Chapter 34: Activity PrepU

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.

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 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 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 is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse documents the presence of what health problem?

Ataxia Explanation: Ataxia refers to a lack of muscle coordination. Tremors are rhythmic, repetitive movements. Chorea is spontaneous, brief, involuntary muscle twitching of the limbs or facial muscles. Athetosis refers to movement characterized by slow, irregular, twisting motions.

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 client is contracting their leg muscles as part of rehabilitation. When the muscles contract, which element is released into the client's sarcoplasmic reticulum?

Calcium Explanation: The transmitting activity occurs when calcium is released into the sarcoplasmic reticulum (site of storage and release for calcium in the muscle), which initiates a complex series of biochemical events that result in muscle contraction.

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 intestinal tone. Exercise increases efficiency of the metabolic system. Exercise increases blood flow to kidneys. Explanation: 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 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. Explanation: 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.

The nurse assists a client who has had a stroke affecting the left side causing difficulty moving the hand and fingers. Which range-of-motion exercise(s) will the nurse use? Select all that apply.

Extension of fingers Flexion of fingers Adduction of fingers Abduction of fingers Explanation: The standard range-of-motion exercises for the fingers of the left hand that will assist the client are extension, flexion, adduction, and abduction of the fingers. Hyperextension of the fingers is not appropriate and may cause injury to the client.

The nurse is caring for a client who has a lower-body injury and who is able to partially assist with transfers. The nurse will perform which action?

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, making it unnecessary to manually roll the client.

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.

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.

A client's job requires moving heavy objects from one surface to another. The nurse will provide which anticipatory guidance to help this client avoid a back injury? Select all that apply.

Standing with your feet close together will improve your balance. Pull objects toward you rather than pushing them away. Work as closely to the objects you are moving as possible. Flex the knees to improve balance and strength. Explanation: Standing with the feet apart and knees flexed will improve balance. Objects should be pushed, not pulled, if possible. Working close to the object and facing in the direction of movement improve strength.

The nurse is planning care for a client with the identified activity intolerance. What assessment concerns the nurse for a client with this health issue?

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 concern. Another altered response would be excessive increase in pulse rate. After walking up 20 stairs, a change in pulse of 4 beats/min is not excessive. Joint stiffness is a defining characteristic of the nursing concern of altered physical mobility. Walking with a slow and uncoordinated movement is another defining characteristic of altered 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 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 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 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 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.

As a part of his workout regimen, a 21-year-old college football player often engages in squats and lateral arm holds. 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.

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.

The nurse is caring for a client who works in a warehouse and has been having low back pain. Which statement by the client indicates the need for more education regarding safe lifting?

"I hold the boxes away from my body so I do not drop them on my feet." Explanation: Heavy objects should be held close to the body to distribute the weight evenly and prevent muscle strain. The other statements are correct lifting techniques.

The nurse has been educating a client about health promotion and exercise. What statement made by the client demonstrates that the education has been successful?

"I will invite a friend to exercise with me." Explanation: Exercising with a friend will add the support of a buddy. Joining a spa, health club, or exercise group is also recommended to provide support to exercise. Exercise sessions should be introduced gradually to prevent overexertion and injury to muscles. Clients should be encouraged to exercise for 30 to 45 minutes 3 or 4 times per week. Alternating types of exercise will help prevent boredom.

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.

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

"To prevent your legs from rotating outward." Explanation: Trochanter rolls prevent the client's legs from rotating outward. The other statements do not describe trochanter rolls. 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.

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

"To prevent your legs from rotating outward." Explanation: Trochanter rolls prevent the client's legs from rotating outward. The other statements do not describe trochanter rolls. 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.

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." 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 health care provider 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.

The nurse is applying graduated compression stockings to the legs of a postsurgical client. The client suddenly complains of sharp pain to his left leg as the nurse is unrolling the stockings. What is the nurse's most appropriate action?

Assess the client's leg for signs and symptoms of deep vein thrombosis and inform the primary care provider. Explanation: If the pain is unexpected, notify the primary care provider because the client may be developing a deep vein thrombosis. Applying padding would be an insufficient response, and it would be dangerous to proceed with applying the stocking.

