EAQ PRACTICE 330 (chapters 39)
While positioning a patient in the supported supine position, the nurse places a pillow under the upper shoulders. Which rationale explains this intervention?
-Maintaining the correct alignment -Placing of pillows under the shoulders while positioning a patient in the supine position maintains correct alignment and prevents flexion contractures of cervical vertebrae. -Placing trochanter rolls to the lateral surface of the patient's thighs may reduce external rotation of the hip. -Placing a small rolled towel under the lumbar area of the back provides support for the lumbar spine. -Placing pillows under pronated forearms reduces internal rotation of the shoulder and prevents extension of the elbows.
While caring for a patient with immobility, the nurse positions the patient in the supported supine position. The nurse places pillows under the pronated forearms keeping the upper arms parallel to the patient's body. Which reason explains this nursing action?
-To reduce the internal rotation of shoulders -While positioning the patient in the supported supine position, the nurse places pillows under the pronated forearms, and keeps the upper arms parallel to the patient's body to reduce the internal rotation of the shoulder and prevent extension of the elbows. Placing the hand rolls on the patient's arms helps reduce the extension of the fingers and abduction of the thumb. Placing pillows under the upper shoulders, neck, or head helps in maintaining the correct body alignment and prevents flexion contractures of the cervical spine. Placing a small rolled towel under the lumbar area of the back provides support to the lumbar spine.
A decrease in which feature is a risk factor for developing pathological fractures in patients with immobility? Select all that apply. One, some, or all responses may be correct. 1) Metabolism 2) Urinary output 3) Tissue catabolism 4) Calcium regulation 5) Urine concentration
1 & 4 -Rationale : Decreased metabolism and calcium regulation are the major risk factors for developing pathological fractures in patients with immobility. -Decreased urinary output is a urinary elimination change seen in patients with immobility because of decreased intake of fluids. Decreased tissue catabolism is tissue breakdown because of muscle weakness and decreased muscle mass in patients with immobility. Decreased urinary concentration is a urinary elimination change seen in patients with immobility because of decreased fluid intake and output.
The nurse is teaching a group of nursing students about tendons. Which statement about tendons is true? Select all that apply. One, some, or all responses may be correct. 1. Tendons are fibrous bands connecting muscles to bone. 2. Tendons are nonvascular supporting connective tissue. 3. Tendons help hold joints together; they connect bone and cartilage. 4. Tendons are strong, flexible, and inelastic. 5. Tendons may also have a protective function.
1 & 4 Tendons are fibrous bands connecting muscles to bone. They are strong, flexible, and inelastic. -Cartilage is nonvascular, supportive connective tissue located in the joints and thorax, trachea, larynx, nose, and ear. -Ligaments help hold joints together and connect bones and cartilage. Some ligaments may also protect two bony surfaces against friction.
How many nurses would be required to place a patient in the semi-prone position?
1 nurse -Positioning the patient in the Sims position or the semi-prone position would require only one nurse. -Positioning the patient in the prone position would require two or three nurses. -For logrolling the patient, the assistance of three or four nurses would be required.
In a long-term care facility, the nurse is evaluating the condition of a patient with immobility. Which assessment would the nurse perform to determine if the patient has developed joint contracture? 1) Measure range of motion 2) Determine the level of comfort. 3) Evaluate the patient's body alignment. 4) Observe the skin for areas of erythema/breakdown.
1) Measure range of motion The nurse should assess range of motion to determine if joint contracture is developing. - The nurse should determine the patient's level of comfort and evaluate the patient's body alignment to determine the level of comfort. Observing the skin for areas of erythema or breakdown, especially under bony prominences, determines if there is need to increase the frequency of repositioning.
What is flexion vs extension???
1) flexion—the movement in which the chin is lowered down toward the chest (below) 2) extension—the neck is extended, as in looking upward toward.
