain. The pain cannot be prevented, but it may be treated with analgesia or nerve stimulation.

An older adult has vertigo accompanied with tinnitus as the result of Ménière's disease. The nurse should instruct the client to restrict which dietary element?

sodium Ménière's disease is commonly seen in older women; the disorder is caused by pressure within the labyrinth of the inner ear as a result of excess endolympha resulting in swelling in the cochlea. Therefore, the nurse should instruct the client about dietary restrictions of sodium to reduce fluid retention. Pharmacologic treatment includes antivertiginous drugs and diuretics. If the client is prescribed a diuretic, the fluid and electrolytes are monitored. The amount of protein does not have a direct influence in this disease process.

A nurse is assessing a 15-year-old adolescent who's being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?

muscle weakness Anorexia nervosa frequently causes muscle weakness resulting from starvation or electrolyte imbalance. The reduced metabolism that occurs with severe weight loss produces bradycardia, not tachycardia and cold extremities, not warmed, flushed extremities. Soft, downlike hair (called lanugo) may cover the extremities, shoulders, and face of an anorectic client.

A client is scheduled to undergo transurethral resection of the prostate. The procedure is to be done under spinal anesthesia. What should the nurse assess the client for after surgery?

respiratory paralysis If paralysis of vasomotor nerves in the upper spinal cord occurs when spinal anesthesia is used, the client is likely to develop respiratory paralysis. Artificial ventilation is required until the effects of the anesthesia subside. Seizures, cardiac arrest, and renal shutdown are not likely results of spinal anesthesia.

A client with a diagnosis of schizophrenia is admitted to the psychiatric hospital in a catatonic state. During the physical examination, the client's arm remains outstretched after the nurse obtains pulse and blood pressure readings, and the nurse must reposition the arm. This client is exhibiting:

waxy flexibility. Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them. Clients with dependency problems may demonstrate suggestibility, a response pattern in which one easily agrees to the ideas and suggestions of others rather than making independent judgments. Catatonic clients may also exhibit negativity (for example, resistance to being moved or being asked to cooperate) and retardation (slowed movement).

A client seeks medical attention for a ganglion. Which statement about this musculoskeletal mass is true?

Dorsiflexion exacerbates signs and symptoms of a ganglion. Dorsiflexion exacerbates signs and symptoms of a ganglion. A ganglion is the most common benign soft-tissue mass in the hand, not foot. It isn't a known precursor to a primary bone tumor. To treat a ganglion, the physician aspirates the ganglion, then injects a corticosteroid into the joint; the physician may also order nonsteroidal anti-inflammatory agents. Surgical excision is necessary only if signs and symptoms persist and the client's range of motion is impaired.

A client has a Pearson attachment on the traction setup. What is the purpose of this attachment?

to support the lower portion of the leg The Pearson attachment supports the lower leg and provides increased stability in the overall traction setup. It also makes it easier to maintain correct alignment. It does not support the thigh and the upper leg or prevent flexion deformities in the ankle and foot. It is not attached to the skeletal pin.

The nurse is instructing the unlicensed assistive personnel (UAP) about how to prevent plantar flexion (footdrop) for a client on complete bed rest. The UAP should:

encourage active range of motion to unaffected extremities. Active range of motion should be encouraged to help prevent the development of contractures, including plantar flexion. A UAP can help a client perform active range-of-motion exercises to unaffected extremities.A bed cradle relieves the pressure of bedclothes on the feet but cannot prevent plantar flexion.Massaging lotion helps maintain skin integrity.A trochanter roll is placed at the hips to prevent external rotation.

A nurse is conducting an assessment of a neonate born 3 hours ago. Which finding makes the nurse suspect a congenital hip dislocation?

unequal gluteal folds Unequal gluteal folds are a sign of congenital hip dislocation. Other signs include unequal thighs, limited adduction of the affected side, and shortening of the limb on the affected side. Crepitus of the affected hip is not felt, but an audible click may be heard when the hip on the affected side is adducted.

The nurse is planning the order of client assessments at the beginning of the shift based on the risk for skin breakdown each client presents. The nurse should assess the clients in which order? All options must be used.

a paraplegic client admitted with dehydration and ordered bedrest an older adult client with a diagnosis of left hip fracture a client with diverticulitis who is occasionally incontinent a client with sickle cell disease who is reporting pain The client who is paraplegic with dehydration and on bedrest has the most risk factors for skin breakdown because of limited motion and is ordered bedrest. The older adult client with a hip fracture will require help with mobility and has risk factors due to mobility and age. The client with occasional incontinence has a risk factor due to wetness and how long the wet garment remains on. While the client with sickle cell disease is in pain which may affect mobility, there are no other factors that would indicate a risk for skin breakdown.

A nurse is caring for a client who had hip pinning surgery 6 hours ago to treat intertrochanteric fracture of the right hip. What assessment finding requires further investigation by the nurse?

client anxious and confused The client is anxious and confused is the appropriate answer. Postoperative complications of hip fractures include hemorrhage, pulmonary emboli, and fat emboli. Anxiety and confusion may be indicative of hypoxia as a result of any of these complications and needs further investigation. Capillary refill of 2-3 seconds is an expected finding. Edema is present from both the injury and the surgical intervention. 100 milliliters of bright red drainage 6 hours after surgery should be watched, but is not of immediate concern.

The client was recently diagnosed with a musculoskeletal disorder and ordered carisoprodol. The nurse completes teaching about the medication. Which statement by the client indicates a need for more teaching about carisoprodol?

