NU272 PrepU Week 2 (Mobility)

A nursing student asks the nurse why older adults are at risk for falls. The best response by the nurse is:

"Muscles atrophy with aging." - Muscle atrophy results in weakness and decreased flexibility, which increases the risk for stumbling and falls.

A month after surgical repair of a rotator cuff tear of the shoulder, a client tells the nurse, "This is not getting any better. I still have a lot of pain and limited motion." Which response by the nurse is most accurate?

"The shoulder joint is complex and can take up to 6 months to heal depending on the injury." - A rotator cuff repair may take several months to fully heal, depending on the sport and injury. After an extended period of joint rest, the client will need a rehabilitation program to regain strength, flexibility, and endurance. If the initial injury was mild, conservative treatment with anti-inflammatory agents, corticosteroid injections, and physical therapy would be implemented before surgical intervention.

Which principle best explains symptoms of amyotrophic lateral sclerosis (ALS), including dysphagia, muscle weakness and spasticity, and dysphonia?

ALS is caused by both an upper motor neuron and lower motor neuron disturbance. - ALS is both an upper motor neuron (UMN) and lower motor neuron (LMN) disorder, leading to wide variety of muscular symptoms.

Reflex activity involves which neurons?

Afferent neurons synapse with efferent neurons directly, innervating a muscle, or with an interneuron that synapses with an effector neuron.

The cerebellum, separated from the cerebral hemispheres by the tentorium cerebelli, lies in the posterior fossa of the cranium. What is one of the functions of the cerebellum?

Coordinates smooth and accurate movements of the body - The cerebellum compares what is actually happening with what is intended to happen. It then transmits the appropriate corrective signals back to the motor system, instructing it to increase or decrease the activity of the participating muscle groups so that smooth and accurate movements can be performed.

A client has developed osteomyelitis and asks the health care provider how the problem occurred. Which response is most accurate?

Direct contamination of an open wound - Osteomyelitis represents an acute or chronic infection of the bone and marrow. All types of organisms—including parasites, viruses, bacteria, and fungi—can cause osteomyelitis, but certain pyogenic bacteria and mycobacteria are the most common. Organisms may reach the bone by seeding through the bloodstream (hematogenous spread), direct penetration or contamination of an open fracture or wound (exogenous origin), or extension from a contiguous site. Vitamin intake or deficiency will not cause infection.

The type of fracture often seen in young children is one in which there is not complete ossification of the bone, and the bone bends and just partially breaks. What type of fracture is this?

Greenstick - Greenstick fractures are one kind of incomplete fracture, caused by incomplete ossification, common in children. The bone bends and often just partially breaks. Spiral fractures are seen when the fracture goes around the bone instead of through (i.e., looks like someone twisted the bone, and can occur in skiing injuries, falls, or abuse). A complete fracture is when the bone is actually broken in two pieces. An epiphyseal fracture occurs at the epiphyseal growth plate.

In a client diagnosed with osteomalacia, what would be recommended to aid with improvement of the condition?

Increasing dietary consumption of vitamin D - Clients with osteomalacia need to have increased vitamin D, and exposure to natural sunlight will help increase the absorption. Losing weight and a bone marrow transplant will not be helpful.

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later. - It is most appropriate to manage the client's pain first. The client will be able to ambulate more easily and it is not necessary to cause the client further pain. Ambulating first considers the needs of the nurse, not the client. The client has not indicated misunderstanding of benefits or the importance of ambulation.

A client has experienced a gradual flattening of affect, confusion, and withdrawal and has been diagnosed with Alzheimer's disease. Which additional findings would the nurse most likely assess?

Personality change, wandering, and inability to perform purposeful movements - Alzheimer's disease is not typically characterized by delusions, transient paresthesias, blindness, or slurred speech. Instead, general changes in personality, wandering, and the inability to perform purposeful, goal-directed movements are impaired.

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 application of graduated compression stockings will increase the incisional pain for this client, therefore the client should be premedicated with prescribed morphine 1 mg I.V. 15 minutes prior to application. Oral acetaminophen 500 mg will not likely provide effective pain relief 15 minutes prior to application of the graduated compression stockings. Although an ice pack may reduce pain, the prescribed morphine will be more effective for relieving pain rated 8/10. Placing a gauze pad to the incision prior to applying the graduated compression stockings may be necessary to absorb drainage, but will not provide pain relief during application.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to circumferential eschar - As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:

Right-sided paralysis. - A left hemispheric stroke will cause right-sided weakness or paralysis. Because upper motor neurons decussate, a disturbance on one side of the body can cause damage on the opposite side of the brain. Refer to Box 47-2 in the text.

A client states during the interview that he has pain in his lower back. He states it is a 10 on a scale of 0 to 10 when he is asked to turn. The nurse should:

avoid a position change that requires turning. - Addressing pain early in the health assessment allows the nurse to individualize the rest of the assessment, avoiding positioning and techniques that are especially uncomfortable for the client.

The primary functions of cartilage are to reduce friction between articular surfaces, absorb shocks, and reduce stress on joint surfaces. Where in the human body is cartilage found?

between the ribs, covering elbow joints & between the vertebrae - Types of cartilage include costal cartilage, which connects the ribs and sternum; semilunar cartilage, which is one of the cartilages of the knee joint; fibrous cartilage, found between the vertebrae (intervertebral disks); and elastic cartilage, found in the larynx, epiglottis, and outer ear.

