ATI Fundamentals Mobility

A nurse is reinforcing teaching with a client who has an unsteady gait about using a walker. Which of the following instructions should the nurse include? 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°." D. "Take a step first before moving the walker."

A. "The top of the walker should be at the level of your wrist." The nurse should reinforce with the client to ensure that the top of the walker is at the level of their wrist. This indicates the walker is measured at the appropriate height and prevents strain on the client's back.

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 objects stabilizes the spine.

A. A stable center of gravity increases stability and balance is correct. Center of gravity is the central point of weight of an object. While standing, center of gravity is an imaginary line that begins at the umbilicus and intersects with the line of gravity. This increases the body's stability and balance. B. A wide base lowers the center of gravity is correct. A wide base lowers the center of gravity, which increases stability and balance and prevents the body from falling over. C. Proper body alignment involves tightening the abdomen is correct. When transferring clients or lifting objects, the nurse should keep the back straight, the chin level, and tighten abdominal muscles to maintain alignment.

A nurse is assisting with 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 The nurse should identify that an increased curvature of the thoracic spine, along with protrusion of the neck, indicates an age-related change to the client's musculoskeletal system. This occurs due to bone loss and degeneration of vertebral discs. This can cause the client to lean forward when standing and have an unsteady gait when walking.

A nurse is reinforcing teaching with a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL? A. Toileting B. Writing C. Ambulating D. Talking

A. Toileting The nurse should include that toileting is an ADL that the AP can assist the client to perform. Other ADLs include dressing, bathing, and feeding.

A nurse is collecting data about a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing? A. Atrophy B. Foot drop C. Joint contracture D. Disuse osteoporosis

B. Foot drop The nurse should suspect the client is experiencing foot drop. Foot drop occurs when the joint of the foot becomes contracted and results in the inability to perform dorsiflexion, or pulling the toes upward. This is due to nerve damage that causes shortening of the muscle. The foot is left with the toes pointing downward and in a dropped position.

A nurse is assisting with 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 The skeletal muscles are attached to the skeleton. They maintain body posture and position.

A nurse is assisting with a skin assessment for 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. Damage into the skin layer B. Damage beyond the skin layer C. Deep damage through the skin and tissue D. Damage with the skin intact

A. Damage into the skin layer The nurse should identify that the client's wound indicates damage into the skin layer. In this stage, the wound can be lighter in color than the client's skin tone, along with temperature differences and an intact or open blister.

A nurse is contributing to the plan of care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis? A. Fowler's B. Lateral C. Prone D. Supine

A. Fowler's The nurse should place the client in Fowler's position to promote lung expansion and prevent atelectasis, which is the partial or complete collapse of a lung. In this position, the client is seated in a semi-sitting position and can have their knees bent or straight.

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

A. Stand as close to the object as possible is the first step. The nurse should stand as close to the object as possible to prevent reaching forward and causing injury to muscles and the back. B. Keep abdominal muscles contracted and the lower back straight is the second step. The nurse should keep the abdominal muscles contracted and the back straight to prevent strain on the back. C. Look straight ahead with shoulders raised up is the third step. The nurse should look straight ahead with shoulders raised up to prevent strain on the neck and shoulders. D. Bend hips slightly and squat is the fourth step. The nurse should bend at the hips, not at the back, when squatting down to pick up an object because this prevents strain on the back. E. Push up from the knees when lifting the object is the fifth step. The nurse should bend at the knees when lifting an object from the floor. The leg muscles are the strongest muscles in the body. They help to limit strain on the back and prevent injury when lifting an object.

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

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. Mechanical lift C. Sit-to-stand lift D. Gait belt

B. Mechanical lift The nurse should use a mechanical lift, along with assistance from two or more health care staff, to transfer a client who is unable to assist. The use of a mechanical lift decreases the risk of injury to both the staff and the client.

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 hr 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. The nurse should remind the client who is at risk for developing atelectasis to use the incentive spirometer. Using the incentive spirometer prevents atelectasis from occurring because the client takes slow, deep breaths to promote lung expansion.

A nurse is reinforcing teaching with 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. Tendons and ligaments are both made of fibrous connective tissue. Tendons attach muscle to bone while ligaments attach bones to other bones.

A nurse is assisting with preparing a presentation for a group of clients 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 receptors 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. When muscles contract, they shorten and pull against the bone they are attached to. This results in flexion at the 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 The nurse should suspect the client is experiencing atrophy of their muscles. Atrophy occurs when the muscles of the body become smaller and weaker. This can occur with prolonged immobility or disuse of a limb.

A nurse is assisting with 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 protection of internal organs.

C. Muscles assist with thermoregulation in the body. Contracting muscles generate heat that assists in maintaining body temperature. Shivering is an example of the muscles working to produce heat.

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 The nurse should place the client who has pneumonia in the prone position to promote postural drainage. In this position, the client lies flat on their abdomen with their head turned to the side.

A nurse is assisting with completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks? A. Walk in place. B. Stand in place for 5 seconds. C. Sit on the edge of the bed for 1 min. D. Step forward and backward.

C. Sit on the edge of the bed for 1 min. The nurse should identify that the client who is at Level 1 Mobility of the MAT requires maximum assistance. The client should be able to sit on the edge of the bed for 2 min and extend their arms across their chest to shake hands with the nurse before advancing to the next level. If the client is unable to complete both tasks, they remain at Level 1 Mobility of the MAT.

A nurse is assisting with teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include? 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. The use of ergonomics increases job satisfaction along with productivity of staff members. When staff members can work safely and effectively, they can perform at a higher level.

A nurse is caring for a client who had a stroke and reports difficulty with proprioception. The nurse should plan to collect data from the client for which of the following? 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 Proprioception, or kinesthesia, is a sense of self-awareness and body position. It is the result of feedback from nerve sensory receptors that alert the brain to fine-tune muscle movement in order to regulate balance, coordination, and movement.

A nurse is reinforcing teaching with a client who has kyphosis. Which of the following information should the nurse include? A. Kyphosis is when the upper back extends 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 a rounded upper back with the pelvis tilted forward.

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

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 The nurse should look at the client face-to-face when transferring. This prevents twisting or turning of the torso, which can cause back injuries.

A nurse is caring for a client who requires assistance 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 The nurse should recommend a referral for an occupational therapist to assist the client with ADLs. An occupational therapist assists clients who have impaired function to perform ADLs, such as bathing and brushing their teeth.

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