"I will stop the medication as soon as the muscle spasticity goes away." The nurse must clarify that muscle spasticity will return when medication is suspended. Carisoprodol is to be taken with food and fluid, should not be used with alcohol, and activities such as driving should be avoided only if drowsy/dizzy.

A client recovering from lumbar surgery is fitted for a contour splint. What should the nurse explain to the client about this device?

"The splint immobilizes the body part in a functional position." Contoured splints are used for health issues to immobilize the area and support the body part in a functional position. Splints are easily removed and are not indicated for use in traction. The splint prevents, not permits, free range of motion of the body area.

The nurse understands that the client with severe dementia and motor apraxia may be able to perform which action?

Brush the teeth when handed a toothbrush. Highly conditioned motor skills, such as brushing teeth, may be retained by the client who has dementia and motor apraxia. Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia. Confabulation is fabrication of details to fill a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe. Finding keys is a memory factor, not a motor function.

The nurse observes as a child with Duchenne muscular dystrophy attempts to rise from a sitting position on the floor. After attaining a kneeling position, the child "walks" his hands up his legs to stand. The nurse documents this as which sign?

Gower's sign With Gower's sign, the child walks the hands up the legs in an attempt to stand, a common approach used by children with Duchenne muscular dystrophy when rising from a sitting to a standing position. Galeazzi's sign refers to the shortening of the affected limb in congenital hip dislocation. Goodell's sign refers to the softening of the cervix, considered a sign of probable pregnancy. Goodenough's sign refers to a test of mental age.

A client is being discharged following an open reduction and internal fixation of the left ankle, and is to wear a non-weight-bearing cast for 2 weeks. What should the nurse teach the client to do when using crutches?

Maintain two to three finger widths between the axillary fold and underarm piece grip. The nurse instructs the client to maintain two finger widths between the axillary fold and the underarm piece grip of the crutches to prevent pressure on the brachial plexus. The client is advised to use the three-point gait; in the four-point and two point-gait there is partial weight bearing of both feet. The client is also advised to keep the affected leg elevated when sitting to prevent swelling, and to use the arms, not the axillae, to maintain balance and support.

The nurse plans to place graduated compression stockings on a client in the preoperative setting. List in order the steps the nurse will follow. All options must be used.

Review medical record and medical orders for graduated compression stockings. Identify the client and explain procedure. Place the client in supine position. Apply powder or lotion to legs. Turn the stocking inside out and ease the stocking over the foot and heel. Smoothly pull the stocking over the ankle and calf. When applying graduated compression stockings, the nurse should first review the medical record and verify the medical order for application. The nurse should then identify the client and explain the procedure to alleviate anxiety and prepare the client for what to expect. The nurse then places the client in a supine position to reduce congestion of blood in vessels. The nurse then applies powder or lotion to the legs to reduce friction and ease the application. Next, the nurse turns the stocking inside out as this technique provides for easier application and with the heel pocket down, eases the stocking over the foot and heel. The nurse then smoothly pulls the stocking up over the heal and calf, making sure there are no wrinkles, as wrinkles may compromise circulation.

Unlicensed assistive personnel (UAP) are helping a client who has had knee surgery 2 days ago get into bed. As the nurse makes rounds, which information requires the nurse to intervene?

The side rails on the head and foot of the bed are in the up position. Side rails are considered restraints and are not used at both the head and foot of the bed. Using side rails at the head of the bed will aid the client in sitting up and are safe, but using side rails at both the head and the foot of the bed presents risks for a client who might become wedged between the rail and the bed or attempt to climb over them. The nurse discusses side rail use with the UAP and lowers the side rail at the foot of the bed. The nurse assures the bed is placed in low position. The accessible call light, dim lighting, and clear path to the bathroom are factors that contribute to fall prevention.

The nurse is planning care for a client having an above-the-knee amputation of the left leg. At which time should the nurse recommend exercising of the remaining left limb?

24 hours after the surgery Exercise of the remaining limb should begin the day after, or 24 hours after, the surgery. The client should be educated on the reasons for the exercises and given adequate pain control to enhance comfort, but the nurse should not wait until the client "feels ready" to begin the exercises. Exercise is necessary to maintain the muscle tone of the remaining limb. Eight hours after surgery, the client will still be recovering from anesthesia and will have pain. This is not an appropriate time to begin exercising the remaining limb. Exercise needs to begin 24 hours after the surgery, which occurs before being admitted to a rehabilitation center.

Which positioning technique is most effective when there is only one person to assist the client to move from the left side to the right side if the client has hemiparalysis?

rolling the client onto the side Rolling the client is the most effective method to use when there is only one person to help the client change positions from one side to another. The nurse must keep the client in anatomically neutral positions and ensure that the limbs are properly supported. Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury. Having the client lift off the bed with a trapeze is an acceptable means to move a client when the client needs use the bedpan or lie on the back.

After assessing the blood pressure of a client with a diagnosis of catatonia, the client's arm remains outstretched in an awkward position. Which of the following is the correct action by the nurse?

Reposition the client's arm. The nurse should reposition the arm as the client is exhibiting waxy flexibility. This is defined as the ability to assume and maintain awkward or uncomfortable positions for long periods. Clients with catatonia sometimes remain in these awkward positions until someone repositions them. There is no indication that the client needs wrist restraints at this time.

