Chapter 25 Mechanical Immobilization & Chapter 26 Ambulatory Aids

Which client would benefit the most from the use of a walker to assist in ambulation? A. client who has weakness on one side of the body B. client who requires considerable assistance with balance C. client who needs permanent assistance when walking D. client who needs brief, temporary assistance ambulating

B. client who requires considerable assistance with balance

A nurse is caring for a middle-aged woman suspected of having a leg fracture following a fall while crossing the road. What is the priority first aid measure that the nurse should apply to provide mechanical immobilization to the client? A. ice packs B. emergency splint C. commercial splint D. cotton bandage

B. emergency splint

A nurse is assessing the neuromuscular status of a client who is recovering from severe neck pain. What should the nurse ask the client to do to assess the neuromuscular status? A. Flex and extend the elbows and wrists. B. Drop down both the shoulders. C. Generate a loose hand grip. D. Contract the fingers.

A. Flex and extend the elbows and wrists

The nurse is caring for a client who has a hip spica. Which nursing intervention is appropriate? A. Prepare for Foley catheterization. B. Provide fracture pan as needed. C. Delegate ambulation to bathroom to UAP. D. Order bedside commode.

B. Provide fracture pan as needed.

What education will the nurse include when teaching a client about proper care for a fiberglass cast? A. "Watch for sharp edges that may cause skin irritation." B. "This cast might feel a bit heavy." C. "Do not get this cast wet, as that will cause cracking and crumbling." D. "It will take 24-48 hours to dry, so be cautious."

A. "Watch for sharp edges that may cause skin irritation."

A 91-year-old female client was admitted to the geriatric unit of the hospital with diagnoses of Hyponatremia, Dehydration, and Failure To Thrive. The care team is aware of the importance of early ambulation and has taken steps to facilitate this. How can the client be best prepared to begin ambulating? A. Assist the client with the performance of isometric exercises. B. Teach the client about energy conservation techniques. C. Use a mechanical ceiling lift when transferring the client into or out of bed. D. Educate the client on the correct use of forearm crutches.

A. Assist the client with the performance of isometric exercises.

A nurse is applying an ankle-foot orthosis to a client. What are the functions of this orthopedic device? Select all that apply. A. Correct deformities. B. Treat pain in the area of injury. C. Align body part. D. Pull contracted muscles. E. Support body part.

A. Correct deformities. C. Align body part. E. Support body part.

A nurse is assisting a client to ambulate at the health care facility using a walking belt. How does the walking belt assist the client when ambulating? A. It allows the nurse to support the client. B. It aids the client in extending the leg. C. It enables the client to stand and support body weight. D. It helps the client to practice ambulating.

A. It allows the nurse to support the client.

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? A. The client is unable to wiggle his toes on demand. B. The client's dorsalis pedis pulses are bounding. C. The client is unable to demonstrate full range of motion of his injured leg. D. The client's toes are pink in color and warm to the touch.

A. The client is unable to wiggle his toes on demand.

Which client would benefit the most from the use of a forearm crutch to assist in ambulation? A. client who needs permanent assistance when walking B. client who has weakness on one side of the body C. client who requires considerable assistance with balance D. client who cannot bear weight with the hands and wrists

A. client who needs permanent assistance when walking

The nurse is caring for a client who has generalized weakness and requires crutches to ambulate. Which crutch-walking gait will the nurse teach? A. four-point B. three-point partial weight-bearing C. swing-through D. two-point

A. four-point

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? A. manual B. skeletal C. Russell's D. Buck's

A. manual

When preparing to teach a client about quadriceps setting, the nurse recognizes that which muscles will be involved? Select all that apply. A. rectus femoris B. gluteus medius C. vastus intermedius D. vastus lateralis E. gluteus minimum F. vastus medialis G. gluteus maximus

A. rectus femoris C. vastus intermedius D. vastus lateralis F. vastus medialis

A nurse is fitting prophylactic braces to a client. What is the major function of prophylactic braces? A. to prevent or reduce the severity of a joint injury B. to allow protected motion of an injured joint C. to provide stability for an unstable joint D. to allow for the elimination of urine and stool

A. to prevent or reduce the severity of a joint injury

A nurse at an outpatient clinic is conducting an assessment of a female client who has been wearing a foam cervical collar since being involved in a motor vehicle accident the week prior. What is the primary purpose of this mechanical immobilization device? A. to remind the client to limit range of motion of her neck B. to reduce the client's risk of subsequent paralysis C. to treat the client's spinal cord injury D. to provide constant low pressure to the client's carotid arteries