The nurse is assessing the gait of an older adult who is walking with knees slightly flexed and body leaning slightly forward. Which is the nurse's best action?

Document 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 and the client leans forward. In the absence of any other atypical findings. the nurse would not propose assistive devices, make referrals or institute falls prevention.

The nurse is assisting with client transfer. Which guideline(s) will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply.

Ensure that the client's bedrails are up prior to transfer. Lower the bed to the lowest position allowing the client's soles to contact the floor. Provide the client with nonskid slippers to put on prior to standing up. Make sure the client's weaker leg is nearest to the chair. Explanation: Lowering the bed to the point where the client is able to touch the ground allows the client to be as stable as possible prior to standing up. Having the client wear nonskid slippers prevents the client from slipping and falling during the transfer. Providing step-by-step instructions to the client allows the nurse to solicit the client's help as much as possible. This action informs the client, encourages self-help, and reduces the workload/burden on the nurse. The nurse should ensure the bedrails are down prior to starting the transfer. Having these up will obstruct movement and make the transfer more difficult. Since the client is not lying in bed, the bedrails do not need to be up for client safety. The client's strongest leg should be positioned closest to the chair to provide stability and prevent a fall as the client moves to lower oneself into the chair.

The nurse is assisting with client transfer. Which guideline(s) will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply.

Ensure that the client's bedrails are up prior to transfer. Lower the bed to the lowest position allowing the client's soles to contact the floor. Provide the client with nonskid slippers to put on prior to standing up. Make sure the client's weaker leg is nearest to the chair. Explanation: Lowering the bed to the point where the client is able to touch the ground allows the client to be as stable as possible prior to standing up. Having the client wear nonskid slippers prevents the client from slipping and falling during the transfer. Providing step-by-step instructions to the client allows the nurse to solicit the client's help as much as possible. This action informs the client, encourages self-help, and reduces the workload/burden on the nurse. The nurse should ensure the bedrails are down prior to starting the transfer. Having these up will obstruct movement and make the transfer more difficult. Since the client is not lying in bed, the bedrails do not need to be up for client safety. The client's strongest leg should be positioned closest to the chair to provide stability and prevent a fall as the client moves to lower oneself into the chair.

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.

The nurse is preparing to apply compression stockings for a client that is at risk for the development of deep vein thrombosis. What action(s) by the nurse demonstrate to the client the appropriate way to apply the stockings? Select all that apply.

Estimate the size of the client's legs, and obtain the stockings. Assess the skin and neurovascular status of the legs and feet before applying. Have the client lie down with legs and feet elevated for at least 15 minutes before applying. Massage the client's legs before applying. Explanation: The nurse needs to measure the client's legs to determine the proper size of stocking. Each leg should have a correct fitting stocking; if measurements are different, then two different sizes of stocking need to be ordered to ensure correct fitting on each leg. The size should not be estimated. The nurse will apply the stockings in the morning before the client is out of bed and while the client is supine. If the client is sitting or has been up and about, the nurse will have the client lie down with legs and feet elevated for at least 15 minutes before applying the stockings. Otherwise, the leg vessels are congested with blood, reducing the effectiveness of the stockings. The nurse will not massage the client's legs before applying the stockings. If a clot is present, massaging the leg may break it away from the vessel wall and it can circulate in the bloodstream.

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 Explanation: A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility and prevent foot drop, which is a contracture in which the foot is fixed in plantar flexion. The nurse's action does not prevent ulcers, spasms or muscle atrophy.

The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply.

Fowler Semi-Fowler Upright Explanation: The Fowler position is a sitting position, also known as upright, that raises the client's head 80 to 90 degrees and benefits the client by preventing aspiration, promoting ventilation, facilitating eating, and improving cardiac output. The semi-Fowler position is a 45-degree angle, which also allows for ventilation without aspiration. The supine and modified supine (pillow under knees) would not be appropriate for facilitation ventilation and preventing aspiration.

The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply.

Fowler Semi-Fowler Upright Supine Explanation: The Fowler position is a sitting position, also known as upright, that raises the client's head 80 to 90 degrees and benefits the client by preventing aspiration, promoting ventilation, facilitating eating, and improving cardiac output. The semi-Fowler position is a 45-degree angle, which also allows for ventilation without aspiration. The supine and modified supine (pillow under knees) would not be appropriate for facilitation ventilation and preventing aspiration.