To help minimize calcium loss from a hospitalized client's bones, the nurse should

encourage the client to walk in the hall. Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn't increase activity sufficiently to minimize bone loss. Providing dairy products and supplemental feedings wouldn't lessen calcium loss — even if the dairy products and feedings contained extra calcium — because the additional calcium doesn't increase bone stimulation or osteoblast activity.

When performing an assessment, the nurse identifies these signs and symptoms in the client: decreased muscle strength, limited range of motion, and reluctance to move. Based on these symptoms, the nurse should perform which interventions? Select all that apply.

encouraging client turning and repositioning every 2 hours having call bell within easy reach initiating hospital fall risk protocols The client with discoordination, decreased muscle strength, limited range of motion, and reluctance to move is at risk for falls and also for pressure ulcers. The nurse should encourage/assist the client in turning and repositioning every 2 hours and ensure that the call bell is within easy reach. The hospital's fall risk protocols should be initiated at this time. Having four-sided rails up is considered a restraint and is not indicated at this time. Gowning and gloving when in the room is appropriate for clients needing isolation precautions—these are not indicated at this time.

A nurse is teaching the proper use of crutches to a school-age child with a femur fracture with no weight bearing. What will the nurse include with teaching about walking with crutches?

"After advancing both crutches the length of one step, move your 'good' leg forward." When walking with crutches, a child should be instructed to advance both crutches, then advance the unaffected leg. The unaffected leg then supports much of the weight associated with ambulation. It will not be effective to move the affected leg forward first. It wouldn't be safe for the child to advance only one crutch.

A nurse is evaluating the proper use of crutches by a client who has fractured the right leg. Which statement indicates the client is using the correct technique?

"I feel pressure on the palms of my hands when I am walking with my crutches." It is normal for the client to feel pressure on the palms of the hands when walking with crutches. The client should move her affected (right) leg forward first as she swings forward with the crutches. Leaning on the crutches can apply pressure to the axillae, leading to neurovascular impairment. If the client's arms are tingling after she uses her crutches, she is probably applying pressure on her axillae when walking.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do?

Explain how to overcome a freezing gait by telling the client to march in place. Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bed rest. A muscle relaxant is not indicated.

A nurse is documenting a health assessment when the client states having problems with balance, as well as fine and gross motor function. When collaborating with the health team, which area on the illustration of the brain would the nurse highlight as an area of concern?

The cerebellum is the portion of the brain that controls balance and fine and gross motor function. The cerebellum is located at the base of the skull and above the brain stem.

The nurse is performing an assessment of a client to determine risk for skin breakdown. Which areas will the nurse include with use of the Braden scale? Select all that apply.

The client is unable to turn in the bed independently. The client has reduced sensation in the lower extremities. The client is NPO (nothing by mouth). The client is occasionally incontinent of urine. The Braden scale is used to assess clients to determine the potential for skin breakdown. The nurse would assess mobility, sensation, nutrition, and moisture as part of this scale. While age and hydration are also factors in skin integrity and prevention of skin breakdown, these are not part of the Braden scale.

A nurse is caring for a client who fell and fractured the neck of femur. When documenting the site for the family members, indicate on the image the area where the fracture occurred.

The neck of the femur is a flattened pyramidal process of bone connecting the femoral head with the femoral shaft just below the ball and socket. When a femoral neck fracture occurs, the ball is disconnected from the rest of the thigh bone.

The nurse is caring for a client with knee high antiembolism stockings. Which assessment finding does the nurse prioritize as needing notification of the healthcare provider?

unilateral swelling Despite the use of antiembolism stockings, a client may develop deep vein thrombosis. Unilateral swelling may be an indication of deep vein thrombosis development and would be reported immediately to the healthcare provider. Dry, flaking skin is not a priority and can be remedied with the use of lotion prior to applying the antiembolism stockings. Capillary refill less than 2 seconds and posterial tibial pulses +2 bilaterally are normal findings and would not require notification of the healthcare provider.

What finding indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful?

maintenance of joint mobility The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralization or have a positive effect on the client's muscle tone.

A nurse is assisting a client with range-of-motion exercises. The nurse moves the client's leg out and away from the midline of the body. What movement does the nurse document?

abduction Movement away from the body or midline is called abduction. Movement toward the midline is called adduction. Pronation is the act of turning the hand so the palm faces downward. Supination is the act of turning the palm anteriorly.

When the nurse is assessing a client who reports a back injury, what should the nurse ask the client about first?

mechanism of injury The mechanism of injury is always the most critical information to obtain from a client with a musculoskeletal injury. In the event of a back injury, the mechanism of injury provides the greatest clue as to the extent of injury and the proper treatment plan. The other questions are important but will not give the critical information needed related to this specific problem and injury.

Bone resorption is a possible complication of Cushing's disease. To help the client prevent this complication, what should the nurse recommend to the client?

Maintain a regular program of weight-bearing exercise. Osteoporosis is a serious outcome of prolonged cortisol excess because calcium is resorbed out of the bone. Regular daily weight-bearing exercise (e.g., brisk walking) is an effective way to drive calcium back into the bones. The client should also be instructed to have a dietary or supplemental intake of calcium of 1,500 mg daily. Potassium levels are not relevant to prevention of bone resorption. Vitamin D is needed to aid in the absorption of calcium. Isometric exercises condition muscle tone but do not build bones.

