Exam 4 P&P Chapters 28,29,35 Study Guide

Which of the following assessment findings indicate that exercise should be discontinued? 1. Heart rate = 145 beats/minute 2. Blood pressure 140/82 3. Respirations 32 breaths/minute 4. Oxygen saturation 95%

1. Heart rate = 145 beats/minute

A patient has experienced an injury to his lower extremity. The orthopedist has prescribed the use of crutches and a dour-point gait. The nurse instructs the patient using this gait to: 1. Move the right crutch forward first 2. Move both crutches forward together 3. Move the right foot and the left crutch together 4. Move the right foot and the right crutch together

1. Move the right crutch forward first

An expected assessment of a toddler's alignment will indicate a: 1. Slight swayback and protruding abdomen 2. Flexed spine without anteroposterior curves 3. Full musculoskeletal function and straight posture 4. Distinct thoracic curvature and weakness

1. Slight swayback and protruding abdomen

The patient had a cerebrovascular accident (CVA/Stroke) with resultant left hemiparesis. The nurse is instructing the patient on the use of a cane for support during ambulation. The nurse instructs the patient to: 1. Use the cane on the right side 2.Use the cane on the left side 3. Move the left food forward first 4. Move the right foot forward first

1. Use the cane on the right side

Patient's who are on prolonged bed rest need to be repositioned at least every __________

2 hours

What is the proper alignment for a patient in the sitting position? 1. Body weight distributed totally to the buttocks 2. Both feet supported on the floor 3. Head flexed forward at a 60degree angle 4. a 10" space maintained between the edge of the seat and the popliteal space

2. Both feet supported on the floor

A patient is admitted to the rehab facility for physical therapy after a car accident. To conduct an assessment of the patient's body alignment, the nurse should begin by: 1. Observing the patient's gait 2. Explaining the process 3. Determining the level of activity tolerance 4. Evaluating the full extent of joint range of motion

2. Explaining the process

A nurse selects which of the following for promoting resistive isometric exercise for a patient? 1. Whirlpool 2. Footboard 3. Weights 4. Stationary bicycle

2. Footboard

A patient is getting up to ambulate for the first time since a surgical procedure. While ambulating in the hallway, the patient complains of severe dizziness. The nurse should first: 1. Call for help 2. Lower the patient gently to the floor 3. Lean the patient up against the wall until the episode passes 4. Support the patient and move quickly back to the room

2. Lower the patient gently to the floor

A nurse is working with a patient who is able to only assist the nurse in moving from the bed to the chair. The correct technique for lifting the patient to stand and pivot to the chair is for the nurse to: 1. Keep the legs straight 2. Maintain a wide base with the feet 3. Keep the stomach muscles loose 4. Support the patient away from the body

2. Maintain a wide base with the feet

For inpatient early progressive mobility, Level 3 includes beginning to have the patient: 1. Sitting in bed with the head of the bed or stretcher elevated to 45 degrees 2. Sitting on the edge of the bed 3. Actively transferring to a chair 4. Initiating ambulation

3. Actively transferring to a chair

One of the expected benefits of exercise is: 1. Decreased diaphragmatic excursion 2. Decreased cardiac output 3. Decreased resting heart rate 4. Increased fatigue

3. Decreased resting heart rate

A patient is able to bear weight on one foot. The crutch walking gait that the nurse teaches this patient is the: 1. Two-point gait 2. Swing-through gait 3. Three-point alternating gait 4. Four point alternating gait

3. Three-point alternating gait

The first step in initiating an exercise program for a patient is to: 1. Select the equipment 2. Design the fitness program 3. Schedule time during the day 4. Seek approval from the health care prescriber

4. Seek approval from the health care prescriber

An average size female patient who resides in an extended care facility requires assistance to ambulate down the hall. The nurse has noticed that the patient has some weakness on her right side. The nurse assists this patient to ambulate by: 1. Standing at the patient's left side and holding her arm 2. Walking in front of her and having her hold onto her waist 3. Standing behind her and encircling one arm around the patient's waist 4. Standing at her right side and using a gait belt