A. to remind the client to limit range of motion of her neck

A client with a right lower limb prosthesis uses a cane for additional stability. Which behavior demonstrates to the nurse that the client is ambulating appropriately? A. raises hip to swing prosthesis forward B. holds cane in left hand C. looks at cane while walking D. places right limb on first step when going downstairs

B. holds cane in left hand

A male client with a history of type 1 diabetes has had a below-the-knee (BK) amputation. The client states that he is eager to be fitted for his prosthesis and to resume activities of daily living. When assisting the client with his adjustment to using his prosthesis, the nurse should prioritize what nursing diagnosis? A. Risk for Disuse Syndrome B. Risk for Impaired Skin Integrity C. Risk for Sedentary Lifestyle D. Risk for Impaired Bed Mobility

B. Risk for Impaired Skin Integrity

A nurse is caring for a client with a cervical collar. What should the nurse include in the client teaching regarding the use of the cervical collar? A. Keep the collar on during neck exercises. B. Wear the collar even when sleeping. C. Use the collar permanently for comfort. D. Avoid any kind of neck exercise.

B. Wear the collar even when sleeping.

A nurse is caring for a client with carpal tunnel syndrome who has been prescribed a mechanical immobilizing device. Which mechanical immobilizing device would be appropriate for this client? A. traction splints B. molded splints C. inflatable splints D. immobilizers

B. molded splints

The nurse is evaluating a client's use of a leg prosthetic. Which client behavior indicates that further nursing teaching is necessary? A. lies supine periodically throughout the day B. cleanses the stump each morning C. uses clean wool stump socks daily D. cleans the valve on the prosthesis with a small brush

B. cleanses the stump each morning

The nurse is caring for a client with an above-the-knee amputation who has just received a new prosthesis. Which crutch-walking gait will the nurse teach? A. swing-through B. three-point partial weight-bearing C. two-point D. four-point

B. three-point partial weight-bearing

A nurse uses a tilt table to assist a client who is recovering from a spinal injury. Just before using the tilt table, the nurse applies an elastic stocking to the client. What is the purpose of applying this stocking? A. It aids the client in extending the legs. B. It helps to compress the vein walls. C. It helps the client to normalize blood pressure. D. It enables the client to stand and support the body.

B. It helps to compress the vein walls.

The nurse is caring for a client who sustained a mild neck sprain while playing football. What teaching regarding the use of a cervical collar will the nurse include? A. Remove the collar while sleeping to let skin breathe. B. Limit neck and head movements. C. Wear the device when playing football. D. Differences in strength on either side of the body are to be expected.

B. Limit neck and head movements.

The nurse tells a newly casted client that "petals" will be applied. What is the appropriate nursing response when the client asks, "What are petals?" A. "A type of plaster that reinforces the strength of the cast." B. "Large bandages that surround the cast to keep it in place." C. "Pieces of moleskin that cover rough edges of the cast." D. "Porous material from which the cast is made."

C. "Pieces of moleskin that cover rough edges of the cast."

A nurse is applying a cervical collar to a client with severe neck strain. Which actions should the nurse perform when applying a cervical collar? Select all that apply. A. Use stainless steel hooks to secure the collar. B. Give local anesthesia to the client when applying a collar. C. Place the client's head in a neutral position. D. Ensure that the collar openings are centered at the back of the neck. E. Position the collar beneath the chin and then slide upward.

C. Place the client's head in a neutral position. D. Ensure that the collar openings are centered at the back of the neck. E. Position the collar beneath the chin and then slide upward.

A nurse is caring for a client with a cervical halter applied. Which intervention should the nurse perform when caring for this client? A. Avoid applying the traction continuously to the client. B. Avoid isometric or isotonic exercises in the client. C. Provide a trapeze or an overbed frame to the client. D. Ensure that traction weights are resting on the floor.

C. Provide a trapeze or an overbed frame to the client.

The nurse is caring for a client with postural hypotension. Which nursing intervention is appropriate? A. using a gait belt to quickly get the client out of bed B. using a tilt table to move from supine to standing C. asking the client to dangle before moving from a reclining position D. applying antiembolism stockings before rising

C. asking the client to dangle before moving from a reclining position

A nurse is caring for a client whose fractured leg is in a cast. Which ambulatory device could the nurse suggest for the client to use at the health care facility? A. walker B. platform crutch C. axillary crutch D. cane

C. axillary crutch

The nurse is educating a client who will be using crutches for approximately 6 weeks. Which exercise would be beneficial to help with crutch use? A. gluteal setting exercises B. quadriceps setting exercises C. flexion and extension of the arms and the wrists D. sit-ups

C. flexion and extension of the arms and the wrists

The nurse is caring for a client with carpal tunnel syndrome. Which type of splint does the nurse anticipate will be ordered? A. traction B. inflatable C. molded D. immobilizer