When the client who has had a hip replacement is lying on the side, the nurse should place pillows or an abductor splint between the legs to prevent:

adduction of the hip joint. After hip replacement surgery, the client should be positioned on the nonoperative side with pillows or an abductor splint between the legs to help prevent adduction of the operative leg. This positioning places the hip in proper alignment. Dislocation of the hip can occur if the leg on the affected side is allowed to adduct.Flexion of the knees is not contraindicated.Abduction of the legs is the correct position.Placing a pillow between the legs will not result in hyperextension of the knee. Hyperextension of the knee is to be avoided in any case because it can result in injury.

After surgery for bilateral adrenalectomy, the client is kept on bed rest for several days. Which exercise will be most effective for preparing a client for ambulation after a period of bed rest?

alternately flexing and relaxing the quadriceps femoris muscles Alternately flexing and relaxing the quadriceps femoris muscles helps prepare the client for ambulation. This exercise helps maintain the strength in the quadriceps, which is the major muscle group used when walking.The other exercises listed do not increase a client's readiness for walking.

When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for which health problem?

aspiration Loss of motor function to the face and throat can cause dysphagia and places the client at risk for aspiration. Bladder dysfunction and hypertension are not associated with myasthenia gravis. Myasthenia affects nerve impulses at the neuromuscular junction, causing loss of motor function; there is no sensory deficit.

The nurse is caring for a client admitted for pneumonia with a history of hypertension and heart failure. The client has reported at least one fall in the last 3 months. The client may ambulate with assistance, has a saline lock in place, and has demonstrated appropriate use of the call light to request assistance. Using the Morse Fall Scale (see chart), what is this client's total score and risk level?

60, high risk Several factors designate this client as a high fall risk based on the Morse Fall Scale: history of falling (25), secondary diagnosis (15), plus IV access (20). The client's total score is 60. There is also concern that the client's gait is at least weak if not impaired due to hospitalization for pneumonia, which may add to the client's fall risk. After evaluating the client's risk, the nurse must develop a plan and take action to maximize the client's safety.

A client has been receiving radiation therapy for 3 weeks to treat cancer and has fatigue. The nurse should consider which factor when planning to help the client cope with the fatigue?

A balance of activity and rest will help manage the fatigue. The plan of care to treat fatigue associated with radiation therapy should include encouraging the client to remain active and to plan scheduled rest periods as necessary before activity. Engaging in activities, such as walking, has been shown to decrease the cycle of fatigue, anxiety, and depression that can occur during treatment. Fatigue is a very common side effect of radiation therapy that typically begins during the third or fourth week of treatment and persists until after treatment ends. The presence of fatigue does not mean that the cancer is not responding to treatment or that the client has developed another health problem.

After undergoing surgery the previous day for a total knee replacement, a client states that they doesn't feel ready to ambulate yet. What should the nurse do?

Discuss the complications that the client's may experience if they don't cooperate with the care plan. The nurse should discuss the care plan and its rationale with the client. Calling the physician to report the client's noncompliance won't alter the client's degree of participation and shouldn't be used to force the client to comply. Doing nothing isn't acceptable. Although the client does have the right to make choices, it's the nurse's responsibility to provide education to help the client make informed decisions. Although the nurse should ultimately document the client's refusal, the nurse should first discuss the care plan with the client.

The nurse is observing a client who is recovering from back strain lift a box as shown in the accompanying image. What should the nurse do?

Praise the client for using correct body mechanics. The client is using correct body mechanics for lifting because she is keeping her back as straight as possible and is holding the box close to her body. She is using her large leg muscles to lift the box. She is using a broad base of support by placing her feet as wide apart as possible. The other suggestions would cause the client to put a strain on her back.

Which findings best correlate with a diagnosis of osteoarthritis?

joint stiffness that decreases with activity A characteristic feature of osteoarthritis (degenerative joint disease) is joint stiffness that decreases with activity and movement. Erythema and edema over the affected joint, anorexia, weight loss, and fever and malaise are associated with rheumatoid arthritis, a more severe and destructive form of arthritis.

The nurse is planning care for a client on complete bed rest. To prevent venous thrombosis, what should the nurse include in the plan of care? Select all that apply.

turning every 2 hours passive and active range-of-motion exercises use of thromboembolic disease support (TED) hose Three factors contribute to the formation of venous thrombus and thrombophlebitis: damage to the inner lining of the vein (prolonged pressure), hypercoagulability of the blood, and venous stasis. Bed rest and immobilization are associated with decreased blood flow and venous pooling in the lower extremities. Keeping the client in the supine position would not be appropriate. Turning the client every 1 to 2 hours, passive and active range-of-motion exercises, and use of TED hose help prevent venous stasis in the lower extremities.

The nurse is instructing the unlicensed assistive personnel (UAP) on how to position the wheelchair to assist a client with left-sided weakness transfer from the bed to a wheelchair using a transfer belt. Which statement by the UAP tells the nurse that the UAP has understood the instructions for placing the wheelchair?

"The wheelchair should be placed on the right side of the bed." When assisting a client with a weakness out of bed, it is important that the client always move toward the stronger side. This allows the client to assist in the move as much as possible. In this case, the client will need to move toward the right side of the bed to maximize the use of the strong arm and leg. Placing the wheelchair at the head of the bed or behind the client does not allow for a safe transfer of the client. The transfer belt is used to help the client balance and provide safety, not to lift the client; the transfer should be made with the least amount of work for both the client and the UAP while ensuring the safety of the client.

A client recovering from a stroke is prescribed a leg brace and needs to be transferred out of bed to a chair. Which action should the nurse take first before beginning this transfer?