4. Standing at her right side and using a gait belt

A patient has a cast on the right foot and is being discharged home. Crutches will be used for ambulation, and the patient has stairs to manage to enter the house and to get to the bedroom and bathroom. The nurse observes that the patient is not confident with the use of the crutches, so plans to teach the patient to use which of the following techniques for stairs? 1. Advance the crutches first to ascend the stairs 2. Use one crutch for support while going up and down 3. Sit on the stairs and lift with he arms and weight bearing leg to move up 4. Use the banister or wall for support when descending the stairs

4. Use the banister or wall for support when descending the stairs

Which of the following are expected findings for assessment of a patient while standing? Select all that apply. A. Head is erect and held midline B. Body parts are asymmetrical C. The spine has a lateral curve D. The abdomen protrudes E. The knees are a straight line between the hips and ankles F. The feet are pointed at an angle and close together G. The arms hang comfortably at the sides

A,E,G

For a patient who has been on prolonged bed rest: A. What should the nurse do to prepare the patient for better ambulation? B. Transfers and position changes for this patient can lead to the development of _________ ?

A. Before ambulation, the nurse should: • Assess activity tolerance, strength, coordination, and balance • Assess the environment, make sure that the floor is clean and dry, identify rest points, remove obstacles • Have the patient wear supportive, nonslip shoes • Have the patient sit up in bed and dangle first • Ask the patient to remain stationary for a minute after standing • Use a gait belt • Prepare for syncopal episodes B. Care should be taken in making position changes slowly as orthostatic hypotension could occur.

Complete the following about transferring patient's A. The general "rule of thumb" for transfers is _______ B. A nurse's priority during patient transfers is _______

A. The general "rule of thumb" for transfers is to GET HELP to transfer a patient. B. Safety during transfers is the priority.

Bathing, dressing, eating

ADLs (Activities of daily living)

The relationship of one body part to another along a horizontal or vertical line

Alignment

Identify at least 3 components to assess to determine a patient's mobility

Assessment of a patient's mobility includes: range of joint motion, gait, exercise, balance, posture, and body alignment.

For an immobilized patient, identify the usual frequency of assessment for anorexia

At meals

For an immobilized patient, identify the usual frequency of assessment for urinary elimination

At the beginning or end of every shift

Collapse of aveoli

Atelectasis

Which of the following are positive effects of exercise? Select all that apply. A. increased fatigue B. Improved muscle tone C. Reduced bone loss D. Decreased cardiac output E. Increased production of body heat F. Decreased use of glucose and fatty acids

B,C,E

Which of the following indicate correct care or technique for a patient who is using crutches? Select all that apply. A. The patient leans on the axillae to support his or her weight B. Both crutches are transferred to one hand when preparing to sit C. Crutches are placed 1 foot to the front and side of the feet D. The patient has a non-weight bearing left leg and is using a 3 point gait E. The unaffected leg is advanced first when the patient goes up the stairs

B,D,E

Which of the following are correct principles of body mechanics? Select all that apply. A. Maintain a narrow base of support B. Face the direction of movement C. Maintain a higher center of gravity D. Divide balanced activity between the arms and legs E. Increase friction between the object and the surface F. Alternate periods of rest and activity

B,D,F

Body alignment during walking, turning, lifting, or carrying

Body Mechanics

Identify the ROJM

Circumduction of the arm

A mechanical device that is used for specific repetitive joint exercise is a:

Continuous passive motion (CPM) machine.

Characterized by bone resorption

Disuse Osteoporosis

Increased urine excretion

Diuresis

An example of a fluid and electrolyte imbalance that may occur with prolonged immobility is:

Diuresis occurs as a result of the increased blood flow to the kidneys. Diuresis causes the body to lose electrolytes such as potassium and sodium and reduces serum calcium levels. Immobility increases calcium resorption from the bones, causing a release of excess calcium into the circulation or hypercalcemia.

Identify the ROJM

Dorsiflexion of the foot

The design of work tasks to best suit the capabilities of workers

Ergonomics

For an immobilized patient, identify the usual frequency of assessment for respiratory status

Every 2 hours

For an immobilized patient, identify the usual frequency of assessment for total intake an output

Every 24 hours for daily measurement

How often are stockings removed?

Every 8 hours or per agency policy

An example of a physiological factor that may influence activity tolerance is _________

Examples of physiological factors that may influence activity tolerance are musculoskeletal abnormalities, diminished cardiovascular function, and diminished respiratory function.

