Chapter 8: Body Mechanics and Patient Mobility

A long-term care facility is committing to a restraint-free environment. What will the health care workers implement to encourage this environment?

-Frequent orientation to surroundings -Explain all procedures and treatments -Maintain toileting routines

The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem(s) that may increase because of the use of SRDs?

-Immobility -Incontinence

When the nurse ambulates with a patient who has left-sided weakness, what actions should the nurse take?

-Keep the leg nearest the patient behind the patient's knee -Use a gait belt

.How should the nurse assist the patient with moving when pain is anticipated?

Administer medication before ambulation

How should the nurse assist the patient with moving when pain is anticipated?

Administer medication before ambulation

What premise is Maslow's hierarchy of needs based on?

Basic needs must be met before the next level of needs can be met.

A patient arrives in the emergency department with a sucking wound to the left chest. What is the first action the nurse should take?

Cover the wound with an airtight dressing taped on three sides

What is the most effective process to ensure that the care plan is appropriate, the nursing interventions worked and the patient outcomes are positive?

Evaluation

Whose influence on nursing practice in the 19th century was related to improvement of patient environment as a method of health promotion?

Florence Nightingale

What must the nurse do before applying a safety reminder device (SRD)?

Get a physician's order

The LPN/LVN assists a patient into the semi-Fowler position per physician order. What would indicate that this patient is in the correct position?

Head of bed is at a 30-degree angle

What system of comprehensive patient care considers the physical, emotional, and social environment and spiritual needs of a person?

Holistic health care

When a fall occurs, the nurse should document the incident and initiate a(n) ___________ report.

INCIDENT

What is important for the nurse to determine in order to decrease the risk for injury to a patient?

If patient is left-handed

A farm worker who has been kicked in the stomach by a mule passes a foul, black, tarry stool. What is this called?

Melena

.The nurse is educating a patient on ways to regain the ability to perform ADLs and maintain normal physiological activities. What will the nurse relay as a requirement?

Mobility

A visitor in the hospital slips and falls. The patient's arm appears dislocated and the visitor is unable to move it. What is the first action the nurse should implement?

Splint the arm

The nurse counsels the immobilized patient in regard to prevention of muscle atrophy and contractures. What will the nurse be sure to include when counseling this patient?

The need for some type of exercise

.A nurse instructs a nursing assistant about moving older adult patients in bed. When should the nurse intervene when observing the nursing assistant perform a return demonstration?

The nursing assistant is pulling the patient across bed linens.The skin of older adults is more fragile and susceptible to injury. When moving or transferring older adults, it is essential to avoid pulling them across bed linens because this may cause shearing or tearing of the skin. The nurse should explain each step in simple language and avoid jerky, sudden movements.

The Good Samaritan law will protect all people who offer assistance. What is necessary for this protection?

The person acts prudently

What skills should health care workers frequently attend in-services about to ensure that staff has competent skills and risk for falls can be decreased?

Transferring

What type of fire extinguisher should the nurse use when the oxygen concentrator machine malfunctions and causes an electrical fire?

Type C

How may a newly licensed LPN/LVN practice?

Under the supervision of a physician or RN

.What implementation might the nurse use to improve safety during a transfer?

Using a transfer belt

What implementation might the nurse use to improve safety during a transfer?

Using a transfer belt

A machinist visits the industrial nurse's clinic with a deep laceration of the thigh. What should be the nurse's first action?

Wash the laceration with an antiseptic

The nurse is assessing a patient who is severely bleeding and at risk for hypovolemic shock. What can the nurse anticipate?

Weak, thready pulse

.What should the nurse do to reduce the effort of moving a heavy object?

Widen the base of support in the direction of movement

What should the nurse do to reduce the effort of moving a heavy object?

Widen the base of support in the direction of movement

The patient is admitted to the emergency department, having suffered frostbite to the hands, which are grayish-white in color. What action should the nurse implement when attempting to warm the hands?

Wrap the hands in hot, moist towels

When a fall occurs, the nurse should document the incident and initiate a(n) ___________ report.

incident

During early civilization _____________ ________ performed witchcraft and rituals to induce the bad spirits to leave the body of the ailing person.

medicine men

What is the order of Maslow's hierarchy of needs beginning with the most basic?

1. Physiological 2. Safety/security 3. Love/belonging 4. Esteem 5. Self actualization

When assessing the adult victim for pulselessness, the CPR rescuer should palpate the most reliable and accessible pulse. Which pulse will be palpated?

Carotid

.The nurse instructs a nursing assistant to use large muscle groups when lifting. What is the rationale for this instruction?

It distributes workload more evenly

The nurse receives a patient from the recovery room following total hip replacement surgery. What will the nurse include when assessing neurovascular status on this patient?

Pain, Sensation, Color, Skin temperature

.The nurse receives a patient from the recovery room following total hip replacement surgery. What will the nurse include when assessing neurovascular status on this patient? (Select all that apply.)