The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply.

Fowler Semi-Fowler Upright Supine The Fowler position is a sitting position, also known as upright, that raises the client's head 80 to 90 degrees and benefits the client by preventing aspiration, promoting ventilation, facilitating eating, and improving cardiac output. The semi-Fowler position is a 45-degree angle, which also allows for ventilation without aspiration. The supine and modified supine (pillow under knees) would not be appropriate for facilitation ventilation and preventing aspiration.

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?

Fowler's Explanation: Fowler's position, a semi-sitting position, will assist the client with dyspnea because this position allows the abdominal organs to drop away from the diaphragm. The other position choices do not promote oxygenation.

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 Ex: 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 health care provider is unnecessary.

The nurse is assessing an infant who has developed one extremity that is shorter than the other. The nurse will suspect what causative factor?

Hip dislocation Explanation: Hip dislocation/subluxation can occur any time during the first year of life. Assessing all infants for hip abnormalities during well-infant examinations is crucial. While each of the other pathologies could lead to limb asymmetry, hip dislocation is among the more common causes.

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.

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.

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.

The nurse is orienting a new unlicensed assistive personnel (UAP) to hospital policies. While a client is participating in physical therapy the UAP decides to make the bed. What are appropriate action(s) by the nurse after entering a hospital room and observing the UAP in the image? Select all that apply.

Inform the UAP the linens should not be placed on the floor for any reason Communicate the importance of using proper body mechanics to avoid straining the back Explanation: The UAP is at risk for back injury or straining due to lifting the linens using the back muscles and the shift in gravity beyond the base of support. The UAP should move close to and work as closely as possible to an object that is to be lifted or moved to avoid injury. The linens should not be placed on the floor for any length of time due to the increase risk for transmission of microorganisms from the hospital room to other areas of the hospital. It is important to educate all health care personnel when a potential risk to safety or possible harm is occurring. This will help minimize possible injury. Avoiding the conversation with the UAP until there is a more appropriate time is not an appropriate action.

The nurse is orienting a new unlicensed assistive personnel (UAP) to hospital policies. While a client is participating in physical therapy the UAP decides to make the bed. What are appropriate action(s) by the nurse after entering a hospital room and observing the UAP in the image? Select all that apply.

Instruct the UAP to leave the linens on the floor for now and suggest a meeting to discuss the actions being performed Inform the UAP the linens should not be placed on the floor for any reason Communicate the importance of using proper body mechanics to avoid straining the back Assist the UAP to pick up the linens and place them in the linen basket Explanation: The UAP is at risk for back injury or straining due to lifting the linens using the back muscles and the shift in gravity beyond the base of support. The UAP should move close to and work as closely as possible to an object that is to be lifted or moved to avoid injury. The linens should not be placed on the floor for any length of time due to the increase risk for transmission of microorganisms from the hospital room to other areas of the hospital. It is important to educate all health care personnel when a potential risk to safety or possible harm is occurring. This will help minimize possible injury. Avoiding the conversation with the UAP until there is a more appropriate time is not an appropriate action.

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. 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 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.

adjust the height of the work area face in the direction of the activity he is performing Explanation: Breath holding is a sign of muscle strain and an inefficient use of body mechanics.

The nurse is assisting with client transfer. Which guideline(s) will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply.

Lower the bed to the lowest position allowing the client's soles to contact the floor. Provide the client with nonskid slippers to put on prior to standing up. Provide step-by-step instructions to the client before the transfer begins. Explanation: Lowering the bed to the point where the client is able to touch the ground allows the client to be as stable as possible prior to standing up. Having the client wear nonskid slippers prevents the client from slipping and falling during the transfer. Providing step-by-step instructions to the client allows the nurse to solicit the client's help as much as possible. This action informs the client, encourages self-help, and reduces the workload/burden on the nurse. The nurse should ensure the bedrails are down prior to starting the transfer. Having these up will obstruct movement and make the transfer more difficult. Since the client is not lying in bed, the bedrails do not need to be up for client safety. The client's strongest leg should be positioned closest to the chair to provide stability and prevent a fall as the client moves to lower oneself into the chair.

