CH.33 PREP U

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response?

- "To preserve the client's functional ability to grasp and pick up objects." Explanation: Trochanter rolls prevent the legs from rotating outward. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop. Side rails help a weak client turn independently and protect the client from falling out of bed.

The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include?

- "Picture yourself with good posture standing; that is how good lying posture works." Explanation: The best posture lying down will be the same as standing posture, except the client is horizontal. Knees should be slightly flexed; feet should be at a right angle from the legs; the head and neck muscles should be in a neutral position, centered between the shoulders. It is not correct to say to keep the knees and legs very straight, to position feet at a 45-degree angle from the legs, or to sleep with the head tilted to one side.

A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction?

- Hold your cane on the right side. Explanation: Because this client is using the cane due to weakness, it should be placed on the "strong" side, in this case the right side. The client should stand tall and not lean into the cane. The cane should be 4 in (10 cm) outside the stronger foot. This client should not switch hands with the cane.

The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement?

- place a small pillow under each arm Explanation: A small pillow may be used to elevate the extremities, shoulders, or incisional wounds. Instructing the client to place the arms on the side rails will place pressure on the arms and affect circulation to the extremity. Elevating the head of the bed (Fowler) will not elevate the arms. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward.

The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?

- placing the client in good alignment with joints slightly flexed Explanation: The inactive client should be repositioned every 2 hours with the use of a low-friction fabric or gel-filled plastic sheet and then placed in good alignment with joints slightly flexed. Skin care should be provided after repositioning.

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?

- "Put your arm in this sleeve." Explanation: When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions. "Put your arm in this sleeve" gives one step in the process of getting dressed. "Put on your shirt" involves many steps and should be broken down into the steps of putting on a shirt. "Put your pants on and zip the zipper" should be broken down into steps and given in clear, short sentences. Furthermore, putting on pants and zipping a zipper involves many steps and may be too complicated for the client with dementia to follow. Instructions should be phrased positively as the client may not register the "Don't"; the client may put the shoes on if the nurse states "Don't put on your shoes yet."

The nurse is caring for a client who is on bed rest. After reviewing the image above, which is the most appropriate reason for the nurse to observe this client perform the activity?

- "A client can perform this activity to prevent a permanent condition in the feet caused by bed rest." Explanation: Assisting and observing the client perform dorsiflexion of the feet helps to reduce the risk of foot drop. Foot drop can occur if the toes of the feet are dropped downward for extended periods of time resulting in plantar flexion caused by changing the length of the muscles. Due to the gravitational pull, this position of the feet occurs naturally when the body is at rest and the toes are placed in a perpendicular position making heel-toe gait impossible. This results in altered mobility. Wearing shoes such as a high-top canvas sneaker could assist to minimize this complication of prolonged bed rest.

An older adult client is transferring from a supine position to a sitting position in a chair. The client reports dizziness when transferring. Which teaching by the nurse is most appropriate?

- "Move slowly and sit on the edge of the bed before transferring to the chair." Explanation: The nurse should allow extra time when older adults are changing their positions, such as from supine to sitting or standing, to prevent orthostatic hypotension. The most important thing is to teach the client is to wait until any dizziness has resolved before moving, thereby decreasing the risk for falls. While lowering the head below the level of the heart is common practice, it is not appropriate for an older client with hypotension. Planting the feet firmly on the floor before standing is to prevent falls, not to address orthostatic hypotension. Drinking water will help fluid volume, but not reduce risk of orthostatic hypotension.

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse?

- positioning a friction-reducing sheet under the client to facilitate movement Explanation: After placing the bed in a comfortable working position (usually elbow height of the caregiver), position a nurse on either side of the bed, place a friction-reducing sheet under the client, and use the leg muscles to pull the client to the side.

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response?

- "You are free to move onto the stretcher without assistance, but I will supervise for your safety." Explanation: If the client is fully able to assist in the transfer, the nurse should allow the client to complete the movement independently, with supervision for safety. A physician order is not necessary for a transfer from a stretcher to a bed. The client can move independently and therefore does not need a friction-reducing device. A nurse should remain at the bedside to monitor the transfer.

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?

- "Your elbows will be slightly bent when you are using your crutches." Explanation: When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down, if fatigued.

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

- A client who has leg strength and can cooperate with the movement Explanation: The gait belt is used to help the client stand and provides stabilization during pivoting. Gait belts also allow the nurse to assist in ambulating clients who have leg strength, can cooperate, and require minimal assistance. A gait belt is not used on clients who have either an abdominal or thoracic incision. A gait belt would not be used on a client who is confined to bed rest.

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?