The registered nurse is teaching a nursing student about the developmental changes that occur because of immobility. Which statement by the nursing student indicates the need for further learning? 1. "Immobilization can lead to social isolation in infants." 2. "Immobilization can delay development of a child's gross motor skills." 3. "Immobilization can affect self-concept in older adults." 4. "Immobilization can result in risk of all physiological systems in older adults."
1. "Immobilization can lead to social isolation in infants." Immobility can lead to developmental changes in all age-groups. Immobilization leads to social isolation in adolescents. Immobilization can delay a child's gross motor skills, intellectual development, and musculoskeletal development. Immobilization can affect self-concept and self-confidence in adults who have an impact on the job status of adults and their family. Immobilization can result in the risk of physiological systems in older adults.
Which outcome is desired when the head of the bed is elevated to 60 degrees in supported Fowler's position? 1. Improves ventilation 2 Prevents shoulder dislocation 3 Relieves the pressure on heels 4 Prevents hyperextension of knee
1. Improves ventilation When the head of the bed is elevated to 60 degrees in supported Fowler's position, it improves ventilation. Using a pillow to support the arms would help prevent shoulder dislocation. Use of heel pressure relief devices would reduce pressure on the heels. Placing a small pillow under the thigh can prevent hyperextension of the knee.
Which nursing intervention would increase the risk of joint dislocation in a patient with hemiplegia who is immobile for an extended period? 1. Supporting the patient by holding the arm 2. Supporting the patient with assistive devices 3. Lowering the patient to the floor if he or she faints 4. Instructing the patient to use a cane while walkin
1. Supporting the patient by holding the arm hemiplegia - paralysis to one side of the body ! Supporting the patient by holding the arm may increase the risk of joint dislocation if the patient falls. -Assistive devices, such as gait belts, reduce the risk of falling by maintaining the center of gravity in the midline. -Lowering the patient to the floor if he or she faints helps reduce the risk of falls. -Instructing the patient to use a cane while walking also helps reduce the risk of falls, but it would not be beneficial for patients with hemiplegia. -Test-Taking Tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies.
Which order of assessments of patient mobility performed by the nurse is correct?
1.Lying position 2. Sitting position in bed 3.Transferring to chair 4.Walking Assessment of mobility focuses on range of motion, gait, exercise, and activity tolerance. Generally, the nurse performs the assessment of movement starting with the patient in a lying position, proceeding to assessing sitting positions in bed, then transferring to a chair, and finally walking.
While assessing a child, the nurse finds that the child's legs are bent outward at the knee. Which instruction to the parents would be beneficial for the child? 1 "You need to limit phosphorus intake for your child." 2 "You should provide a vitamin D-rich diet for your child." 3 "You should limit mobility in your child for a few days." 4 "You should purchase a Denis Browne splint for your child."
2 "You should provide a vitamin D-rich diet for your child." Outward bending of the legs at the knee indicates bowlegs. It is generally associated with rickets, which occurs because of deficiency of vitamin D. Therefore the child should be provided with foods that are rich in vitamin D. Phosphorus reduces the risk of rickets in the children. Therefore parents should not limit phosphorus in a child's diet. Limiting mobility in a child with rickets can impair mobility permanently. A Denis Browne splint is used to reduce the risk of clubfoot; however, it is not useful as a treatment for rickets.
While helping a patient move up in bed, the nurse turns the patient from side to side to place the drawsheet under the patient. Which rationale explains this nursing action? 1) To make lifting and positioning easier 2) To reduce the friction during the movement 3) To prevent striking of the patient's head against the head of the bed 4) To provide strong handles to grip the drawsheet without slipping
2) to reduce the friction during the movement While helping a patient move up in bed, the nurse turns the patient from side to side to place the drawsheet under the patient, extending from the shoulders to the thighs to support the patient's body weight and to reduce the friction during movement. -Returning the patient to the supine position to achieve even distribution of the patient's weight makes lifting and positioning easier. -Removing the pillow from under the head and shoulders and placing it at the head of the bed helps keep the patient from striking his or her head against the head of the bed. The nurse should fanfold the drawsheet on both sides, with each nurse grasping firmly near the patient to provide strong handles to grip the drawsheet without slipping.