The nurse is performing an assessment of a client's joint mobility. What documentation should the nurse provide related to this assessment if joint function is considered normal? Select all that apply.

No masses, deformities, or muscle atrophy Full range of motion with each joint No swelling, heat, tenderness, pain, nodules, or crepitation Walks 20 feet Explanation: The nurse should document the size, shape, color, and symmetry of joints: note any masses, deformities, or muscle atrophy. Range of motion of each joint. Any limitation in the normal range of motion or any unusual increase in the mobility of a joint (instability); range of motion varies among people and decreases with aging. Muscle strength when performing range-of-motion exercises against resistance. Any swelling, heat, tenderness, pain, nodules, or crepitation (palpable or audible crunching or grating sensation produced by motion of the joint). Comparison of findings in one joint with those of the opposite joint.

Which strategy(ies) does the nurse use to maintain proper body mechanics and prevent self-injury? Select all that apply.

Place feet shoulder width apart when lifting an object Plant feet firmly on the floor when supporting the client during dangling Explanation: When lifting an object, the nurse will place the feet shoulder width apart with feet planted firmly to provide a stable base of support. When supporting the client during dangling, the nurse will tighten the gluteal and abdominal muscles to avoid back strain or injury. When lifting an object, the nurse will bend at the knees instead of the waist because the thigh muscles are larger in mass than either the buttocks or back muscles. The nurse will get close to the object to be lifted to prevent excess stress on arm and back muscles. The nurse does not hold heavy object away from the body nor lock the elbows during lifting and carrying objects. These actions put extra stress on the muscles of the back and this strain could lead to injury.

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.

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.

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.

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).

A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take?

Tell the client he can remove them for 20 or 30 minutes during this shift. Explanation: Antiembolism stockings should be removed once every shift for 20 to 30 minutes to allow for assessment of circulatory status and the condition of the skin on the lower extremity and for skin care. The nurse should not disregard the health care provider's prescription and allow the client to remove the stockings indefinitely, as this could endanger the client's health.

At a well-child visit, the nurse is observing siblings at play. Which observed behaviors would be of concern to the nurse and would require additional assessment? Select all that apply.

The 3-year-old sits by as the 5-year-old stacks a tower of blocks. The 3-year-old does not join the 5-year-old in the jumping game. Explanation: A 3-year-old should be able to build a tower with blocks and should be able to jump. The 18-month-old should be able to run, but climbing steps is not an expected behavior.

The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table?

The client is aware of spatial relationships to avoid the table. Explanation: The client has awareness of spatial relationships (where objects are located in space). This ability comes from the visual or optic reflexes. The labyrinthine sense relates to the sensory organs in the inner ear and provides a sense of position, orientation, and movement. It does not contribute to where objects are in space. When the extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture (e.g., when the knee buckles under, the reflex contraction aids the person to straighten the knee). This does not contribute to perception of where objects are in space.

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 health care provider is unnecessary.

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.

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct?

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Explanation: Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight alignment when the client is being turned. The nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement. The nurse should avoid twisting the client's head, spine, shoulders, knees, or hips while logrolling. A chair is not used with logrolling.

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.

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.

A nurse is providing care for a client recovering from a stroke and teaches the spouse about caring for the client. Which strategy(ies) does the nurse include about how the spouse can maintain proper body mechanics and prevent injury to oneself? Select all that apply.

When supporting your spouse during dangling, tighten your gluteal and abdominal muscles to avoid back strain or self-injury. Grip the gait belt as your spouse walks so that you can provide aid if your spouse begins to fall. Use a gait belt to help your spouse transfer from bed to chair. Always keep your spouse close to your body during the transfer. Use the muscles in your legs to lift and/or pull. Explanation: When teaching the spouse about his or her safety while providing care for the client who had a stroke, the nurse will explain that when the caregiver supports the spouse during dangling, the caregiver should tighten the gluteal and abdominal muscles to avoid back strain or self-injury. In addition, the nurse will tell the caregiver to use a gait belt to help the spouse transfer from bed to chair to prevent the caregiver injuring one's own shoulders and back. The caregiver will also be advised to always keep the spouse close to one's body to prevent shoulder and back strain to self. The caregiver will be told to use the muscles in the legs to lift and/or pull rather than using the shoulders and back. When transferring a client, the body should turn with the client and there should not be a rotation movement as this will cause back injury.