- Adduction Explanation: Adduction is a lateral movement of a body part toward the midline of the body. An example of adduction is when a person's arm is moved from an outstretched position to a position alongside the body. Abduction is a lateral movement of a body part away from the midline of the body. An example of abduction is when a person's arm is moved away from the body. Circumduction is turning in a circular motion. This motion combines abduction, adduction, extension, and flexion. An example of this movement is the circling of the arm at the shoulder, as in bowling or a serve in tennis. Extension is the state of being in a straight line. An example of extension is when a person's cervical spine is extended, the head is held straight on the spinal column.

The occupational nurse is teaching employees about maintaining good posture. Which teaching will the nurse include? (Select all that apply.) - Alternate placing weight on one foot versus the other. - Bend the knees slightly to avoid straining joints. - Maintain the hips at an even level. - Push the buttocks out and hold the abdomen up to properly align the spine. - Keep the shoulders even and centered above the hips.

- Bend the knees slightly to avoid straining joints. - Maintain the hips at an even level. - Keep the shoulders even and centered above the hips. Explanation: Proper posture includes distributing weight equally on both feet to provide a broad base of support, bending the knees slightly to avoid straining joints, maintaining the hips at an even level and keeping the shoulders even and centered above the hips, and pulling the buttocks in and holding the abdomen up to properly align the spine. Alternating the weight on one foot at a time and pushing the buttocks out can lead to injury.

An older adult who experienced a complication during an open cardiac surgery 4 weeks ago has been on prolonged bed rest during recovery. The nurse is new to the client and is reviewing the chart prior to assuming care.

- Client reports inability to sleep at night and subsequently sleeps during the day - often verbalizes sadness associated with missing out on so much - Respirations shallow - increased instability and weakness upon standing - Last bowel movement reported as hard to pass occuring 2 days ago Explanation: The neurologic clinical manifestations associated with immobility include an altered sleep pattern, which the client has demonstrated by sleeping through the day and being awake at night. Immobility is associated with depression and feelings of powerlessness. The negative effects of immobility are associated with a decreased respiratory depth and rate. Altered gas exchange is evidenced by reduced capillary refill and can be associated with immobility. Orthostasis, or orthostatic hypotension, is clinically manifested as a drop in blood pressure upon standing. The client may become weak or unsteady upon standing. Other signs include lightheadedness or fainting upon standing. The immobile client is subject to decreased gastrointestinal persistalsis, which can contribute to delay of function and constipation. Normal neurovascular findings that are not associated with immobility for this client include being verbal, pleasant, and having full orientation. Normal findings include pupils that are equally round and reactive to light, as well as accomdate to light appropraitely. Being able to enjoy conversations with others demonstrate a postive health behavior, which is associated with the postive effects of exercise.

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?

- Equipment is positioned to the side, 50 degrees away. Explanation: Proper ergonomics promote comfort, performance, and health in the workplace. All findings support proper ergonomics, with the exception of equipment positioning. Equipment should be positioned 20 to 30 degrees away, in front, not off to the side, to avoid turning or twisting of the head, neck, and shoulders.

A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply. - Exercise increases resting heart rate and blood pressure. - Exercise increases intestinal tone. - Exercise increases efficiency of the metabolic system. - Exercise increases blood flow to kidneys. - Exercise decreases appetite. - Exercise decreases rate of carbon dioxide excretion.

- Exercise increases intestinal tone. - Exercise increases efficiency of the metabolic system. - Exercise increases blood flow to kidneys. The benefits of exercise include increasing intestinal tone, increasing efficiency of the metabolic system, and increasing blood flow to the kidneys. Exercise decreases resting heart and blood pressure. Exercise increases appetite. Exercise increases the rate of carbon dioxide excretion

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?

- If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Explanation: Be prepared to apply the stockings in the morning before the client is out of bed. Assist the client to a supine position. If the client has been sitting or walking, have him or her lie down with legs and feet well elevated for at least 15 minutes before applying the stockings. Powder the leg lightly unless client has a breathing problem, dry skin, or sensitivity to the powder. If the skin is dry, a lotion may be used. Powders and lotions are not recommended by some manufacturers; check the package material for manufacturer specifications.

A nurse is educating a client on how to walk with crutches. Which teaching points are recommended guidelines for this activity? Select all that apply. - Keep elbows close to sides. - Crutches should be at least 3 inches from the feet. - Support body weight with hands and arms. - Place pressure on the axillae when walking. - When descending stairs, move crutches and the unaffected leg first, followed by the affected leg. - When climbing stairs, advance the unaffected leg past the crutches, place weight on the unaffected leg, and then advance the affected leg followed by the crutches.