A patient is being transferred from bed to stretcher. Which precaution would the nurse take to ensure patient safety during transfer? Select all that apply. One, some, or all responses may be correct. 1. Release the brakes of the bed to allow movement. 2. Raise the bed to the level of the stretcher. 3. Cross the patient's arms on chest while transferring. 4. Involve multiple caregivers for safe transfer. 5. Unlock the stretcher's wheels once it is in place alongside the bed.
2,3 & 4 -The bed should be raised to the level of the stretcher to allow the patient to slide from the bed to the stretcher. Keep the patient's arms crossed when transferring to prevent any injury to the arm. Three caregivers are needed to transfer a patient safely and are positioned specifically to minimize caregivers stretching. The bed brakes should be locked to prevent it from moving. Once the stretcher is placed alongside the bed, the wheels should be locked to prevent further movement. -Test-Taking Tip: Stay as calm as possible during the examination. Staying calm helps you recognize reasonable choices. For this question, you would recognize that allowing the bed or the stretcher to move during transfer is not desirable, helping you eliminate both incorrect responses.
The nurse is teaching a nursing student about various deformities of the spine. Which statement is true about spine deformities? Select all that apply. One, some, or all responses may be correct. 1. Scoliosis is the medial deviation and plantar flexion of the foot 2. Kyphosis is the increased convexity in curvature of the thoracic spine. 3. Kyphosis is the internal rotation of forefoot or entire foot. 4. Lordosis is the exaggeration of the anterior convex curve of lumbar spine. 5. Scoliosis is the lateral S- or C-shaped spinal column with vertebral rotation.
2,4,5 STUDY TIP: Use visual imagery to memorize the spinal deformities. Picture the S or C of SColiosis superimposed over a spine with the condition. Picture a person bending the thoracic spine forward to fit inside the right side of the letter K for Kyphosis. Picture the angle of an L from Lordosis poking someone in the lumbar region to exaggerate the lumbar curve. (table 39.1 in textbook , page 822)
A patient who has hemiplegia is unable to dorsiflex and invert the feet. Which condition does the patient likely have? 1. Lordosis 2. Footdrop 3. Genu varum 4. Genu valgum
2. Footdrop The inability to dorsiflex and invert the feet indicates that the patient has footdrop, which is usually found in patients who are bedridden and immobile. The foot becomes permanently fixed in plantar flexion, making ambulation difficult. The patient is unable to lift the toes off the ground. -Exaggeration of the anterior convex curve of the lumbar spine is called lordosis. -One or both legs bent outward at the knee indicates genu varum. -Legs curved inward so the knees come together while walking is a sign of genu valgum.
While assessing a patient with impaired mobility, the nurse prioritizes which type of related complication? 1. Social isolation 2. Respiratory 3. Integumentary 4. Musculoskeletal
2. Respiratory Lack of movement and exercise place patients at risk of respiratory complications. (remember cough & deep breathing is important !! Helps to move some secretions in lungs and open chest/ airways which will help w respiratory status) The metabolic changes seen in patients with impaired mobility are altered endocrine metabolism and calcium resorption. An ulcer is characterized by inflammation and usually forms over a bony prominence. It is seen because of integumentary changes in patients with impaired mobility. The musculoskeletal changes seen in patients with impaired mobility are temporary impairment and permanent disability. According to Maslow's hierarchy of needs, physiological complications take priority over social isolation. Respiratory complications take top priority to ensure the ABCs: Airway, Breathing, Circulation.
Which circumstance can cause contracture of a joint? 1. The adductor muscles are weakened as a result of immobility. 2. The muscle fibers become shortened because of disuse. 3. The calcium-to-phosphorus ratio becomes disrupted. 4. There is a deficiency in vitamin D.