More than 45% of adults aged 45-54 meet the national activity guidelines. True or False?

False

The best way to determine a patient's level of pain is to observe for redness or swelling of the joints. True or False?

False

Permanent plantar flexion

Footdrop

A patient will be getting out of bed for the first time after having surgery and receiving general anesthesia. What actions should be taken by the nurse to promote the patient's safety?

For the patient, there are safety considerations associated with the first time he will be getting out of bed. He could be prone to orthostatic hypotension, which is the drop in blood pressure when moving from lying down or sitting to a standing position. When transferring from a supine position into a chair, move the patient gradually. First, obtain a baseline blood pressure and pulse with the patient in the supine position. Then raise the patient to a high Fowler's position and measure blood pressure and pulse again to detect decreases in blood pressure or elevations in pulse. Leave the patient in this position for 2 minutes to allow the body to adapt. Monitor the patient for dizziness or light-headedness. The patient is now ready to sit at the side of the bed with the feet on the floor (dangling). If there is no dizziness, assist the patient to a chair. When transferring an immobile patient for the first time, make sure that assistance is available, if necessary.

Resistance that a moving body meets from the surface on which it moves

Friction

Manner or style of walking

Gait

To reduce extension of the fingers and abduction of the thumb, the nurse should use _________ when positioning the patient

Hand splints or hand rolls

Identify the ROJM

Hyperextension of the hip

Lung inflammation from stasis or pooling of secretions

Hypostatic pneumonia

A nurse observes a patient and notes that there is limited range of motion in a few areas. This could be the result of:

Inflammation, such as arthritis, fluid in the joint, altered nerve supply, or contractures.

Temporary decrease in blood supply to an organ or tissue

Ischemia

Identify the patient's position

Lateral

Half of all back pain is associated with:

Manual lifting tasks

Capacity to maneuver around freely

Mobility

Identify the steps, in order, for the use of a mechanical lift.

More than one nurse is needed for this transfer. The correct sequence of steps for the use of a mechanical lift is: • Position the chair near the bed. • Raise the bed to working height with the mattress flat (as tolerated). • Roll the patient away from you (side rail is up on the far side, other nurse is on far side). • Place the sling under the patient. • Roll the patient toward you. • Pull the sling through so that it is under the patient from the upper torso. • Check the position of the sling. • Move the lift under the bed and attach the sling to the lift. • Have the patient fold the arms over the chest. • Slowly lift the patient and maneuver the sling over the chair. • Lower the patient into the chair and disconnect the lift. • Position the patient for comfort and safety.

You are the nurse in a long term care facility and your assignment includes several older adults who are immobile. What actions should be taken specifically for this older adult population?

Older adult patients are especially susceptible to the hazards of immobility. It is important to make sure that the following interventions are included in the patients' care: • Assess overall physiological and psychological status regularly • Skin - provide moisture, be gentle in moving and positioning • Respiratory - encourage deep breathing, coughing, moving • Musculoskeletal - incorporate range of motion into daily activities • Diet - make sure that sufficient fluids, vitamins, and proteins are included • Elimination - assist in positioning, dietary intake of fluids and roughage • Cognitive/psychological - provide diversionary activities/stimulation, reality orientation, emotional support; offer explanations before care • Work with other members of the health care team to provide safe care and prevent complications

For a patient who has severe arthritis and is unable to perform activities of daily living because of discomfort on movement, the priority is _____________

Pain relief.

Identify at least two pathological influences on alignment, exercise, or activity.

Pathological influences on alignment, exercise, and activity include congenital defects; disorders of bones, joints, and muscles; central nervous system damage; and musculoskeletal trauma.

Identify a nursing diagnosis associated with a change in a patient's ability to maintain physical activity

Possible nursing diagnoses associated with a change in a patient's ability to maintain physical activity include: • Inability to participate in daily activity • Altered body image • Potential for injury • Altered physical mobility • Acute or chronic pain

Maintenance of optimal body position

Posture

Improper positioning of patient's in bed can lead to:

Pressure ulcers and contractures.