Pain,Sensation,Color Skin temperature

A newly hired group of graduate practical/vocational nurses are attending orientation at a long-term care facility. What information will be included regarding considerations of mobility and the older adult?

-The skin of older adults is more fragile and susceptible to injury. -Aging tends to result in loss of flexibility and joint mobility. -Older adults sometimes become fearful when hydraulic lifts are used for transfers.

.To maintain a wide base of support, the nurse should stand with the feet separated by the distance of _______ times the length of the nurse's shoe.

1.5

The worried mother of an accident victim asks the nurse how much circulating blood an average adult male is supposed to have.What will the nurse reply?

12 pints

The 125-pound nurse assesses the weight of a patient. What weight is the heaviest the nurse may safely lift by herself?

168.75 lb Nurses should never attempt to lift more than 35% above their own body weight.

.What is considered to be the minimum number of hours of daily activity necessary to prevent the negative consequences of immobility?

2

The nurse is performing passive range-of-motion exercises on a patient following a traumatic injury. What is the number of times the nurse should move each joint when performing passive range-of-motion (ROM) exercises?

5

A nurse is assessing victims in an emergency situation. What will the nurse assess for first?

Abnormal breathing

.What is the term for range of motion (ROM) when it is performed by the patient?

Active

What is the term for range of motion (ROM) when it is performed by the patient?

Active

The nurse arrives on the scene of a fire. What is the first thing the nurse will do for a burn victim?

Cool the burn immediately

The nurse is attempting to control bleeding in a patient with a profusely bleeding scalp wound. What is the most effective initial treatment of this bleeding?

Apply direct pressure

What should the nurse do to protect his or her back when lifting or moving a patient?

Bending knees and hips

The nurse points to the X in the illustration below and describes this point as the ________ of _________.

Center,Gravity

The patient arrived at the emergency department in pain and bleeding profusely with the following vital signs: BP 80/54, P 102, RR 22. What does the nurse recognize that these symptoms indicate?

Circulatory shock

Where should the nurse place the load when carrying heavy objects?

Close to the body midline

The acronym RICE directs the nurse in the care of a sprain. The "C" in the acronym stands for ________.

Compression

_________________________________machines flex and extend joints to mobilize them passively without the strain of active exercises.

Continuous passive motion (CPM)

The patient's lower chest has been punctured with a knife that is still in place. What should the nurse's first action be?

Immobilize the knife with dressings and tape

The nurse instructs a nursing assistant to use large muscle groups when lifting. What is the rationale for this instruction?

It distributes workload more evenly

What is the site of the most common strain injury acquired by the nurse when working?

Lumbar muscle group

A nurse instructs a nursing assistant about the proper use of a gait belt and is observing a return demonstration. What action by the nursing assistant should cause the nurse to intervene?

Nursing assistant is walking on the patient's strong side

The relationships among nursing, patients, health, and the environment are the basis for:

Nursing models.

What profession has the highest workers' compensation claim rates of any occupation or industry?

Nursing personnel

What is the title of the American Hospital Association's 1972 document that outlines the patient's expectations to be treated with dignity and compassion?

Patient's Bill of Rights

The emergency department nurse admits a victim of poisoning. Who should the nurse call to receive the best assistance for dealing with this victim?

Poison control center

A patient has been stung by a bee and is brought to the emergency department. The nurse observes the sting site and identifies that the stinger is still in the skin. What action should the nurse take?

Scrape the stinger with the side of a knife

A nurse instructs a nursing assistant about moving older adult patients in bed. When should the nurse intervene when observing the nursing assistant perform a return demonstration?

The nursing assistant is pulling the patient across bed linens.

The nurse is performing passive range of motion (ROM) for the patient. How will the nurse move the joint through ROM?

The point of pAIN

The nurse is performing passive range of motion (ROM) for the patient. How will the nurse move the joint through ROM?

The point of pain

What is the wellness/illness continuum defined as?

The range of a person's total health

.A newly hired group of graduate practical/vocational nurses are attending orientation at a long-term care facility. What information will be included regarding considerations of mobility and the older adult? (Select all that apply.)

The skin of older adults is more fragile and susceptible to injury, Aging tends to result in loss of flexibility and joint mobility, Older adults sometimes become fearful when hydraulic lifts are used for transfers.

What must the nurse realize when assessing physical and social environmental factors affecting health and illness?

They affect one another.

Primitive medical interventions were based on the belief that illness was caused by the presence of

evil spirits

Patient care emphasis on wellness, rather than illness, begins as a result of:

increased education concerning causes of illness.

.Place the nursing activities in priority order for the preparation of a patient to ambulate.

roll up head of bed, dangle, apply belt, and assist to stand.

When reinforcing the PASS acronym for fire extinguisher use, the nurse reminds the staff that the final "S" stands for ______________.

sweep

The most common cause of musculoskeletal disorders in nurses involves a movement that requires the nurse to ________ and _________ at the same time.

twist, lift