Apply the leg splint before beginning the transfer. It is recommended that any braces or devices the client wears to be applied before assisting the client out of bed. The head of the bed should be raised so that the client is in a sitting position before beginning the transfer. There is no reason to roll the client away from the side of the transfer. This would not facilitate the movement and could cause injury to both the client and nurse during the transfer.

A client recovering from surgery to repair a fracture of the tibia and fibula of the left leg is reporting increased pain at the site. What sign must the nurse be alert to that would indicate compromised circulation to the leg?

increased edema in the toes of the affected leg Constriction of circulation decreases venous return and increases pressure within the vessels. The increased pressure in the venous side of the capillary prevents reabsorption of fluid from the interstitial spaces, causing edema. Foul odor, increased body temperature, and purulent drainage from the incision site indicate the presence of an infection.

The school nurse is planning an educational session to prevent injuries in children with juvenile arthritis. Which information should the nurse include in the teaching?

Schedule the completion of daily range-of-motion exercises to support joint mobility. Daily range-of-motion exercises are required to help a child with juvenile arthritis strengthen the muscles and use the joints to their full range of motion. Participation in group sports may be too strenuous for the child with juvenile arthritis and may increase the risk for injuries. Excessive exercise, such as running and jumping during play, should be discouraged because it places an excessive amount of pressure on the joints. The child should remain active and independent, but avoid overexertion during activities. Homeschooling to avoid activity and walking would not support the child's need for exercise to maintain joint flexibility.

Which nursing approach is most helpful to a client with Parkinson disease who is experiencing a freezing of gait with difficulty initiating movement?

Tell the client to march in place. When a freezing gait occurs, having the client march in place or step over actual lines, imaginary lines, or objects on the floor can promote walking. Instructing the client to take one step backward and two steps forward may also stimulate walking. Pulling the client forward can cause imbalance. The nurse does not instruct the client to use a wheelchair. The client obtains much exercise as possible; having the client remain still does not help the client obtain the momentum needed to walk.

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?

When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight. To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the walker should be level with the client's waist, not below it. If one leg is weaker than the other, the walker and the weak leg move together while the stronger leg bears the client's weight. To use a standard walker correctly, a client should pick it up to move it. However, some walkers have wheels and can glide across the floor.

A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside?

suction machine with catheters MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade is an appropriate seizure precaution, but should not be used in this client because its large size could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen delivery; this client requires a mechanical ventilator.

The nurse is preparing a 45-year-old female for a vaginal examination. The nurse should place the client in which postion?

lithotomy position Although other positions may be used, the preferred position for a vaginal examination is the lithotomy position. This position offers the best visualization. If the client is an older adult and frail, staff members may need to support the client's flexed legs while the examiner conducts the examination and obtains the Papanicolaou smear. Positioning the client in the other positions will make visualization more difficult and may not be as comfortable for the client.

Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which client?

a 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance Using the Morse fall scale, risk factors for this client include history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, weak gait/transfer, and forgetting limitations (100 points). Client no. 1 is also high risk with a secondary diagnosis, history of falling, IV access, and confusion but is on bed rest (75 points). Client no. 2 risks include IV access and secondary diagnosis (35 points). Client no. 4 is at risk due to his IV access only (20 points).

The nurse is admitting a client diagnosed with multiple sclerosis (MS). Which medication would the nurse expect to find on the client's record?

baclofen Multiple sclerosis (MS) is a progressive disease characterized by demyelination of the brain and spinal cord. This disease causes a number of manifestations including muscle spasticity. Therefore, baclofen will be given on a routine basis. Antibiotics are not routinely needed. Sinemet is given for Parkinson's disease, not for MS. Methotrexate is given for rheumatoid arthritis.

A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation, which laboratory result is the priority for the nurse to report to the physician?

blood culture Osteomyelitis is a bacterial infection of the bone and soft tissue that occurs by extension of soft tissue infection, direct bone contamination following surgery, or spreading from other infection sites in the body. A positive blood culture would be reported immediately to the physician so that specific antibiotic therapy can begin or be adjusted based on the positive culture. A negative rheumatoid factor would be expected in a possible diagnosis of osteomyelitis. An alkaline phosphatase level of 60 IU/L (1.0 nkat/L) is within the normal range, and an ESR of 10 mm/hour is also within the normal range.

A male client underwent a lumbar spinal fusion yesterday. Which nursing assessment should alert the nurse to the development of a possible complication?

clear yellowish fluid on the dressing Clear yellowish fluid on the dressing may be cerebrospinal fluid (CSF). This fluid must be tested for glucose to determine whether it is CSF. If so, the client is at great risk for an infection of the central nervous system, which has a high mortality rate. The client should be able to laterally rotate the head and neck, which is above the surgical site in the spinal column. During the nursing postoperative neuromuscular-vascular assessment of movement of the head and neck, the nurse should find results consistent with the preoperative baseline status. Using the standing position to void is normal for a male client. Coughing is the body's defense mechanism to help clear the lungs of the anesthetic agents and to ventilate the lungs in response to a sustained deep inspiration for ventilation of the lower lobes of the lungs. A frequent cough could place a strain on the incision site and should be avoided. Also, a productive cough of thick, yellow sputum would indicate the complication of a respiratory infection.

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent:

contractures typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications.Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.