Identify the patient's position

Prone

Awareness of the position of the body and it's parts

Proprioception

Mobility of the joint

Range Of Motion

Calcium stones in the kidney

Renal Calculi

Identify the ROJM

Rotation of the neck

Identify the ROJM

Supination of the forearm

Identify the patient's position

Supine

Lying facing up

Supine

When transferring patients who are able to assist from the bed to a chair, the chair should be positioned:

The chair should be positioned on the patient's strong side at a 45-degree angle to the bed.

How does the nurse determine a patient's activity tolerance?

The nurse determines patients' activity tolerance by: observing after ambulation, self-bathing, or sitting in a chair for several hours, and assessing their verbal report of fatigue and weakness. Do they show difficulty breathing or report being short of breath after exercise? Assess heart rate and blood pressure response to activity by comparing with baseline rates at rest.

Case Study A patient has just gone to the rehab facility. She has been immobilized with a spinal cord injury from an automobile accident. You are aware of the physical hazards of mobility, but her withdrawn behavior is your concern now. What can you do to prevent the possible psychological and emotional effects of the patient's period of immobility?

The patient may benefit the most from discussing her feelings, needs, and concerns with the nurse, and being involved, as much as possible, in the decision-making process for her plan of care. In addition, she may benefit from the following interventions: • Orienting her to the environment, routine/schedule, and staff members • Placing her with mobile patients who can interact with her • Encouraging frequent visits from family members and friends • Providing her with materials she enjoys, such as books and magazines • Providing stimulating diversional activity for her, such as music and games • Engaging in conversation with her during meals and implementation of nursing actions • Encouraging her to use any necessary assistive aids, such as glasses • Having vision and hearing assessments done, if it appears there are sensory deficits • Encouraging and assisting her (as necessary) to attend to daily grooming • Providing a stimulating physical environment, such as changing her view or decorating with personal objects

The patient, who has some mobility in the upper arms and legs, needs to be moved up in bed. What should the nurse do to reduce friction when moving the patient?

The patient who is able to assist in positioning can be instructed to bend the knees and lift the hips and/or push up with the hands and arms. A draw sheet may also be used to move the patient up in bed.

What aspects of the patient's gait are assessed by the nurse?

The patient's gait is assessed for its rhythm, cadence, length of stride, speed, conformity, a regular, smooth rhythm, and symmetry in the length of leg swing and arm swing.

accumulation of platelets, fibrin, clotting factors, and cellular elements attached to the interior wall of an artery or vein

Thrombus

The objectives or advantages of bed rest are:

To decrease physical activity and oxygen needs, allow the ill/debilitated patient to rest, and prevent further injury.

A nurse anticipates that a patient on prolonged bed rest will have an increased heart rate. True or False?

True

Range of motion can be determined by observing the patient's gait and ability to perform activities of daily living. True or False?

True

Sociocultural factors have an impact upon the amount of physical activity that is done by an individual. True or False?

True

Using the algorithm for patient transfers, the appropriate intervention for a patient who is cooperative, has upper body strength, but cannot bear full weight should be

With the algorithm, a transfer aid should be selected for use or the assistance of another person.

CASE STUDY: A nurse is assigned to work with an 80-year old woman residing in a nursing home. There is conflicting information in the chart about her ability to move around independently. The nurse is concerned about meeting the patient's needs for proper body mechanics as well as her safety. A. What important assessment information is needed to plan meeting the patient's needs? B. If the patient is unable to ambulate independently, what nursing interventions should be planned?

a. The patient should be assessed for her ability to move independently, including her posture, muscle strength, range of motion, gait (if able), balance, activity tolerance, and cognitive status. If the patient is able to bear weight on both legs and maintain an erect position, the nurse must determine if she is capable of ambulating safely. Initial assessment of the patient's transfer out of bed should be accomplished with assistance in the event that the patient is unable to maintain a standing position. b. If the patient is not able to ambulate independently, she may be able to use an assistive device, such as a cane or walker. If possible, one or more nurses may use a gait belt to assist the patient in ambulating. Should the patient not be able to ambulate safely, even with assistance, a wheelchair may be necessary. To assist the patient in gaining muscle strength, a program of exercise may be implemented.

Specific range of motion exercises to prevent thrombophlebitis include:

ankle pumps, foot circles, knee flexion, and hip rotation.

