NCLEX-RN Mobility

The nurse is teaching a pregnant client about injury prevention. Which instruction should the nurse include?

"Change your shoes from high heels to flats."

A 74-year-old client receiving fluphenazine decanoate therapy develops pseudoparkinsonism, and is ordered amantadine hydrochloride. With the addition of this medication, the client reports feeling dizzy when standing. Which response by the nurse is best?

"When you change positions, do so slowly."

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do?

Explain how to overcome a freezing gait by telling the client to march in place.

A nurse is preparing a teaching plan for a newly married female client with a cervical (C5) spinal cord injury. The client does not want to become pregnant at this time. What sexuality teaching will be important for the nurse to include? Select all that apply.

Provide brochures on adaptations for sexual practice. Encourage her to be patient and practice a variety of sexual techniques. Instruct the client's spouse on how to properly insert a diaphragm.

After surgery and insertion of a total hip prosthesis, a client develops severe sudden pain and an inability to move the extremity. What do these findings indicate?

The client has a joint dislocation.

A client has a leg immobilized in traction. Which observation by the nurse indicates that the client understands actions to take to prevent muscle atrophy?

The client performs isometric exercises to the affected extremity three times per day.

The nurse is caring for the following infant after surgery. Which short term goal is the priority?

The infant will remain infection free in the postoperative period.

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?

The nurse uses a rocking motion while helping the client to stand.

Unlicensed assistive personnel (UAP) are helping a client who has had knee surgery 2 days ago get into bed. As the nurse makes rounds, which information requires the nurse to intervene?

The side rails on the head and foot of the bed are in the up position.

The nurse on a rehabilitation unit is caring for a 56-year-old male client who had an above-the-knee amputation of the right leg 1 week ago because of complications from diabetes. Before the amputation, the client had limited mobility because of weakness, fatigue, and poorly controlled diabetes. Click to highlight the findings that indicate that the client's condition is showing improvement.

The stump is less edematous than on the client's admission to the rehabilitation unit No pain is reported when the client is moving in bed. moving from side to side in bed prone position for about 10 minutes at a time The right hip is flexed at a 150-degree angle when the client is lying supine. The left leg is in proper alignment, with foot drop noted. The client transfers to a chair with the assist of one person. The client's BP is 138/86 mm Hg when the client is supine and 130/84 mm Hg when the client is standing.

A client with right-sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity?

Turn the client regularly.

When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for which health problem?

aspiration

Which positioning technique is most effective when there is only one person to assist the client to move from the left side to the right side if the client has hemiparalysis?

rolling the client onto the side

A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?

shearing forces

The nurse enters the room to do an initial assessment on a client with a fracture of the femoral head. What would be the expected findings on the affected limb?

shortening of the affected extremity with external rotation

The nurse is caring for an elderly patient who needs help with ADLs. Which is most important for the nurse to understand to avoid injury when implementing care?

Bending and twisting while providing care may cause injury.

When the nurse is conducting a preoperative interview with a client who is having a vaginal hysterectomy, the client states that she forgot to tell her surgeon that she had a total hip replacement 3 years ago. Why should the nurse communicate this information to the perioperative nurse?

The client should not have her hip externally rotated when she is positioned for the procedure.

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?

ring or donut

The nurse is creating a plan of care for an older adult client with osteoarthritis. Which nursing diagnosis is most appropriate?

risk for injury related to altered mobility

A nurse is caring for a client who had hip pinning surgery 6 hours ago to treat intertrochanteric fracture of the right hip. What assessment finding requires further investigation by the nurse?

client anxious and confused

The nurse observes as a child with Duchenne muscular dystrophy attempts to rise from a sitting position on the floor. After attaining a kneeling position, the child "walks" his hands up his legs to stand. The nurse documents this as which sign?

Gower's sign

The client was recently diagnosed with a musculoskeletal disorder and ordered carisoprodol. The nurse completes teaching about the medication. Which statement by the client indicates a need for more teaching about carisoprodol?

"I will stop the medication as soon as the muscle spasticity goes away."

The nurse is caring for a client admitted for pneumonia with a history of hypertension and heart failure. The client has reported at least one fall in the last 3 months. The client may ambulate with assistance, has a saline lock in place, and has demonstrated appropriate use of the call light to request assistance. Using the Morse Fall Scale (see chart), what is this client's total score and risk level?

60, high risk

The nurse is caring for a client with graduated compression stockings. The nurse removes the stockings and assessment findings include a blister on the right heel. What is the next action by the nurse?

Discontinue the graduated compression stockings and notify the healthcare provider.