2. The muscle fibers become shortened because of disuse. The adductor muscles are stronger than the abductor muscles. When patients are immobile and the joint is not exercised through its range of motion (ROM), the adductor muscle fibers shorten, resulting in the contracture of that joint, which is usually permanent. The calcium-to-phosphorus ratio disruption is related to bone integrity and not muscle disuse, as with a contracture. Vitamin D deficiency affects bone integrity in its relationship to calcium and is not related to muscle disuse, as with a contracture. (see box 39.1)
The nurse is assessing range of motion of a patient. Which condition does the nurse observe when the forearm of the patient is fixed in a position of full supination? 1. The patient's grasp is weakened. 2. The patient's use of hand is limited. 3. The patient has difficulty moving the arms. 4. The patient cannot perform fine-motor skills, such as painting.
2. The patient's use of hand is limited. Most functions of the hand are best carried out with the forearm in moderate pronation. When the forearm is fixed in a position of full supination, the patient's use of the hand is limited. When the wrist is fixed in even a slightly flexed position, the grasp is weakened. When the patient has limited movement in the shoulder, he or she may have difficulty moving the arms. When there is impaired range of motion in the fingers and thumbs, the patient is less able to perform fine-motor skills such as carpentry and painting.
A 60-year-old female patient sustained a femur fracture because of a fall in the bathroom. The patient complains of severe pain. Which mineral supplement is likely to be added to the patient's prescription to manage osteoporosis? 1. Zinc 2. Calcium 3. Sodium 4. Iron
2. calcium In osteoporosis the bones lack calcium because of demineralization. Therefore calcium supplements are added to the prescription to improve bone strength. Zinc is useful in cellular metabolism but has no role in bone health. Sodium is important for cells to function but has no role in promoting bone health. Iron is needed for hemoglobin production. It does not help in managing osteoporosis related to bone changes.
Which hormone contributes to metabolic activity in the human body? Select all that apply. One, some, or all responses may be correct. 1. Prostacyclin 2. Erythropoietin 3. Thyroid hormone 4. Pancreatic hormone 5. Gastrointestinal hormone
3,4 & 5 Thyroid hormone Pancreatic hormone Gastrointestinal hormone Thyroid hormone increases the basal metabolic rate (BMR) of the human body, and energy becomes available to cells through the integrated action of pancreatic and gastrointestinal hormones. Prostacyclin plays a major role in blood pressure control through the renin-angiotensin system, but not in metabolism. Erythropoietin stimulates red blood cell production but is not directly linked to metabolism.
Which urinary elimination change is often observed as the period of immobility continues for a patient? Select all that apply. One, some, or all responses may be correct. 1. Increased fluid intake 2. Increased urinary output 3. Increased risk of renal calculi 4. Increased urinary concentration 5. Increased risk of urinary tract infections
3,4,5 The urinary elimination changes that are often observed as the period of immobility continues include increased renal calculi, because immobilized patients may have hypercalcemia that causes calcium stones. As the immobility continues, the fluid intake decreases and the concentration of urine increases. As the concentration of urine increases, urinary tract infections also increase. As the period of immobility continues, fluid intake often diminishes and therefore urinary output also decreases. -basically patients urinary tract is affected & they pee less -More concentrated urine means that there are more solutes and less water in the sample (so means u pee less & r dehydrated vibes ~~~)
Which is a common debilitating contracture? 1. Disuse 2. Atrophy 3. Footdrop 4. Shortening of the muscle
3. Footdrop rationale : Footdrop is a common and debilitating contracture in which the foot is permanently fixed in plantar flexion. Disuse, atrophy, and shortening of muscle fibers are the causes of joint contractures. (see box 39.1 in textbook)
Which assistive device would the nurse use to reduce surface area and friction when patients are unable to assist with moving up in bed? 1. Arm splints 2. Trapeze bar 3. Full-body sling 4. Trochanter roll
3. Full-body sling To decrease surface area and to reduce friction when patients are unable to assist with moving up in bed, the nurse uses an ergonomic assistive device such as a full-body sling to help lift patients off the surfaces of beds. Arm splints help in reducing musculoskeletal injury. A trapeze bar helps in performing upper arm exercises. Trochanter rolls prevent external rotation of the hips when a patient is in the supine position.