Which of the following pathophysiology changes occur with immobility? Select all that apply. A. Increased basal metabolic rate B. Decreased gastrointestinal motility C. Orthostatic Hypotension D. increased Appetite E. Increased oxygen availability F. Hypercalcemia G. Increased lung expansion H. Decreased cardiac output I. Increased dependent edema J. Decreased stressors K. Increased urinary stasis L. Decreased passive behaviors

b, c, f, h, i, and k.

Contraindications for the use of stockings.

dermatitis, open skin lesions, new skin grafts, and decreased circulation.

What are anthropometric measures and how often are they assessed?

mid upper arm circumference and triceps skinfold measurements, assessed every 2-4 weeks. A dietitian or physical therapist may be responsible to taking these measurements.

What areas are included in a focused patient assessment of overall mobility?

mobility, pain, endurance, and activity.

A nurse makes sure that stockings are NOT:

partially rolled down or wrinkled, and the toes should not be uncovered.

Identify the four pathological influences on mobility and an example of each one.

postural abnormalities (torticollis, lordosis, kyphosis, scoliosis, congenital hip dysplasia, genu valgum, genu varum, clubfoot, footdrop, pigeon toes); muscle abnormalities (muscular dystrophy); damage and disorders of the CNS (trauma, stroke, meningitis, ALS, MS, Parkinson's, myasthenia gravis); direct trauma to the MS system (fractures, osteoporosis, osteogenesis imperfecta).

With an immobilized child, the nurse's focus is on:

providing physical and psychosocial stimulation in order to keep pace with motor and intellectual development.

Where should a nurse check for edema in an immobilized patient?

sacrum, hips, legs, and feet.

An important concept when working with patients who are immobilized is to maintain the patient's autonomy. The nurse can accomplish this by:

the nurse encourages the patient to do as much as possible, demonstrate activities, and participate in goal setting and decision making.

Logrolling a patient in bed requires at least _________ caregivers to perform

three

The Virchow triad is related to ___________, and the three associated problems are _______________

thrombus formation and the three associated problems are (1) blood stasis resulting from decreased blood flow and increased viscosity, (2) hypercoagulability due to a change in clotting factors or increased platelet activity, and (3) vessel trauma.

Identify at least three components of a safe patient handling program

• An ergonomics assessment protocol for health care environments • Patient assessment criteria, algorithms for patient handling and movement • Special equipment kept in convenient locations to help transfer patients • Back injury resource nurses • An "after-action review" that allows the health care team to apply knowledge about moving patients safely in different settings• A no-lift policy

Name at least one major change that may occur to the respiratory system as a result of immobility and a nursing intervention to prevent or treat the change:

• Hypostatic pneumonia and atelectasis. Encourage coughing and deep breathing, adequate fluid intake, and exercise; turning; upright positioning; and chest physiotherapy.

Name at least one major change that may occur to the musculoskeletal system as a result of immobility and a nursing intervention to prevent or treat the change:

• Loss of strength and endurance, reduced muscle mass, decreased stability and balance, with possible contractures and disuse osteoporosis: Provide or encourage range-of-joint-motion exercises, turn every 1-2 hours, change position, and refer to physical therapy.

Name at least one major change that may occur to the cardiovascular system as a result of immobility and a nursing intervention to prevent or treat the change:

• Orthostatic hypotension: Move the patient slowly from one position to another. • Increased cardiac workload: Place the patient in an upright position (if possible), provide regular exercise and adequate fluid intake. • Thrombus formation: Provide regular exercise, adequate fluid intake, and antiembolic stockings.

Name at least one major change that may occur to the Integumentary system as a result of immobility and a nursing intervention to prevent or treat the change:

• Pressure ulcers: Assess the skin, use supportive devices, provide adequate nutrition and hydration, change position every 1-2 hours, and perform meticulous skin care.

Name at least one major change that may occur to the gastrointestinal system as a result of immobility and a nursing intervention to prevent or treat the change:

• Reduced appetite, inadequate/imbalanced nutrition, decreased peristalsis: Provide adequate nutrition (fruits, vegetables, fiber) and hydration, measure I&O, administer prescribed cathartics, promote activity or movement, and institute a bowel program.

Name at least one major change that may occur to the Urinary system as a result of immobility and a nursing intervention to prevent or treat the change:

• Urinary stasis resulting in greater risk for infection and calculi: Provide adequate hydration and promote activity and movement.