The nurse is teaching a client recovering from a femur fracture repair to walk with crutches using a four-point gait, beginning with the left foot. Prioritize the steps of this nurse's instructions.

Assume tripod position, bearing weight on the handgrips. Move the right crutch forward 4 to 6 inches (10 to 15 cm). Move the left foot forward to the level of left crutch. Move the left crutch forward 4 to 6 inches (10 to 15 cm). Move the right foot forward to the level of right crutch.

Client presents to emergency department disheveled and reports pain in the left hip. Client states falling at home and may have "broken something." Client rates the pain a level 9/10. Client claims to live alone and have no help. Client has body odor and clothes are dirty. Answer the question by choosing from the lists of options.

Based on the client's cues, the nurse would have concerns of altered self-care as well as injury risk

The nurse understands that the client with severe dementia and motor apraxia may still be able to perform which action?

Brush the teeth when handed a toothbrush.

A client in the postoperative setting asks the nurse if he or she will have compression stockings like after the last surgery. What is the next action by the nurse?

Check the medical record for a provider's prescription for compression stockings.

The nurse on a rehabilitation unit is caring for a 56-year-old male client who had an above-the-knee amputation of the right leg 1 week ago because of complications from diabetes. Before the amputation, the client had limited mobility because of weakness, fatigue, and poorly controlled diabetes. Drag the assessment findings that require follow-up to the box on the right.

Findings That Require Follow-up blood pressure readings left leg externally rotated right hip flexion

The nurse is instructing a client following right-knee replacement on how to use crutches. Which instructions are included? Select all that apply.

Have your elbows bent when holding the crutch handles. Place crutches 1 foot in front of you. Pivot on your left leg. Swing your left leg forward.

The nurse on a rehabilitation unit is caring for a 56-year-old male client who had an above-the-knee amputation of the right leg 1 week ago because of complications from diabetes. Before the amputation, the client had limited mobility because of weakness, fatigue, and poorly controlled diabetes. The nurse and physical therapist are assisting the client in transferring from the bed to a wheelchair. Which action should the nurse take before the transfer? Select all that apply.

Lock the wheels on the wheelchair. Review the procedure for the transfer with the client and physical therapist. Place the wheelchair on the left side of the bed. Place a gait belt around the client's waist. Lock the wheels on the bed.

While assessing a client's spine for abnormal curvatures, the nurse notes lordosis. Identify the area of the spine that is affected by lordosis.

Lordosis is characterized by an accentuated curve of the lumbar area of the spine.

Bone resorption is a possible complication of Cushing's disease. To help the client prevent this complication, what should the nurse recommend to the client?

Maintain a regular program of weight-bearing exercise.

The nurse develops the plan of care for a child with early Duchenne's muscular dystrophy. What is the priority goal for this client?

Maintain function of unaffected muscles.

The nurse is reviewing the medical record and finds orders to apply graduated compression stockings on a client. What is the next action by the nurse?

Measure the client's legs.

The nurse on a rehabilitation unit is caring for a 56-year-old male client who had an above-the-knee amputation of the right leg 1 week ago because of complications from diabetes. Before the amputation, the client had limited mobility because of weakness, fatigue, and poorly controlled diabetes. For each potential nursing intervention, click to specify whether the intervention is indicated, nonessential, or contraindicated for the care of this client.

Nonessential: Have the client wear socks while in bed. Contraindicated: Position the foot in the plantar flexion position. Prevent internal rotation of the legs. Indicated: Turn the client frequently, including in the prone position. Have the client sit at the side of the bed before rising to a standing position. Use pillows to support proper body alignment.

The nurse is measuring a client for thigh high antiembolism stockings. The client's thigh measurements are outside the guidelines for available sizes. What is the next action by the nurse?

Notify the provider.

A client with a leg incision has a prescription for graduated compression stockings. The client rates the incision pain at 8/10. What is the best action by the nurse prior to applying the graduated compression stockings?

Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application.

The nurse plans to place graduated compression stockings on a client in the preoperative setting. List in order the steps the nurse will follow. All options must be used.

Review medical record and medical orders for graduated compression stockings. Identify the client and explain procedure. Place the client in supine position. Apply powder or lotion to legs. Turn the stocking inside out and ease the stocking over the foot and heel. Smoothly pull the stocking over the ankle and calf.

The school nurse is planning an educational session to prevent injuries in children with juvenile arthritis. Which information should the nurse include in the teaching?

Schedule the completion of daily range-of-motion exercises to support joint mobility.