When assessing a patient, the nurse observes that the patient's legs are curved inward while walking. Which abnormality would the nurse anticipate in the patient? 1. Bowlegs 2. Footdrop 3. Knock-knee 4. Congenital hip dysplasia
3. Knock-knee Knock-knee is the abnormality that curves the legs inward so the knees come together while walking. Patients with bowlegs have legs that bend outward at the knee. Footdrop is the inability to dorsiflex and invert the foot because of perineal nerve damage. Congenital hip dysplasia is an abnormality in which hip instability is seen with the limited abduction of the hips. (see table 39.1 in textbook - postural abnormalities - has all of these & more)
A patient is undergoing treatment in a long-term care facility. Which type of immobility complication is likely to develop in the immobilized patient? 1. Footdrop 2. Atelectasis 3. Pressure ulcers 4. Pathological fractures
3. pressure ulcer A pressure ulcer is an impairment of the skin as a result of prolonged ischemia in the tissues, and the prevalence of pressure ulcers is highest in long-term care facilities because of decreased blood supply to the tissues. -Patients who have suffered cerebrovascular accident with resulting left- or right-sided paralysis are at high risk of footdrop. -Patients who are immobilized are at high risk of developing a pulmonary complication such as atelectasis, but it may not be observed in patients who are in long-term care facilities. -Patients with disuse osteoporosis are at high risk of pathological fractures.
Which positioning aid decreases the shearing action from sliding across up and down in bed? 1. Thin pillow 2. Thick pillow 3. Trapeze bar 4. Trochanter roll
3. trapeze bar The trapeze bar decreases the shearing action from sliding across or up and down in bed. -Thin and thick pillows are used for positioning patients. The trochanter roll prevents external rotation of the hips when a patient is in a supine position.
Which definition describes cartilage? 1. Connection between bones 2. White fibrous bands of tissues that connect muscles to bones 3. Nonvascular supporting connective tissue located chiefly in joints 4. Shiny white flexible bands of fibrous tissues that bind joints together
3.Nonvascular supporting connective tissue located chiefly in joints Cartilage is nonvascular supporting connective tissue located chiefly in joints and the thorax, trachea, nose, and ear. -Joints are the connections between bones. -Tendons are the white, glistening fibrous bands of tissue that connect muscles to bones and are strong, flexible, and inelastic. -Ligaments are shiny, white, flexible bands of fibrous tissue that bind joints together, connect bones and cartilage, and aid joint flexibility and support.
Which positioning aid is contraindicated in a patient with spastic paralysis? 1) Pillows 2) Gait belt 3) Trochanter rolls 4) Rolled washcloths
4) Rolled washcloths Rolled washcloths are contraindicated in a patient with spastic paralysis, because they do not keep the thumb well abducted. -Pillows under the patient's head increase cervical flexion (thick pillow), which is not desirable and does not protect the skin and tissue from damage caused by pressure when placed under bony prominences (thin pillow). A gait belt would help the patient with walking. Trochanter rolls prevent the external rotation of the hips when a patient is in supine position.
A patient with left-sided weakness asks the nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." Which therapeutic response would be best? 1. "Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you." 2. "Would you like me to walk on your right side so you feel more secure?" 3. "Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side." 4. "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist, I would protect your shoulder if you should start to fall or faint."
4. "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist, I would protect your shoulder if you should start to fall or faint." Walking on the affected (weak side) side and holding the patient around the waist or using a gait belt gives the nurse better control if the patient starts to fall. If the nurse were holding the patient's arm as the patient was falling, this might dislocate the shoulder.
The nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which statement made by a woman in the audience reflects a need for further education? 1 "I usually go swimming with my family at the YMCA 3 times a week." 2 "I need to ask my doctor if I should have a bone mineral density check this year." 3 "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." 4 "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill."
4. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." Just because a multivitamin has calcium in it does not mean that the woman is receiving enough to meet her needs. She must know her requirement and make the decision based on that rather than on the value for calcium on the label. Any type of activity can help with calcium metabolism and is beneficial for helping to reduce the risk of osteoporosis. Patients should have a bone density scan yearly or according to their primary care physician's recommendations. To decrease the risk of osteoporosis, patients should be eating foods high in calcium and vitamin D.
A patient sustained a femur fracture as a result of a fall in the bathroom. The attending nurse understands that the femur bone forms a hip joint with the pelvic bone. Which type of joint is the hip joint? 1. Hinge joint 2. Pivot joint 3. Cartilaginous joint 4. Ball-and-socket joint
4. Ball-and-socket joint The head of the femur acts as a ball and the pelvic bone as a socket, and together they form a ball-and-socket type of joint, which is a freely movable synovial joint. The elbow and knee joints are examples of hinge joints. The joints in the neck are pivot joints. Cartilaginous joints are found in the sternum, where cartilage unites with bone.
An elderly patient has undergone hip replacement surgery. On the second postoperative day, the nurse finds that the pedal pulses are absent, and the lower extremities are cold to the touch. Which interpretation would the nurse make from this finding? 1. It is an age-related effect. 2. The patient's hip joint has dislocated. 3. The room temperature is too cold. 4. The patient has venous thrombus formation.
4. The patient has venous thrombus formation. The absence of pedal pulses and abnormally cold extremities indicate that the patient has venous thrombus formation. Venous thrombus formation occurs because of stagnation or alteration in the blood flow as a result of immobility or injury to the vessel wall during surgery. The thrombus may block the blood supply to the extremities. The clinical manifestations in the patient are not age-related effects. Hip joint dislocation may not result in the absence of pedal pulses. A cool room temperature may cause the extremities to become cold but may not lead to an absence of pedal pulses.
Which positioning aid prevents external rotation of the hips when the patient is in the supine position? 1. Thin pillow 2. Thick pillow 3. Trapeze bar 4. Trochanter roll
4. Trochanter roll -A trochanter roll prevents external rotation of the hips when a patient is in the supine position. A thin or thick pillow would not be helpful for preventing the external rotation of the hips, but may lead to increased flexion when the appropriate pillow size is not used. The trapeze bar allows the patient to raise the upper extremities to raise the trunk off the bed, which helps in decreasing the shearing action from sliding across or up and down the bed.
A 60-year-old female patient sustained a femur fracture because of a fall in the bathroom. The patient complains of severe pain and expresses that she did not expect a fracture because the fall was not very severe. The nurse tells the patient that fracture is common for people her age. Which condition would the nurse cite as the most common cause of fracture in postmenopausal patients? 1. Osteosarcoma 2 Osteoclastoma 3. Osteomyelitis 4. Osteoporosis
4. osteoporosis In a postmenopausal patient, osteoporotic changes in the bone increase the risk of fractures. Impaired calcium metabolism causes bone resorption, making it less dense. Bones affected by resorption are fragile and more susceptible to fractures. Osteosarcoma and osteoclastoma are bone tumors. Osteomyelitis is an infection of the bone.
The nursing student is performing range-of-motion (ROM) exercises for a patient who has been immobile for an extended period. Which action performed by the nursing student needs correction? 1. Performing ROM exercises when the pain score is 2 2. Performing ROM exercises 5 times during a session 3. Performing ROM exercises from smaller joints to larger joints 4. Performing ROM exercises by extending the joint as much as possible
Performing ROM exercises from smaller joints to larger joints The nurse should perform the ROM exercises from larger joints to smaller joints. -Because a pain score of 0 is not possible, a pain score 2 is considered the minimum in which ROM exercises can be performed. -The movements should be repeated 5 times during each session. -The joint can be extended as much as possible, but it should not be extended beyond resistance, and force should not be applied to perform the ROM exercises.
Which nursing action prevents tension on the spinal column and adduction of the hips while logrolling the patient?
