Chapter 23 PrepU and Chapter info

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

A nurse applies padded boots to maintain the unconscious client's foot in dorsiflexion. The nurse is protecting the client from what complication?

foot drop

Adjustable bed

can be raised or lowered and allows the position of the head and knees to be changed

fowler position

semi-sitting position

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

Sims

The nurse is preparing the client for the administration of an enema. The nurse will place the client into which position?

Sims

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."

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."

The unlicensed assistive personnel (UAP) 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."

The occupational nurse is teaching an administrative assistant about proper posture when sitting. Which teaching will the nurse include?

"both of your feet should rest on the floor"

The nurse directs the unlicensed assistive personnel (UAP) to help a partially blind older adult client with meals. Which information is appropriate for the nurse to provide the UAP to facilitate the client's comfort and safety during mealtime? Select all that apply.

- Place client in upright position at a 45- to 90-degree angle in the bed or chair - Provide verbal cues regarding location of food on plate - Cut food into small pieces - Ensure that the temperature of food is safe

roller sheet

Also known as a slider sheet

Which items are appropriate for the nurse to prevent pressure sores when caring for an inactive client? Select all that apply.

Alternating air mattress and Foam mattress overlay.

hand rolls

Devices that preserve the clients functional ability to grasp and pick up objects. Prevents contractures.

"to avoid a nurse related injury as well as promote safe handling of a client before repositioning from a supine to a lateral position, which nursing assessment question is most important?"

Is the client able to assist?

A nurse is caring for a client with a leg fracture. The client is placed on an adjustable bed in the Trendelenburg position. How will this position help the client?

It prevents the client from sliding down toward the foot of the bed.

The nurse is assisting a client from the bed to a chair that is positioned next to the bed. The client requires partial assistance in the transfer. What action will the nurse perform to prevent injury to self?

Keep the knees bent while assisting the client from the bed.

A nurse is providing care for a frail older adult client with chronic obstructive pulmonary disease (COPD). The client always remains in a sitting position, leaning forward to improve oxygenation. Which assessment(s) provide data of possible impaired tissue integrity? Select all that apply.

Monitor skin integrity of heels. Monitor ischial tuberosities for pressure injury. Evaluate the client's awareness of pressure sensation. Assess for edema.

functional mobility

Moving from one position or place to another (during performance of everyday activities), such as in-bed mobility, wheelchair mobility, and transfers (e.g., wheelchair, bed, car, shower, tub, toilet, chair, floor). Includes functional ambulation and transportation of objects.

he meal tray has been delivered to the client's room. The client needs to be repositioned higher in the bed with the head raised. The client is unable to assist with moving in the bed. What action is best for the nurse to perform to prevent injury to the nurse and/or the client?

Obtain assistance from another nursing staff member.

foot drop

Permanent dysfunctional position caused by shortening of the calf muscles and lengthening of the opposing muscles on the anterior leg

which nursing measure is best to keep a client from sliding down in bed?

Place the client in a slight Trendelenburg position

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.

When the nurse instructs a nursing assistant to place a client in a Sims position, which description indicates the nursing assistant has performed the task correctly?

The client is in a semiprone position.

mattress

a large thick pad filled with resilient material and often incorporating coiled springs, used as a bed or part of a bed

ergonomics

a specialty field of engineering science devoted to promoting comfort, performance, and health in the workplace

A client is postoperative day 2 following hip replacement surgery, and the nurse is helping the physical therapist ambulate the client for the first time since surgery. How can the nurse and therapist best assist the client from a seated position at the edge of the bed to a standing position?

apply a transfer belt around the client's waist

The nurse is performing discharge teaching with the family of a male client who has limited mobility and a significant cognitive deficit. The nurse has described the phenomenon of foot drop to the client's family and should describe what intervention to prevent its development?

applying a foot splint correctly to maintain neutral foot positioning

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

A client who works in a warehouse and must lift heavy objects asks the nurse how to avoid musculoskeletal injuries. Which information would the nurse include?

bend from the knees, carry objects close to your body, and push rather than lift heavy objects

muscle spasms

cramps, sudden, painful, involuntary muscle contractions

repetitive strain injury

disorders that result from cumulative trauma to musculoskeletal structures

A nurse is preparing to move a client up in bed. How can the nurse best demonstrate the principles of correct ergonomics?

facing the direction of movement

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair 3 times per day. Which action will be most effective to transfer the client safely into the chair?

having the client sit on the side of the bed for several minutes before moving to the chair

supine position

lying on back, facing upward

neutral position

maintaining the spine in a neutral position facilitates the best lying position

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

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

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?

patient's ability to assist

Contractures

permanently shortened muscles that resist stretching

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

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

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

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

quad cane

After assessing a client, the nurse determines the client is at risk for disuse syndrome. The nurse will reposition the client every 2 hours to achieve which goal?

relieve pressure and maintain sufficient capillary circulation

bed board

rigid structure placed under a mattress

trochanter rolls

rolled towels used to keep a resident's hips from turning outward.

lateral position

side lying position

disuse syndrome

signs and symptoms that result from inactivity

mechanical lift

special equipment used to lift and move or lift and weigh a person; also called hydraulic lift

A nurse is demonstrating the proper use of body mechanics to a group of nursing students. What would be most appropriate for the nurse to do?

stand with legs wide apart

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 patient's back

posture

the position of the body, or the way in which it is held affect's a person's appearance, stamina, and ability to use the musculoskeletal system efficiently.

body mechanics

the proper use of the body to facilitate lifting and moving and prevent injury