Which nursing approach is most helpful to a client with Parkinson disease who is experiencing a freezing of gait with difficulty initiating movement?

Tell the client to march in place.

A nurse is documenting a health assessment when the client states having problems with balance, as well as fine and gross motor function. When collaborating with the health team, which area on the illustration of the brain would the nurse highlight as an area of concern?

The cerebellum is the portion of the brain that controls balance and fine and gross motor function. The cerebellum is located at the base of the skull and above the brain stem.

A nurse is caring for a client who fell and fractured the neck of femur. When documenting the site for the family members, indicate on the image the area where the fracture occurred.

The neck of the femur is a flattened pyramidal process of bone connecting the femoral head with the femoral shaft just below the ball and socket. When a femoral neck fracture occurs, the ball is disconnected from the rest of the thigh bone.

The nurse is explaining the nature of the fracture to the parents of a school-age client who has a greenstick fracture. Which drawing should the nurse choose to explain the fracture to the parents?

The nurse should show the parents the figure of the greenstick fracture as noted in answer C in which the fracture does not completely cross through the bone. Answer A is a plastic deformation, or a bend in the bone. Answer B is a buckle. Answer D is a complete fracture.

A nurse must restrain a client to ensure the safety of other clients. When using restraints, which principle is a priority?

Use an organized, efficient team approach to apply and secure the restraints.

The nurse is assisting a client who has had a spinal fusion apply a back brace. In which order of priority should the nurse assist the client applying the brace? All options must be used.

Verify the prescriptions for the settings for the brace. Have the client in a side-lying position. Assist the client to log roll and rise to a sitting position. Ask the client to stand with arms held away from the body.

The nurse unit manager is making rounds on a team of clients and notices a client with a color-coded armband that indicates the client is at risk for falling walking down the hall unassisted. The client is at the end of the hallway farthest from the client's room, but is not tired. What should the nurse do first?

Walk with the client back to the room, and assist the client to get in bed or a chair.

Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which client?

a 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance

When assessing the client with Parkinson's disease, the nurse should observe the client for:

a stiff, masklike facial expression.

A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital?

conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use.

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent:

contractures.

The nurse is assessing a client receiving levodopa-carbidopa for treatment of Parkinson's disease. The nurse should document which assessment findings as evidence of a positive response to treatment? Select all that apply.

decreased dyskinesia reduced rigidity and tremor

To help minimize calcium loss from a hospitalized client's bones, the nurse should

encourage the client to walk in the hall.

When performing an assessment, the nurse identifies these signs and symptoms in the client: decreased muscle strength, limited range of motion, and reluctance to move. Based on these symptoms, the nurse should perform which interventions? Select all that apply.

encouraging client turning and repositioning every 2 hours having call bell within easy reach initiating hospital fall risk protocols

A client diagnosed with rheumatoid arthritis reports that pain and stiffness are worse when arising in the morning. What interventions can the nurse suggest to assist the client in decreasing the pain? Select all that apply.

energy conservation techniques adaptive equipment hot bath to alleviate stiffness

Before planning care for a group of clients with mobility issues, the nurse wants to ensure best practices are incorporated into the plan. Which source should the nurse access to ensure safe quality care is provided?

evidence-based research

The nurse is developing the discharge teaching plan for a client after a lumbar laminectomy L4-L5. What action should the nurse encourage the client to avoid when returning to work in 6 weeks?

sitting whenever possible

The nurse is instructing the unlicensed assistive personnel (UAP) on how to position the wheelchair to assist a client with left-sided weakness transfer from the bed to a wheelchair using a transfer belt. Which statement by the UAP tells the nurse that the UAP has understood the instructions for placing the wheelchair?

"The wheelchair should be placed on the right side of the bed."

The parent asks the nurse whether a child with hemiparesis due to spastic cerebral palsy will be able to walk normally because he can pull himself to a standing position. Which response by the nurse would be most appropriate?

"It is difficult to predict, but his ability to bear weight is a positive factor."

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help?

"Obtain the sliding board or two other people to assist us."

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

"The paralysis caused by this disease is usually temporary."

A client recovering from lumbar surgery is fitted for a contour splint. What should the nurse explain to the client about this device?

"The splint immobilizes the body part in a functional position."

The nurse is caring for a client during the postoperative period. The client was prescribed thigh high antiembolism stockings and pneumatic compression devices for prevention of deep vein thrombosis. Assessment data reveal +3 pitting edema to the lower extremities bilaterally. What is the priority action by the nurse?

Measure client's thighs and calves to ensure the antiembolism stockings are the correct size.

