Chapter 25 (Mobility)
A client is beginning to ambulate with crutches after surgery on his right leg. He is allowed to bear weight only on his left leg. The nurse would work with the client to use which gait?
Three-point
A group of nursing students is reviewing the major joints in the body and their movement. The students demonstrate understanding of the material when they identify which joint as an example of a saddle joint?
Thumb
A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as:
Tremor
During an initial assessment, the nurse observed that the client has a festinating gait. The nurse bases this determination of the fact that:
The client walks on the toes as if being pushed
Which clients will develop mobility issues in the future?
-The 35 yr old computer technician -The 55 yr old clinical secretary who is to retire after 30 years of working same job
Clients admitted in an acute care setting are at high risk for falls. The following interventions keep the client safe
-use a chair alarm when the client it out of the bed -frequently monitor clients
A nurse is performing range of motion exercises for a client and moves the clients fingers apart and then back together. The nurse is performing which range of motion?
Addiction/ abduction
A group of nursing students is reviewing the aspects of motor function control by the nervous system. The students demonstrate understanding of this information when they identify what as a function of the cerebellum:
Coordination of movement motor activities
A nurse is assessing the musculoskeletal system of a client during an initial visit to the clinic. The assessment reveals the insufficient joint lubrication in the knees. The nurse documents this finding as
Crepitus
A nurse is performing range of motion to a clients ankle and foot. Which movements would the nurse include?
Eversion Dorsiflexion Extension
A nurse is working with a female client with osteoporosis on an exercise program. The nurse instructs the client to increase her tolerance gradually. The nurse determines that the education was effective when the client states
If I experience pain when I'm exercising, I should stop.
A nurse is providing care to a client who has a cast on his leg. While educating the client on how to perform quadriceps setting exercise to strengthen the quadriceps muscle, he asks, "what kind of exercise is this?" The nurse identifies this type of exercise as:
Isometric
While performing a physical examination on a client, the nurse observed that the client has scoliosis based on
Lateral deviation of the thoracic spine
While ambulating I'm the hallway of a hospital, the client complains of extreme dizziness. The nurse, alert to syncopal episode, should first:
Lower the client gently to the floor
Assessment of a client who is bedridden due to hip fracture reveals atrophy of the leg muscles due to immobility. The nurse demonstrates understanding of muscle atrophy by identifying what as a characteristic?
Reduction in muscle cell size
A nurse is caring for a frail older adult client with chronic COPD. The client always remains in a sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assessed which area of this client?
Sacrum
A client has severe right sided weakness and is unable to complete bathing and grooming independently. Based on this observation, the nurse identifies a nursing diagnosis of
Self-care deficit
A nurse is providing postoperative care for a client who is immobilized due to rod fixation. The nurse would place the client in which position?
Semi-Fowler's
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
When assisting a patient with hemiparesis to transfer or ambulate, what does the nurse instruct the patient to do?
Use the strong hand to assist