Before planning care for a group of clients with mobility issues, the nurse wants to ensure best practices are incorporated into the plan. Which source should the nurse access to ensure safe quality care is provided?

evidence-based research Evidence-based research provides information to serve as a basis for nursing care decisions. Outcome criteria are the expected behaviors or conditions that result from the implementation of approved standards. Organizational policies will not necessarily provide specific content about best practices. Assessment data are used to determine if a particular intervention was appropriate to address a client's health problem.

A nurse is assessing a client for neurologic impairment after a total hip replacement. Which finding would indicate impairment in the affected extremity?

inability to move Being unable to move the affected leg suggests neurologic impairment. A decrease in the distal pulse, diminished capillary refill, and coolness to touch of the affected extremity suggest vascular compromise.

The nurse is performing an assessment in the nursery on an infant with a developmental hip dysplasia. Which findings should the nurse anticipate?

ortolani's sign Assessment in a child with a congenital hip dislocation typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.

The nurse is teaching a pregnant client about injury prevention. Which instruction should the nurse include?

"Change your shoes from high heels to flats." Balance changes during pregnancy. Wearing high heels places the woman off balance and can lead to falls. They can also lead to leg fatigue and increased swelling. Low heel or flat-heeled shoes are more appropriate for correct balance. When traveling in a car, the shoulder belt should cross between the breasts and over the upper abdomen, above the uterus. The lap belt should cross over the pelvis below the uterus. The steering wheel should be positioned as best as possible away from the uterus. Going to the gym every day is good exercise for the pregnant client, but the purpose is not for balance. Exercise promotes a sense of well-being, improves circulation, helps reduce constipation, and promotes muscle strength, tone, and endurance. For the working pregnant client, it is recommended to take two 10-15 rest periods in an 8-hour workday.

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help?

"Obtain the sliding board or two other people to assist us." To successfully move an obese client from the stretcher to the bed without incurring injury, at least four staff members must perform the transfer. If only two people are available, the nurse should use the sliding board. The hydraulic lift isn't the appropriate equipment to use with a sedated patient. The nurse shouldn't place the client in a semi-Fowler's position unless there is a head injury or other complicated medical condition. To perform a safe transfer using a drawsheet, the nurse must place the sheet directly under the client's body.

A client had a total hip replacement today. How should the nurse position the client when the client is transferred from the transport cart to the bed?

Maintain the affected extremity in slight abduction using an abduction splint or pillows placed between the thighs. After total hip replacement, proper positioning by the nurse prevents dislocation of the prosthesis. The nurse should place the client in a supine position and keep the affected extremity in slight abduction using an abduction splint or pillows or Buck's extension traction. The client must not abduct or flex the operated hip because this may produce dislocation.

The nurse develops the plan of care for a child with early Duchenne's muscular dystrophy. What is the priority goal for this client?

Maintain function of unaffected muscles. The primary nursing goal is to maintain function in unaffected muscles for as long as possible. There is no effective treatment for childhood muscular dystrophy. Children who remain active are able to forestall being confined in wheelchair. Remaining active also minimizes the risk for social isolation. Preventing rather than encouraging wheelchair use by maintaining function for as long as possible is an appropriate nursing goal. Children with muscular dystrophy become socially isolated as their condition deteriorates and they can no longer keep up with friends. Maintaining function helps prevent social isolation. Circulatory impairment is not associated with muscular dystrophy.

A nurse explains the process of cane usage to a hospitalized client with left-sided weakness. Prioritize the steps of proper cane usage. All options must be used.

Perform hand hygiene. Secure a gait belt around client's waist. Place the cane in the right hand. Hold the cane on the right side and advance the left leg. Advance the cane 6 to 10 inches (15 to 25 cm) with each step First, the nurse should perform hand hygiene. Next, the nurse should secure a gait belt around client's waist. Then, place the cane in the right hand and hold the cane on the right side and advance the left leg. Finally, advance the cane 6 to 10 inches (15 to 25 cm) with each step.

A nurse notes that a client has kyphosis and generalized muscle atrophy. Which problem is a priority when the nurse develops a nursing plan of care?

ineffective coughing and deep breathing In kyphosis, the thoracic spine bends forward with convexity of the curve in a posterior direction, making effective coughing and deep breathing difficult. Although the client may develop other problems because respiratory status deteriorates when pulmonary secretions are not adequately cleared from airways, ineffective coughing and deep breathing should receive priority attention.

Which nursing diagnosis takes the highest priority for a client with parkinsonian crisis?

ineffective airway clearance In parkinsonian crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of an ineffective airway clearance takes the highest priority. Although imbalanced nutrition: less than body requirements, impaired urinary elimination, and risk for injury are also appropriate nursing diagnoses, they are not immediately life-threatening.

The client is being discharged today after having an above-the-knee amputation a week ago. Which complications should the nurse include in the discharge directions? Select all that apply.

new openings in wound or skin around the wound pulling away worsening pain not controlled by medication skin around the stump or wound dark or turning black Complications for above-the-knee amputaton include new openings in wound or skin around the wound is pulling away; skin around the stump or wound is dark or is turning black; and pain is worse and is not controlled by medication. Other complications include swelling, new drainage or bleeding from the wound; temperature 38.6° C or higher, foul smell, red streaking up the extremity; if stump is redder, feels warmer, is bulging, or if it has gotten bigger. Pink, fleshy tissue and temperature of 36.8° C are normal findings.