A client's job requires moving heavy objects from one surface to another. The nurse will provide which anticipatory guidance to help this client avoid a back injury? Select all that apply.

Work as closely to the objects you are moving as possible. Flex the knees to improve balance and strength. Explanation: Standing with the feet apart and knees flexed will improve balance. Objects should be pushed, not pulled, if possible. Working close to the object and facing in the direction of movement improve strength.

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 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.

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 Explanation: Breath holding is a sign of muscle strain and an inefficient use of body mechanics.

A nurse is interviewing a client about the client's usual activity level. The client states, "I swim laps 2 to 3 times a week and walk 1 to 2 miles twice a week. The nurse interprets this activity as which type of exercise?

isotonic Explanation: Isotonic exercise involves muscle shortening and active movement. Examples include carrying out ADLs, independently performing range-of-motion exercises, and swimming, walking, jogging, and bicycling. Isometric exercise involves muscle contraction without shortening (i.e., there is no movement or only a minimal shortening of muscle fibers). Examples include contractions of the quadriceps and gluteal muscles, such as that which occurs when someone holds a yoga pose. Isokinetic exercise involves muscle contractions with resistance. The resistance is provided at a constant rate by an external device that has a capacity for variable resistance. Examples include rehabilitative exercises for knee and elbow injuries and lifting weights. Range-of-motion exercise refers to the maximum degree of movement of which a joint is normally capable.

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene?

lowering the height of the bed prior to moving the client Explanation: Lowering the height of the bed is an incorrect action that would require the nurse to intervene. The bed should be raised to the height of the caregiver's elbow, or to a comfortable working height before the client is positioned. All other options are appropriate positioning techniques.

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.

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness. For what adverse condition is the nurse assessing in the client?

orthostatic hypotension Explanation: The nurse would stand in front of the client and assess for any balance problems or reports of dizziness upon standing due to orthostatic hypotension. Orthostatic hypotension occurs when the blood pressure drops when standing from the sitting or lying position. Standing in front of the client prevents falls or injuries. Hypertension or high blood pressure is a condition in which the force of the blood against the artery walls is too high. Hypertension needs to be treated to lower the blood pressure. Deep vein thrombosis is a thrombosis or blood clot in a vein lying deep below the skin, especially in the legs. Treatment is by medications, compression stockings, and filters. There are other circulatory alterations like peripheral artery disease, which is caused by narrowed blood vessels that reduce blood flow to the limbs.

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 developing a plan of care for a client who has been in the (protective) prone position. What should the nurse be sure to monitor the client for, related to the positioning?

plantar flexion of the feet Explanation: It is important to be aware of client positioning and nursing actions required to prevent complications. The client who is in the prone position is at risk for foot drop (plantar flexion of the feet) because of the pull of gravity on the feet—unless the legs and feet are positioned carefully. The client in the prone position is not at risk for flexion contracture of the neck, because the body is straight—the shoulders, head, and neck are in an erect position. The client would be at risk for flexion contractures of the hips when in the supine or Fowler position. The client in the prone position is lying on his abdomen and therefore would be at risk for skin breakdown of the sacrum. The client in the Fowler position would be at risk for skin breakdown of the sacrum. When in the prone position, the hips are prevented from flexing or hyperextending.

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 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 for 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 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 for 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 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 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.

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 Explanation: 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.

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.

An 85-year-old white woman walks 1 mile (1.6 km) every morning and every evening. She continues to smoke but has cut back to half a pack per day. She had a total oophorectomy at age 45 secondary to stage I ovarian cancer. This client is currently not on any medications. Which is not a primary risk factor for osteoporosis for this client?

sedentary lifestyle Explanation: The client is engaging in weight-bearing activity. This is protective against osteoporosis. Smoking, white race, and postmenopausal age are all risk factors for osteoporosis.