- Keep elbows close to sides. - Support body weight with hands and arms. - When climbing stairs, advance the unaffected leg past the crutches, place weight on the unaffected leg, and then advance the affected leg followed by the crutches. Explanation: The client should keep the elbows close to sides. The crutches should not be any closer than 12 inches from the feet to help prevent the client from falling. The client should support body weight with hands and arms and should not put pressure on the axillae when walking. Pressure on the axillae can cause damage to nerves and circulation. When climbing stairs, the client should advance the unaffected leg past the crutches, then place weight on the unaffected leg. Then the client should advance the affected leg and the crutches to the step. When descending stairs, the client should move crutches and the affected leg first, followed by the unaffected leg

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?

- Raise the head of the bed to a sitting position. Explanation: When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair.

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

- Shift their weight back and forth, from back leg to front leg. Explanation: The nurses would use a rocking motion to counteract the client's weight. The nurses would shift their weight back and forth, from back leg to front leg, count to three, and then move the client up toward the head of the bed. Rocking the client or turning the client from side to side is not used to move a client.

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body?

- Short bones contribute to movement. Explanation: Short bones contribute to movement and are located in the wrist and ankle. The wrist is classified as a short bone. Long bones, such as the femur and humerus, are located in the upper and lower extremities and contribute to height and length. The flat bones are relatively thin and contribute to shape. The flat bones are found in the ribs and several of the skull bones and contribute to shape (structural contour).

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

- Sims Explanation: Sims' position, a semi-prone position, can be used for certain examinations of the rectum and vagina. The other positions do not allow adequate examination of this area.

Using proper body mechanics, which motions would the nurse make to move an object?

- The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. Explanation: Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The internal girdle is made by contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward. It is helped further by making a long midriff by stretching the muscles in the waist. The nurse would not relax the stomach muscles or use the muscles of the back when moving an object. The nurse would not lift an object when it can be safely slid, rolled, pushed, or pulled.

The nurse is caring for a client who is ordered to be in the Fowler position. When assessing the client's position in bed, the nurse will adjust the client in bed if what is observed? Select all that apply. There is a large pillow under the client's head. The client's forearms are supported on pillows. The knee gatch on the bed is engaged. The client's foot is in the plantar flexion position. There is a rolled towel beside the client's hips.

- There is a large pillow under the client's head. - The knee gatch on the bed is engaged. - The client's foot is in the plantar flexion position. In the Fowler position, the client's head should be against the mattress or supported by a small pillow only. Using a large pillow may cause flexion contracture of the neck. The knee gatch should be avoided to prevent pressure on the popliteal artery that could compromise lower extremity circulation. When the client's foot is in the plantar flexion position, the client is at risk for foot drop. A foot board, high-top sneakers, or improvised firm foot support should be used. It is appropriate to place the client's forearms on pillows. This will prevent pull on the shoulders and help prevent dislocation of the shoulder. A rolled towel or trochanter roll will help prevent external rotation of the hips.

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?

- When I lift and carry a heavy box of supplies I will keep it at arm's length from my body. Explanation: The nurse teaching a group of UAPs about proper body mechanics recognizes the need for additional education when a class participant states that, when lifting and carrying a heavy box of supplies, the UAP will keep it at an arm's length from body. This motion will result in injury and the UAP should be instructed to keep items close to the body. The UAPs should lift an object with feet shoulder width apart by bending at the knees instead of the waist and getting close to the object being lifted. These actions reflect the correct understanding of proper body mechanics.

Which type of mobility aid would be most appropriate for a client who has poor balance?

- a cane with four prongs on the end (quad cane) Explanation: Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold but are not recommended for clients with poor balance. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.

The nurse is caring for a client who is postoperative from a hip fracture repair. The nurse must be careful to avoid:

- adduction of the affected leg. Explanation: For some types of hip surgery, dislocation can result from movement of the leg toward or past the midline of the body (adduction). Thus, to prevent injury, it is important to avoid hip adduction on clients who have had hip replacement surgery.

The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply. - hold his breath only when lifting heavy objects - adjust the height of the work area - face in the direction of the activity he is performing - use a wide stance and lift with the large leg muscles

- adjust the height of the work area - face in the direction of the activity he is performing - use a wide stance and lift with the large leg muscles Explanation: holding is a sign of muscle strain and an inefficient use of body mechanics.

The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher?

- alongside the bed at the same height Explanation: By placing the bed and the stretcher at the exact same height, it makes for easier transfer and decreases risk of potential injury. If the stretcher were lower or higher, it would not make for a smoother transfer and the client could be injured during transfer.

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?

