Chapter 15, 23, 25, 26, 30 (PrepU Foundations)

gluteal setting

contraction and relaxation of the gluteus muscles to strengthen and tone them

While preparing a client with a forearm fracture for casting, the nurse washes and dries the skin. Which nursing action is next?

covering arm with stockinette

platform crutches

crutches that support the forearm, used by clients who cannot bear weight with their hands and wrist

forearm crutches

crutches with an arm cuff but no axillary bar

A client with severe arthritis needs temporary immobilization of the wrist and hand. Which type of cast does the nurse anticipate will be ordered?

cylinder bivalve

tilt table

device that raises client from a supine to a standing position

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

footdrop

A client with an unstable patella has seen the health care provider to discuss options to provide stability to this joint. Which type of immobilizer does the nurse anticipate applying?

functional brace

A client is having a fiberglass cast applied. The client says to the nurse, "Years ago, I had a plaster cast and it wasn't like this one. Is this better?" What advantages of the fiberglass cast would the nurse cite? Select all that apply.

lightweight porous unaffected by water

A client with a dislocated shoulder has come to the emergency department (ED) in extreme pain. Which type of traction will the nurse prepare to be used?

manual

The nurse is caring for a client who has a dislocated shoulder. Which type of traction intervention does the nurse anticipate will be used to address this concern?

manual

A home care nurse is assessing a client in the home. The client had a cerebrovascular accident and has right side paralysis. After 6 weeks of rehabilitation, the client has increasing mobility when:

she can lift the right arm ½ inch.

What are examples of orthoses? Select all that apply.

splints immobilizers braces

immediate postoperative prosthesis (IPOP)

temporary artificial limb. consists of a walking pylon, a lightweight tube, attached to a shell made of plaster or plastic on the stump and a rigid root.

A flexion contracture usually occurs because of inactivity and:

tensor muscles being stronger that flexors.

Debilitated clients

those who are frail or weak from prolonged inactivity require physical conditioning before they can ambulate

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

The nurse is caring for a client in skeletal traction. What should the nurse tell the client to avoid doing in order to prevent bony fragments from moving against one another?

turning side to side

crutch palsy

weakening of forearm, wrist, and hand muscles because of nerve impairment in the axilla caused by incorrectly fitted crutches or poor posture

The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene?

weights hanging and touching the floor

Give three examples of ambulatory aids.

canes, walkers, and crutches

A client must wear a cervical collar and asks the nurse how long she will have to use the device. Which time frame would the nurse state?

10 to 14 days

The health care provider has just applied a fiberglass cast to a client with a forearm fracture. How long will the nurse assure that the client holds the extremity in place while the cast dries?

15 minutes

A teenager is having a plaster cast applied. The client's mother asks how long it will take for the cast to dry. What response from the nurse is correct?

24 to 72 hours

The nurse is helping to apply an arm sling for a client with an injured elbow. How many degrees of flexion is the maximum? Record your answer using a whole number

90

The nurse is caring for a client who is in skeletal traction. To prevent the complication of skin breakdown in a client with skeletal traction, what preventive measure would the nurse implement?

Assess the pin insertion site every 8 hours

A group of students is studying for a test on traction. The students demonstrate understanding of the types of traction when they identify what as an example of skin traction?

Buck's

A client with a recent fracture is suspected of having compartment syndrome. Data findings may include which symptoms?

Inability to perform passive movement, pain with active movement

The nursing instructor in the skills lab at the nursing school is showing a group of nursing students how to apply traction. What is an appropriate example of proper traction use?

Knots in the rope should not be resting against pulleys.

Explain the purpose of a temporary prosthetic limb.

Promotes an intact body image immediately after surgery. It helps to control stump swelling.

describe three characteristics of appropriately fitted crutches

Measure from the anterior skinfold of the axilla to approximately 4-8in. diagonally from the foot add 2 in. or subtract 16in from height. Adjust the handgrips so there is 30 degrees of elbow flexion and 15 degrees of wrist hyperextension

The nurse is caring for a client who is on strict bed rest. Her medical history includes partial paralysis from a stroke suffered several years ago. There is also evidence of early dementia. The nurse correctly recognizes the client is at an increased risk for which complication?

Muscle atrophy

Name four components of above-the-knee and below-the-knee prosthetic limbs.

Permanent prostheses for BK amputees include a socket, a shank, and an ankle/foot system. AK prostheses also include a knee system to replace the knee join

The nurse is caring for an older adult client who has pain and loss of function associated with arthritis. Which nursing teaching is appropriate?

Physical and occupational therapy may be initially helpful.

A nurse is providing care for a client in skin traction. What is a recommended guideline?

Place the client in a supine position with the foot of the bed elevated slightly.

The nurse would like to assist a client out of bed and into a chair. The client is uncooperative, has a leg cast, and can bear weight on the unaffected leg. Which equipment or assistive device should the nurse use?

Powered full-body lift

A nurse is applying an ankle-foot orthosis to a client. What are the functions of this orthopedic device? Select all that apply.

Support body part. Align body part. Correct deformities.

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.

A nurse is caring for a male client who has recently been fitted with a cast following a tibial fracture. Which assessment findings would be suggestive of neurovascular dysfunction?

The client is unable to wiggle his toes on demand.

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client?

The client's ability to assist

Name four types of crutch-walking gaits.

The four types of crutch-walking gaits are the four-point gait, the three-point gait (non-weight-bearing or partial weight-bearing), the two-point gait, and the swing-through gait

The nurse is caring for a client who had a cast applied yesterday for a tibia fracture. When the client returns today with swelling in that extremity, for which procedure does the nurse prepare?

bivalving of the cast

The telehealth nurse is speaking with a parent whose child jumped off a couch and now is crying and holding the forearm. Which teaching will the nurse provide regarding emergency splinting?

Use a rigid splinting material.

A nurse has to perform pin site care. Place the steps of the skill in the correct sequence from first to last.

Wash your hands or perform an alcohol-based hand rub. Don gloves. Open the package containing cotton-tipped applicators without touching the applicator tips. Pour enough cleansing agent to saturate the dry applicators while holding them over a basin or wastebasket. Cleanse the skin at the pin site moving outward in a circular manner. Discard soiled supplies in an enclosed, lined container.

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)

tone

ability of muscles to respond when stimulated

Name four activities that prepare clients for ambulation.

performing isometric exercises with the lower limbs, performing isotonic exercises with the upper arms, dangling at the bedside, and using a device called a tilt table

An older adult man who suffered a hip fracture and is 1 day postoperative is to receive heparin 5,000 units subcutaneous daily. This is administered to:

prevent deep vein thrombosis.

A nurse is caring for an older adult client who is very ill. The nurse uses a lifting sheet to transfer the client from the bed to the stretcher. How does transfer by lifting sheet help the client?

prevents shearing of tissue

A client has a knee injury, and the nurse practitioner prescribes the use of a brace to reduce the severity. The nurse knows that the type of brace the client is most likely using is:

prophylactic brace.

To promote venous circulation,

reduce stump edema, and avoid any joint contractures, the nurse should encourage the client to lie in a supine or prone position periodically during the day

point

refers to the sum of the crutches and legs used when performing the gait.