C. molded

A nurse is caring for a client who is on complete bed rest while recovering from hip surgery 12 hours ago. When the client is able to start walking, which ambulation aid will most likely be recommended for use? A. axillary crutch B. forearm crutch C. walker D. cane

C. walker

The nurse is caring for an older adult client who is recovering from hip surgery. Which assistive device will the nurse use to facilitate client ambulation? A. crutches B. cane C. walker D. gait belt

C. walker

The nurse is preparing a client with a radial-ulnar fracture, and a history of multiple environmental and chemical allergies, to be casted. When the client says, "I don't want one of those plaster casts," what is the appropriate priority nursing response? A. "This is a less expensive type of casting." B. "Plaster casts dry completely within 24-72 hours." C. "Let's talk with the health care provider about other possible choices." D. "Plaster casts have a lower incidence of allergic reaction."

D. "Plaster casts have a lower incidence of allergic reaction."

A client's plan of care specifies the goal that the client perform quadriceps setting four times daily. The nurse has explained the rationale for this exercise to the client and is now teaching the client to perform the exercises safely and effectively. What instructions should the nurse provide to the client? A. "Flex the muscles in your thighs and then slowly rotate your feet outward." B. "Slowly bend your leg at the knee then gradually return it to a straight position." C. "Progressively tighten your muscles in your toes and then your calves." D. "Slowly alternate between tightening the muscles in your thighs and then relaxing them."

D. "Slowly alternate between tightening the muscles in your thighs and then relaxing them."

Later today, a client will mobilize for the first time since surgery. The client has a history of orthostatic hypotension and experienced a fall prior to admission. How can the nurse best normalize the client's blood pressure to ensure safety during mobilization? A. Obtain a walker for the client to use when mobilizing for the first time. B. Encourage the client's fluid intake throughout the morning. C. Withhold beta-blockers, diuretics or ACE inhibitors until the client has successfully mobilized. D. Have the client dangle at the edge of the bed for several minutes prior to standing.

D. Have the client dangle at the edge of the bed for several minutes prior to standing.

A nurse is caring for an older client with osteoarthritis who is recovering from the West Nile virus. Isometric exercises have been prescribed. What will the nurse teach the client about isometric exercises? A. Isometric exercises will promote cardiovascular conditioning. B. Isometric exercises measure the extent of muscle weakness caused by the virus. C. Isometric exercises promote tissue perfusion for quick recovery. D. Isometric exercises will improve muscle tone and strength.

D. Isometric exercises will improve muscle tone and strength.

A teenage boy has suffered an arm fracture during a football game and been brought to the emergency department by his coach. The boy is adamant in his preference for a splint rather than a cast. Why do skeletal injuries require mechanical immobilization? A. Musculoskeletal injuries are associated with a high risk of infection. B. Musculoskeletal injuries require immobilization to prevent internal hemorrhage. C. Musculoskeletal injuries are characterized by neurovascular damage. D. Musculoskeletal injuries heal much more slowly than soft tissue injuries.

D. Musculoskeletal injuries heal much more slowly than soft tissue injuries.

An older adult client with weakness on one side of the body needs to use a cane for walking. How should the nurse determine the correct height of the cane to be used by the client? A. The cane's handle should be at waist level. B. The cane should provide elbow flexion of 50. C. The cane's handle should be straight with a hand grip. D. The cane's handle should be parallel with the hip.

D. The cane's handle should be parallel with the hip.

The nurse is preparing to assist the client from a supine to a standing position using a tilt table. What action by the nurse will prevent the client from fainting when using the table? A. tilt the table at once until the client is in a vertical position B. If the client develops hypotension, maintain the upright position. C. have the client's feet 2 inches (5 centimeters) above the footboard during transfer D. apply elastic stockings to both lower extremities

D. apply elastic stockings to both lower extremities

A client was fitted with a cast this morning after fracturing the left ulna and radius in a workplace accident. Which actions should the nurse prioritize in the care of this client? A. teaching the client to perform active range of motion exercises to facilitate healing B. assessing the client's skin proximal to the cast C. teaching the client to compensate for the cast when performing activities of daily living D. assessing the neurovascular status of the client's hand

D. assessing the neurovascular status of the client's hand

A client with severe arthritis needs temporary immobilization of the wrist and hand. Which type of cast does the nurse anticipate will be ordered? A. body B. body bivalve C. spica D. cylinder bivalve

D. cylinder bivalve

A nurse is caring for an athlete who has been provided with a cervical collar to immobilize the neck following a neck injury. What is the most important advantage of mechanical immobilization of a body part? A. heals wounds and infected injuries B. treats structural damage and deformity C. allows movement while injuries heal D. relieves pain and muscle spasm

D. relieves pain and muscle spasm