Placing a small pillow between the patients knees rationale : Placing small pillows between the patient's knees helps prevent tension in the spinal column and adduction of the hips. Crossing the patient's arms across the chest prevents injury to the arms. Placing the patient in the supine position on the side of the bed prepares the patient for turning onto the side. Fanfolding, or rolling the drawsheet alongside the patient, provides strong handles to grip the drawsheet.
The nurse is positioning a patient in supported Fowler's position. Which action would the nurse perform to prevent flexion contractures of the cervical spine?
Rest the head of the patient against the mattress. While positioning a patient in the supported Fowler's position, the nurse should rest the patient's head against the mattress or on a small pillow to prevent flexion contractures of the cervical vertebrae. With a patient in the supine position, the nurse elevates the head of the bed from 45 to 60 degrees to increase patient comfort and to improve ventilation. To prevent hyperextension of the knee, the nurse should place a small pillow under the thigh. Positioning a small pillow at the lower back helps support the lumbar vertebrae and decreases the flexion of the vertebrae. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as not or except in the statement. 51%
The nurse is positioning a postoperative patient to place the major portion of the body weight on the hip and shoulder. In which position does the nurse place the patient?
Side-lying In a side-lying position, most of the body's weight is dependent on the hip and shoulder. In the Sims' position, the patient places the weight on the anterior ileum, humerus, and clavicle. In the prone position, the major portion of the body weight rests on the chest. In the supported Fowler's position, the major weight of the body rests on the back.
While positioning a patient with pressure ulcers, the nurse observes lateral flexion of the neck and an internally rotated shoulder and hip joints. Which patient positioning would have caused the patient's position?
Side-lying position A 30-degree side-lying position is recommended for patients with pressure ulcers. Some trouble points are common in the side-lying position, such as lateral flexion of the neck and internally rotated shoulder and hip joints. Placing patients in the prone position may cause neck hyperflexion and hyperextension of the lumbar spine. Placing the patient in the supine position may cause extended elbows and externally rotated hips. When the patient is placed in the supported Fowler's position, he or she may suffer from increased cervical flexion and external rotation of the hips.
Which site is at risk of skin breakdown when the patient is in the side-lying position?
Trochanter -In the side-lying position, lack of protection for the pressure point at the trochanter may result in skin breakdown and pressure ulcers. Lack of protection for pressure points at the ileum, humerus, clavicle, knees, and ankles may lead to skin breakdown in the Sims' position.
The nurse places the patient in the prone position. Which nursing action reduces the flexion or hyperextension of the cervical vertebrae?
Turning the patient's head to one side and supporting it with a small pillow (see table for ex) By turning the patient's head to one side and supporting it with a small pillow in the prone position, flexion or hyperextension of the cervical vertebrae can be prevented. Bringing the dependent shoulder blade forward in the side-lying position helps prevent the patient's weight from resting directly on the shoulder joint. Supporting the lower legs with pillows to elevate the toes may prevent footdrop. Placing a small pillow under the patient's abdomen below the level of the diaphragm in the prone position helps decrease the hyperextension of lumbar vertebrae and strain on lower back.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.
Which positioning aid increases cervical flexion? 1. Pillows 2. Arm splints 3. Trapeze bars 4. Trochanter rolls
`1. pillows When thick pillows are used under the patient's head, they increase cervical flexion. - Arm splints help reduce musculoskeletal injuries. A trapeze bar helps patients perform upper arm exercises. Trochanter rolls prevent external rotation of the hips when a patient is in the supine position.
The registered nurse is supervising a nursing student who is using positioning aids with a patient. Which nursing action may lead to skin and tissue damage caused by pressure? 1) Applying the positioning boots 2) Placing a thin pillow under the bony prominences 3) Placing the pillow under the knees by slight elevation 4) Using rolled washcloths as hand rolls in trochanter rolling
b) Placing a thin pillow under the bony prominences Placing a thin pillow under bony prominences may lead to skin and tissue damage because of pressure. -Positioning boots are applied to reduce the risk of footdrop. -Placing a pillow under the knees with slight elevation increases the peripheral circulation. -Rolled washcloths should not be used as hand rolls because they do not keep the thumbs well abducted.