A nurse is assessing a client with a diagnosis of a thoracic spinal cord tumor. Which finding is expected?

positive Babinski's sign A positive Babinski's sign is an expected finding in a thoracic spinal cord tumor. Nystagmus and Horner's syndrome are expected findings in a cervical spinal cord tumor. A positive Brudzinski's sign indicates meningeal irritation, such as meningitis.

The nurse is creating a plan of care for an older adult client with osteoarthritis. Which nursing diagnosis is most appropriate?

risk for injury related to altered mobility Typically, a client with osteoarthritis has stiffness in large, weight-bearing joints, such as the hips. This joint stiffness alters functional ability and range of movement, placing the client at risk for falling and injury. Therefore, risk for injury is the most appropriate nursing diagnosis. Activity intolerance related to sedentary lifestyle assumes that the client with osteoarthritis is limited in physical activity. Self-care deficit related to immobility assumes that the client with osteoarthritis is unable to complete self-care activities. Imbalanced nutrition: Less than body requirements is incorrect because osteoarthritis does not affect nutrition.

The nurse teaches the client to perform isometric exercises to strengthen the leg muscles after arthroplasty. Isometric exercises are particularly effective for clients with rheumatoid arthritis because they:

strengthen the muscles while keeping the joints stationary. An exercise program is recommended to strengthen muscles after arthroplasty. Isometric (or muscle-setting) exercises strengthen muscles but keep the joint stationary during the healing process.Isometric exercise do not require specialized equipment, but this does not explain the benefits of the exercises.Isometric exercises may help improve a client's morale by promoting self-care, but this is not the reason for doing them.Because the joint is kept stationary, isometric exercise will not help prevent joint stiffness.

The nurse is measuring a client for thigh high antiembolism stockings. The client's thigh measurements are outside the guidelines for available sizes. What is the next action by the nurse?

Notify the provider. If a client's thigh measurements are outside the guidelines for available thigh high antiembolism stockings, the nurse should notify the provider. The client may require custom fitted stockings or some other option for deep vein thrombosis prevention. Improperly fitted stockings are uncomfortable and may cause the client harm, therefore the nurse would not place the next size available or stockings based on the calf measurement. The nurse would not place knee high antiembolism stockings as this would require a provider's order.

The nurse is caring for a client during the postoperative period. The client was prescribed thigh high antiembolism stockings and pneumatic compression devices for prevention of deep vein thrombosis. Assessment data reveal +3 pitting edema to the lower extremities bilaterally. What is the priority action by the nurse?

Measure client's thighs and calves to ensure the antiembolism stockings are the correct size. For the client with antiembolism stockings and pneumatic compression devices in place for prevention of deep vein thrombosis, it is important for the nurse to remove the stockings and assess the client's skin every 8 hours. If the client has a significant change in the size of the legs, such as with postoperative edema, it would be the nurse's priority to measure the client's legs to ensure the stockings are the correct size. If the measurement showed the need for another size stockings, the nurse would apply them at that time. Clients in the postoperative period are at risk for deep vein thrombosis, therefore it is the priority to ensure the appropriate sized antiembolism stockings, not to discontinue them. Applying a larger size would be implemented after measuring the client's legs to ensure the stockings are the correct size. There is no need to notify the healthcare provider if the nurse applies a larger size.

The nurse is reviewing the medical record and finds orders to apply graduated compression stockings on a client. What is the next action by the nurse?

Measure the client's legs. After receiving orders for graduated compression stockings, the nurse would explain the procedure to the client and then measure the client's legs to determine the appropriate sized stocking. Improperly fitting stockings are uncomfortable and may be harmful to the client. Compression stockings should be placed in the morning, before the client is out of bed for the day to prevent blood vessels from being congested with blood, therefore, the nurse should place the compression stockings prior to having the client use the restroom. The nurse would not want to massage the legs. If a blood clot is present, this may cause the clot to break away from vessel and circulate in the bloodstream. Applying graduated compression stockings may be delegated to unlicensed assistive personnel, but only after the nurse has determined the correct size stocking by measuring the client's legs.

While gently abducting the hips during a newborn assessment, the nurse hears a "click" as the femoral head slips into the acetabulum. The nurse interprets this as positive for which physical finding?

Ortolani's sign Ortolani's sign refers to the "click" made when the femoral head slips forward into the acetabulum when forward pressure is exerted from behind the greater trochanter and the knee is held laterally. This sign indicates hip dislocation.A positive Barlow's test, evidenced by the femoral head slipping out over the acetabulum when pressure is applied then slipping back into place when the pressure is released, indicates that the hip is unstable with increased risk of dislocation.Galeazzi's sign refers to shortening of the affected limb in congenital hip dysplasia. It is elicited by flexing the infant's hips and knees while the infant lies supine. The soles of the feet are placed flat near the buttocks, and the knee heights are assessed for equality.Trendelenburg's sign refers to a downward tilting of the pelvis toward the normal side when a child with a dislocated hip stands on the affected side with the uninvolved leg elevated.

The nurse is explaining the nature of the fracture to the parents of a school-age client who has a greenstick fracture. Which drawing should the nurse choose to explain the fracture to the parents?

The nurse should show the parents the figure of the greenstick fracture as noted in answer C in which the fracture does not completely cross through the bone. Answer A is a plastic deformation, or a bend in the bone. Answer B is a buckle. Answer D is a complete fracture.