A nurse explains the process of cane usage to a hospitalized client with left-sided weakness. Place the steps of teaching proper cane usage in the correct order. All options must be used.

Perform hand hygiene. Secure a gait belt around client's waist. Place the cane in the right hand. Have client advance the cane and the left leg. Have client advance the right leg.

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?

When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight.

Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment?

free, easy movement of the joints

To promote early and efficient ambulation for a client after an above-the-knee amputation, the nurse is aware that the leg will need to be positioned in which way?

in functional alignment

A nurse is evaluating a client with Parkinson disease. The nurse uses what assessment finding(s) to help determine that the client is in a later stage of Parkinson disease? Select all that apply.

inability to stand without help bradykinesia posturing of the hips and neck

A client recovering from surgery to repair a fracture of the tibia and fibula of the left leg is reporting increased pain at the site. What sign must the nurse be alert to that would indicate compromised circulation to the leg?

increased edema in the toes of the affected leg

A nurse notes that a client has kyphosis and generalized muscle atrophy. Which problem is a priority when the nurse develops a nursing plan of care?

ineffective coughing and deep breathing

Which findings best correlate with a diagnosis of osteoarthritis?

joint stiffness that decreases with activity

The nurse is preparing a 45-year-old female for a vaginal examination. The nurse should place the client in which position?

lithotomy position

What finding indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful?

maintenance of joint mobility

When the nurse is assessing a client who reports a back injury, what should the nurse ask the client about first?

mechanism of injury

A nurse is assessing a 15-year-old adolescent who's being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?

muscle weakness

The client is being discharged today after having an above-the-knee amputation a week ago. Which complications should the nurse include in the discharge directions? Select all that apply.

new openings in wound or skin around the wound pulling away worsening pain not controlled by medication skin around the stump or wound dark or turning black

Which cells are involved in bone resorption?

osteoclasts

The nurse is aware that frequent repositioning in bed will assist in the prevention of which condition for a client?

pneumonia

The nurse on a rehabilitation unit is caring for a 56-year-old male client who had an above-the-knee amputation of the right leg 1 week ago because of complications from diabetes. Before the amputation, the client had limited mobility because of weakness, fatigue, and poorly controlled diabetes. Select all that apply.

pressure injuries activity intolerance deep vein thrombosis falls

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy?

raising all side rails while the client is in bed

Which is not a typical clinical manifestation of multiple sclerosis (MS)?

sudden bursts of energy

A client with a diagnosis of schizophrenia is admitted to the psychiatric hospital in a catatonic state. During the physical examination, the client's arm remains outstretched after the nurse obtains pulse and blood pressure readings, and the nurse must reposition the arm. This client is exhibiting:

waxy flexibility.

After undergoing surgery the previous day for a total knee replacement, a client states not feeling ready to ambulate yet. What should the nurse do?

Discuss the complications that the client may experience if they don't cooperate with the care plan.

A client is scheduled to undergo transurethral resection of the prostate. The procedure is to be done under spinal anesthesia. What should the nurse assess the client for after surgery?

respiratory paralysis

The nurse is planning care for a group of clients who requested the use of yoga. The client with which condition is not a candidate for yoga?

spinal fusion

The nurse is assessing the infant shown in the figure. On observing the client from this angle, the nurse should document that this infant has which finding?

asymmetric gluteal folds

While gently abducting the hips during a newborn assessment, the nurse hears a "click" as the femoral head slips into the acetabulum. The nurse interprets this as positive for which physical finding?

Ortolani's sign

A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation, which laboratory result is the priority for the nurse to report to the physician?

blood culture

A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside?

suction machine with catheters

The nurse on a rehabilitation unit is caring for a 56-year-old male client who had an above-the-knee amputation of the right leg 1 week ago because of complications from diabetes. Before the amputation, the client had limited mobility because of weakness, fatigue, and poorly controlled diabetes.

When assisting this client out of bed, the nurse is most concerned about the risk for falls because of the drop in systolic blood pressure greater than 10 mm Hg when the client goes from a lying to a standing position, which indicates orthostatic hypotension. Orthostatic hypotension increases the risk for falls because the client may become dizzy and experience syncope. Phantom leg pain and pressure injuries do not increase the risk for falling. When assisting this client out of bed to a chair, the nurse understands that a priority concern is falls, as evidenced by the client's ---

A client is being discharged following an open reduction and internal fixation of the left ankle, and is to wear a non-weight-bearing cast for 2 weeks. What should the nurse teach the client to do when using crutches?

Maintain two to three finger widths between the axillary fold and underarm piece grip.