- bed trapeze Explanation: A trapeze bar is a handgrip suspended from a frame near the head of the bed. A client can grasp the bar with one or both hands and raise the trunk from the bed. The trapeze makes moving and turning considerably easier for many clients and facilitates transfers into and out of bed. A foot board helps reduce the risk of foot drop. A bed cradle is usually a metal frame that supports the bed linens away from the client while providing privacy and warmth. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward.

The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change?

- decrease in flexibility Explanation: A decrease in the flexibility of joints is a normal age-related finding. Pain in the lower back, stumbling gait, and unequal pupil can be indicators of pathology and are not normal age-related findings.

What is a benefit of regular exercise over time?

- decreased heart rate Explanation: Regular physical activity over time results in cardiovascular conditioning and therefore decreased heart rate. Regular exercise increases circulating fibrinolysin that serves to break up small clots, thus decreasing the risk for blood clots. Over time, regular exercise leads to improved pulmonary function, including decreased work of breathing. Venous return is improved when contracting muscles compress superficial veins and push blood back to the heart against gravity.

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

- foot drop. Explanation: A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Foot drop is a contracture in which the foot is fixed in plantar flexion.

A nurse is assessing a client's mobility status. What data would the nurse document as normal findings? Select all that apply. - increased joint mobility - independent maintenance of correct alignment - scissors gait - head, shoulders, and hips aligned in bed - full range of motion - Fasciculations

- independent maintenance of correct alignment - head, shoulders, and hips aligned in bed - full range of motion Explanation: Normal findings that the nurse would document regarding a client's mobility would include independent maintenance of correct alignment, full range of motion, and the alignment of the client's head, shoulders, and hips in bed. A fasciculation is a muscle twitch, which would not be a normal finding regarding a client's mobility. The documentation of a client having a scissors gait would not be a normal finding. Increased joint mobility would not be a normal finding regarding the client's mobility.

The nurse observes an older adult client walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating?

- is demonstrating a common gait for the older adult. Explanation: Many older people have more difficulty overcoming inertia and using gravity efficiently. One contributing factor is the shift in the center of gravity. To compensate for this shift, the knees flex slightly for support.

As a part of his workout regimen, a 21-year-old college football player often engages in both a 10-minute squat hold and 10-minute lateral arm hold. These are examples of what type of exercise?

- isometric Explanation: Isometric exercise isolates a specific muscle or muscle group and exercises it by holding the muscle steady and maintaining tension. Both squat holds and lateral arm holds involve maintaining a position, in this case, for 10 minutes each.

The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action?

- move the client to edge of the bed opposite the side that client will be turning Explanation: When turning a client in bed, the nurse would use a friction-reducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Pushing the client to the opposite side of the bed is not good for back safety. Consult a Safe Patient Handling algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client.

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed?

- near the client's hip, with legs shoulder width apart and one foot near the head of the bed Explanation: When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight to assist the client to a sitting position safely. The dominant or nondominant side is not relevant when moving a client with equal strength but would be helpful with a client who has had a stroke.

A nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program?

- obtain a pre-exercise medical examination for clearance Explanation: The client has underlying medical conditions and should obtain a pre-exercise medical examination before beginning any exercise program. Picking an enjoyable activity and understanding that the activity will have positive benefits will help promote success. Variety is preferable to a single-exercise activity to promote success.

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

- predisposition to renal calculi Explanation: In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk of urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.

The nurse is caring for a client who has a lower-body injury and who is able to partially assist with transfers. The nurse should:

- provide the client with an overhead trapeze. Explanation: Overhead trapezes may provide handholds for clients to assist with transfers and repositioning. The headboard should not normally be used for this purpose. A pull sheet may be unnecessary if the client can partially assist.

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity?

- pull the shoulder blade forward and out from under the client Explanation: Positioning the shoulder blade in this manner removes pressure from the bony prominence and thus helps decrease the risk of impaired skin integrity. The other actions should also be performed but do not decrease the risk of impaired skin integrity.

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group?

- scoliosis Explanation: Numerous factors, including growth and development, influence a person's posture, movement, and daily activity level. The adolescent should be assessed for scoliosis (curvature of the spine). Kyphosis is increased convexity in the thoracic spine from disk shrinkage and decreased height, common in older adults. A shifted center of gravity occurs during pregnancy (in the adult) because of the developing fetus. Older adults have an increased need for calcium and vitamin D related to the risk for osteoporosis

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern?