When assessing the client with Parkinson's disease, the nurse should observe the client for:

a stiff, masklike facial expression. Typical signs of Parkinson's disease include drooling; a low-pitched, monotonous voice; and a stiff, masklike facial expression.Dry mouth is not associated with Parkinson's disease.Aphasia is not a symptom of Parkinson's disease.An exaggerated sense of euphoria would not be typical; more likely, the client would exhibit depression, probably related to the progressive nature of the disease and the client's difficulties dealing with it.

The nurse is caring for the following infant after surgery. Which short term goal is the priority?

The infant will remain infection free in the postoperative period. The client has spinal bifida with a myelomeningocele (protrusion of the spinal cord and meninges). Surgery is completed within the first days of life. Following surgery and in the recovery period, it is most important to maintain meticulous care to the incision to reduce the potential for infection. Infection can spread through the incision and up the spinal tract to the brain. All other goals are important but not as great a priority as infection.

The nurse is caring for a child in Bryant's traction (see figure). What action should the nurse take?

Provide frequent skin care. The traction is positioned correctly; the nurse should provide frequent skin care to the back and shoulder areas. The hips and buttocks should be lifted off the bed to provide counter traction; the nurse should not adjust the weights. The nurse should not place a pillow under the buttocks as this would prevent counter traction. The elastic wraps should remain on the legs unless removal is prescribed by the health care provider (HCP).

A client is being discharged to a rehabilitation care facility following a hip replacement using the posterior surgical approach. When reporting to the licensed practical/vocational nurse (LPN/VN), which nursing actions would the orthopedic nurse stress as essential? Select all that apply.

Avoid any hip flexion exercises. Place two pillows between the client's knees. Place a raised toilet seat in the bathroom. The hip is one of the body's largest joints. In a total posterior approach hip replacement surgery, the damaged bone and cartilage are removed and replaced with prosthetic components. Until healing occurs, the legs must be spread outward (abducted) away from the body by placing pillows or an abductor foam wedge between the legs. Adduction of the hip or flexion greater than 90° may dislocate the prosthesis from the joint. Raising the head of the bed 90° creates excessive hip flexion. Using a raised toilet seat is appropriate to avoid bending. The client will be out of bed for physical therapy once to twice daily. Keeping the feet elevated is not part of the hip replacement protocol.

The health care provider prescribes raloxifene hydrochloride for a 60-year-old woman. The drug is effective if the client does not develop:

osteoporosis. raloxifene hydrochloride, an estrogen receptor modulator, increases bone mineral density without stimulating the endometrium. The drug is useful in preventing osteoporosis in postmenopausal women. This drug is contraindicated for women who smoke cigarettes or who have a history of venous thrombosis.Raloxifene does not prevent hot flashes or hyperglycemia.One of its adverse effects is increased headaches.

A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. What should the nurse do first?

Draw a mark around the site. The priority action is to draw a mark around the site of bleeding to determine the rate of bleeding. Once the area is marked, the nurse can determine whether the bleeding is increasing or decreasing by the size of the area marked. Because the spot is bright red, the bleeding is most likely arterial in origin. Once the rate and source of bleeding are identified, the surgeon should be notified. The stump is not elevated because adhesions may occur, interfering with the ability to fit a prosthesis. The dressing would be reinforced if the bleeding is determined to be of venous origin, characterized by slow oozing of darker blood that ceases with the application of a pressure dressing. Typically, operative dressings are not changed for 24 hours. Therefore, the dressing is reinforced to prevent organisms from penetrating through the blood-soaked areas of the initial postoperative dressing.

The nurse is preparing to help a client move up in bed with a goal of prevention of skin breakdown. Place the following steps in order for the procedure. All options must be used.

Place a friction-reducing sheet under the client's midsection. Place the bed in the Trendelenburg position to prepare for the move. Have the client place the feet flat on the bed during the move. Have the client lift the head during the move. The client will have the most benefit to the skin to reduce friction and shear by having a sheet under the midsection to help with the move and this is a beginning step to prepare for the move. The client would be placed in Trendelenburg position to help with gravity reduction and ease of moving. If the heels are lying against the bed during the move, it can cause friction and shear due to being a bony prominence when lying on the back. The client can place feet flat on the bed and help push to move up in the bed. The head, while usually padded with hair or the pillow, can have friction and shear against the scalp if not lifted during the move.

For which client(s) does the nurse anticipate the healthcare provider's orders for pneumatic compression devices? Select all that apply.

client who had extended low anterior resection for colonic mass client in the intensive care unit on a ventilator with sepsis client with four vessel coronary artery bypass graft with bilateral chest tubes Pneumatic compression devices may be used with graduated compression stockings or alone to apply sequential pressure to the legs to enhance blood flow and venous return. They require a prescriber's order and are usually prescribed for high-risk surgical clients, clients with decreased mobility, and those at risk for deep vein disorders. Clients with extended low anterior resection and coronary artery bypass graft would be surgical clients at high risk for deep vein thrombosis. The client in the intensive care unit on a ventilator with sepsis has decreased mobility and is also at risk for deep vein thrombosis. Same-day procedures such as endoscopy and laparoscopy would not be considered high risk for deep vein disorders and would not require pneumatic compression devices.

The nurse is making rounds and observes a client who is unconscious (see figure). The unlicensed assistive personnel (UAP) has just turned the client from lying on her back and raised the side rail next to the bedside stand. Before raising the side rail on the opposite side, the nurse should:

inspect the skin at pressure points from the back-lying position. The client is positioned correctly in the side-lying position. The pillows support the client's joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the client's skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.