The type of traction in which a pin, wire, tongs, or other device is surgically inserted through a bone is:

skeletal traction. - Skeletal traction exerts pull directly on skeletal structures by means of a pin, wire, tongs, or other device surgically inserted through a bone. Skin traction applies pull on tape, rubber, or a plastic material attached to the skin, which indirectly exerts pull on the musculoskeletal system. Examples of skin traction are Bryant traction, Buck extension traction, and Russell traction.

A client is experiencing pain, joint instability, and difficulty walking due to an injury to the knee ligaments. The injury was judged not to require surgery. Which intervention would not be included in this client's care?

traction - Joint immobilization, limited weight bearing, ice, and NSAIDs would be included in the initial treatment. Traction is not required because there is no break, and surgery is not required.

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

"Change your shoes from high heels to flats." - Balance changes during pregnancy. Wearing high heels places the woman off balance and can lead to falls. They can also lead to leg fatigue and increased swelling. Low heel or flat-heeled shoes are more appropriate for correct balance. When traveling in a car, the shoulder belt should cross between the breasts and over the upper abdomen, above the uterus. The lap belt should cross over the pelvis below the uterus. The steering wheel should be positioned as best as possible away from the uterus. Going to the gym every day is good exercise for the pregnant client, but the purpose is not for balance. Exercise promotes a sense of well-being, improves circulation, helps reduce constipation, and promotes muscle strength, tone, and endurance. For the working pregnant client, it is recommended to take two 10-15 rest periods in an 8-hour workday.

The nurse is caring for a client diagnosed with osteoarthritis (OA). What does the nurse teach the client about the disease?

"OA is a disease of the weight-bearing joints." - OA is a slowly progressive destruction of articular cartilage of weight-bearing joints and fingers of older adults and the joints of younger people who have experienced trauma.

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?

Prevent internal rotation of the affected leg. - The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.

The nurse is caring for a client who has recently developed psychomotor retardation. Based on this information, which behavior would the nurse expect to see in this client?

Slowness of body movements - Slowing of thought processes and bodily movements is referred to as psychomotor retardation. Repeated tapping of foot is referred to as automatism which is often caused due to anxiety. Speaking words that are only meaningful to the client and nobody else is referred to as neologisms. Maintenance of an awkward posture for a long time is an abnormal behavior and is referred to as waxy flexibility.

Fall prevention in older adults should focus on which types of exercise?

Strength building and balance - Fall prevention in the older adults should focus on strength and balance exercises and vitamin D supplements to improve mobility and bone strength. Swimming and brisk walking are examples of aerobic exercise, while stretching is an example of a flexibility exercise.

An adult is swinging a small child by the arms, and the child screams and grabs his left arm. It is determined in the emergency department that the radial head is partially dislocated. What is this partially dislocated radial head documented as?

Subluxation - A partial dislocation is referred to as a subluxation. A Volkmann's contracture is a claw like deformity that results from compartment syndrome or obstructed arterial blood flow to the forearm and hand. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space and affects nerve innervation, leading to subsequent palsy. A sprain is injury to the ligaments surrounding the joint.

A nurse is caring for a client who injured her knee while playing basketball. Tests reveal a torn connective tissue that connects muscles to bones. Based on this finding, the nurse prepares to teach the client about which anatomical structure that is injured?

Tendons -Tendons and ligaments are dense connective tissue structures that connect muscles and bones. Tendons connect muscles to bones and ligaments connect the movable bones of joints.

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. - The client has spinal bifida with a myelomeningocele (protrusion of the spinal cord and meninges). Surgery is completed within the first days of life. Following surgery and in the recovery period, it is most important to maintain meticulous care to the incision to reduce the potential for infection. Infection can spread through the incision and up the spinal tract to the brain. All other goals are important but not as great a priority as infection.

A female client is diagnosed with Parkinson's disease and is having difficulty performing her activities of daily living. Her health care provider orders pramipexole. Pramipexole may be used alone for which purpose? To improve motor performance and improve ability to participate in usual activities of daily living

To improve motor performance and improve ability to participate in usual activities of daily living - Pramipexole (Mirapex), ropinirole (Requip), and rotigotine-transdermal (Neupro) stimulate dopamine receptors in the brain. They are approved for both beginning and advanced stages of Parkinson's disease. In early stages, one of these drugs can be used alone to improve motor performance, improve ability to participate in usual activities of daily living, and delay levodopa therapy.

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?

Weakness on one side of the body and difficulty with speech - The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.

The nurse is encouraging a client to cough frequently and complete deep breathing exercises. The nurse knows that many factors can cause a decrease of gas exchange for clients. Based on this information, what factors can cause a decrease in gas exchange? Select all that apply.

immobility thoracic/pulmonary surgery pneumonia - Many factors can cause a decrease in gas exchange, including immobility, thoracic/pulmonary surgery, or pneumonia. Encouraging frequent coughing and deep breathing exercises should assist in improving oxygen delivery to the lungs and tissues. Certain portions of the brain stem are particularly sensitive during infancy; neurons can be destroyed if the child is shaken violently or dropped. This results in "shaken baby syndrome" and can lead to death.

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse?

positioning a friction-reducing sheet under the client to facilitate movement - After placing the bed in a comfortable working position (usually elbow height of the caregiver), position a nurse on either side of the bed, place a friction-reducing sheet under the client, and use the leg muscles to pull the client to the side.