- shortness of breath after walking up five stairs Explanation: Activity Intolerance may result from any condition that interferes with the transport of oxygenated blood to tissue. The altered response to activity includes exertional dyspnea, shortness of breath. Shortness of breath after walking up five stairs would be included in this nursing diagnosis. Another altered response would be excessive increase in pulse rate. After walking up 20 stairs, a change in pulse of 4 points is not excessive. Joint stiffness is a defining characteristic of the nursing diagnosis Impaired Physical Mobility. Walking with a slow and uncoordinated movement is another defining characteristic of Impaired Physical Mobility.

The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client?

- slight Trendelenburg Explanation: Placing a client in slight Trendelenburg position may help keep the client from sliding down toward the foot of the bed. Placement into the other position choices does not accomplish the same purpose.

The nurse is assessing an older adult client who is having difficulty with mobility. Assessment reveals that the client has stiff and awkward muscle movements. The nurse identifies this as:

- spasticity. Explanation: Spasticity refers to stiff or awkward muscle movements. Hemiparesis refers to weakness on one side of the body. Ataxia refers to impaired muscle coordination. Disequilibrium would lead to balance problems.

The nurse is assessing the client for muscle mass, tone, and strength and determines that there is increased tone that interferes with movement. How does the nurse document this finding?

- spasticity. Explanation: skeletal muscle mass, tone, and strength are prerequisites to appropriate body movement and work performance. Spasticity, or hypertonicity, is defined as increased tone that interferes with movement. Spasticity is caused by neurologic impairments, and is often described as a stiffness, tightness, or pulling of the muscle. Hypertrophy refers to increased muscle mass resulting from exercise or training. Atrophy describes muscle mass that is decreased through disuse or neurologic impairment. Flaccidity, or hypotonicity, results from disuse or neurologic impairments, and is described as a weakness of paralysis.

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:

- steps into the walker when walking. Explanation: A walker is mechanical aid that enhances the client's balance and ability to bear weight. Education is usually done by physical medicine or physical therapy, but the nurse should continue to assess the client's ability to use the walker properly. The client should step into the walker when walking rather than walking behind it. When the client is rising from a seated position, the arms of the chair, not the walker, should be used for support. The client should be cautioned to avoid pushing the walker out too far in front. Also, the client should avoid leaning over the walker but should instead stay upright while moving.

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?

- supine Explanation: Supine position is recommended as a way to reduce the incidence of sudden infant death syndrome (SIDS) among newborns. The other positions are inappropriate for placing an infant to sleep.

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?

- supporting the client's back Explanation: The nurse would place the pillow under the client's back to provide support and help maintain the proper position. A pillow can also be placed between the knees. More than one pillow under the client's head is not necessary. Placing a pillow in front of the client's abdomen would be helpful for a client who has undergone abdominal surgery. Placing a pillow under the client's feet is not helpful for the side lying position

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

- the 24-month-old child who is unable to walk unassisted Explanation: At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raise the head, but this is not expected at this age. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month-old infants. Stacking blocks is accomplished by most 3-year-olds, but doing so at 18 months is considered early.

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?

- thrombus formation Explanation: Prolonged sitting can increase a client's risk for thrombus formation. The nurse will emphasize this and teach stretching exercises. Skeletal contractures, pooling of secretions, and oliguria are not risk factors associated with flying (prolonged sitting).

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?

- transfer belt Explanation: A transfer belt is designed for clients who can bear weight and help with the transfer but are unsteady. The other options are inappropriate for this client.

The nurse is working to increase functional ability of a client who is bedbound. Which assistive technique should the nurse prioritize in the plan of care?

- trapeze bar Explanation: Promoting client independence with movement and activity is an important intervention for clients who are bedbound, especially ones with musculoskeletal problems. Unlike log rolling, trochanter rolls, and pull sheets, which are nurse-initiated methods, the overhead trapeze is used by the client.

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?

- trochanter rolls Explanation: Trochanter rolls prevent the legs from turning outward. The trochanters are the bony protrusions at the heads of the femurs, near the hip. Placing positioning devices at the trochanters helps prevent the legs from rotating outward. Other devices are inappropriate for this client.

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate?

-placing a small towel under the neck Explanation: Kyphotic changes can cause pressure on cervical vertebrae when someone is in a supine position. Effects of this can be minimized by placing a small towel or cervical pillow under the neck. Placing the client on the stomach is incorrect, and a muscle relaxer will not help reduce the pressure caused by the kyphosis. Contacting the physician is unnecessary.

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. - removing clutter from the floor - placing nightlights in the bathroom and hallways - moving the bedroom to the ground floor - installing hardwood floors

Removing clutter from the floor, placing nightlights in the bathroom and hallways, and moving the bedroom to the ground floor will reduce the risk of falling and encourage the client to increase his mobility. Installing hardwood floors may induce falls due to the smooth surface; wall-to-wall carpeting would provide traction.