PN Mobility Assessment 2.0

a nurse is discussing proper body mechanics w/a group of assistive personnel. which of the following information should the nurse include? (select all that apply) -a stable center of gravity increases stability & balance -a wide base lowers the center of gravity -proper body alignment involves tightening the abdomen -leaning slightly back while carrying an object equalizes the center of gravity -bending at the waist when picking up objects stabilizes the spine

-a stable center of gravity increases stability & balance -a wide base lowers the center of gravity -proper body alignment involves tightening the abdomen

a nurse is assisting w/a skin assessment for a client who has a wound on their heel that is blistered & lighter in color than the client's skin tone. the nurse should identify that the wound is in which of the following stages of damage? -damage into the skin layer -damage beyond the skin layer -deep damage through the skin & tissue -damage w/the skin intact

-damage into the skin layer

a nurse is collecting data from a client who had a stroke & is immobile. the nurse should identify that the client is at risk for which of the following conditions? -deep vein thrombosis (DVT) -asthma -hernia -hypertension (HTN)

-deep vein thrombosis (DVT)

a nurse is assisting w/performing a focused assessment on an older adult client's mobility. which of the following findings should indicate to the nurse that the client is experiencing an age-related change to their musculoskeletal system? -increased curvature of the thoracic spine -reduced depth perception -narrower stance when standing -quick steps when ambulating

-increased curvature of the thoracic spine

a nurse is reinforcing w/a client who has kyphosis. which of the following information should the nurse include? -kyphosis is when the upper back extends posteriorly to the lower back -kyphosis is an inward curvature of the lower back -kyphosis is a sideways curvature of the spine -kyphosis is a rounded upper back w/the pelvis tilted forward

-kyphosis is a rounded upper back w/the pelvis tilted forward

a nurse is preparing to transfer a client from a bed to wheelchair. which of the following actions by the nurse demonstrates proper use of body mechanics? -twisting the torso when transferring the client -bending at the waist when transferring the client -placing the bed in the high position before transferring the client -looking at the client face-to-face when transferring the client

-looking at the client face-to-face when transferring the client

a nurse is assisting w/preparing a presentation about muscle function for a group of newly licensed nurses. which of the following information should the nurse plan to include? -muscles store calcium & magnesium -muscles produce RBCs & platelets -muscles assist w/thermoregulation in the body -muscles provide protection of internal organs

-muscles assist w/thermoregulation in the body

a nurse is caring for a client who requires assistance w/ADLs. which of the following referrals should the nurse recommend for this client? -speech therapist -physical therapist -respiratory therapist -occupational therapist

-occupational therapist

a nurse is assisting in the care of a client who is at risk for developing atelectasis. which of the following actions should the nurse take? -reposition the client every 2 hrs while in bed -remind the client to use the incentive spirometer -obtain the client's weight daily -encourage the client to eat food that are high in fiber

-remind the client to use the incentive spirometer

a nurse is assisting w/completing the bedside mobility assessment tool (BMAT) for a client & determines that the client is at level 1 mobility. the nurse should identify that the client is unable to perform which of the following tasks? -walk in place -stand in place for 5 seconds -sit on the edge of the bed for 1 min -step forward & backward

-sit on the edge of the bed for 1 min

a nurse is preparing to lift a heavy object off the floor. in which order should the nurse perform the following steps to demonstrate the proper use of body mechanics? (put steps in order) -look straight ahead w/shoulders raised up -keep abdominal muscles contracted & the lower back's straight -stand as close to the object as possible -bend hips slightly & squat -push up from the knees when lifting the object

-stand as close to the object as possible -keep abdominal muscles contracted & the lower back's straight -look straight ahead w/shoulders raised up -bend hips slightly & squat -push up from the knees when lifting the object

a nurse is reinforcing teaching w/a client who injured their ankle. which of the following information should the nurse include? -cartilage is always remodeling & changing -tendons connect muscle to bone -ligaments are flexible connective tissue that coat bony areas -synovial joints attach to the skeleton to maintain posture

-tendons connect muscle to bone

a nurse is evaluating a client who has a broken leg & is using crutches. which of the following actions by the client demonstrates proper use of the crutches? -the hand grips of the crutches are at the level of the client's umbilicus -the client's elbows are bent 45 degree when holding the crutches -the client places their weight on their axilla when using the crutches -the client has the crutches resting 5cm (2 in) below their axilla

-the client has the crutches resting 5cm (2 in) below their axilla

a nurse is assisting w/preparing a presentation for a group of clients who are scheduled for joint replacement surgery. which of the following information should the nurse plan to include regarding flexion of a joint? -synovial joints contain sensory receptors that trigger flexion -the contraction of a muscle results in flexion of a joint -neurotransmitters coordinate w/cartilage to initiate flexion -ligaments extend to enable flexion of a joint

-the contraction of a muscle results in flexion of a joint

A nurse is reinforcing teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include? -the top of the walker should be at the level of your wrist -when using the stairs, place the walker before taking a step -when holding the walker, bend your elbows 30 degrees -take a step 1st before moving the walker

-the top of the walker should be at the level of your wrist

A nurse is assisting in the care of a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client? -gait belt -mechanical lift -cane -sit-to-stand lift

Mechanical lift

A nurse is assisting w/teaching in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include? -the use of ergonomics improves blood circulation in the body -the use of ergonomics eliminates cost related to workers' compensation -the use of ergonomics increases job satisfaction -the use of ergonomics maintains the body's balance & a lower center of gravity

The use of ergonomics increases job satisfaction

a nurse in a long-term care facility is caring for an older adult client & notes their muscles have become smaller & weaker. which of the following should the nurse suspect the client is experiencing? -sarcopenia -disuse osteoporosis -atrophy -joint contracture

atrophy

a nurse is caring for a client who had a stroke & reports difficulty w/preprioception. the nurse should plan to collect data from the client for which of the following? -restricted movement due to abnormal fixation of a joint -a drop in blood pressure that occurs w/a change in position -altered gait w/dragging of the toes while ambulating -diminished awareness of body position & balance

diminished awareness of body position & balance

a nurse is collecting data about a client's mobility & notes one of the client's feet is dragging behind them when ambulating. which of the following conditions should the nurse suspect the client is experiencing? -atrophy -foot drop -joint contracture -disuse osteoporosis

foot drop

a nurse is contributing to the plan of care for a client who is postoperative. in which of the following positions should the nurse place the client to prevent atelectasis? -fowler's -lateral -prone -supine

fowlers

a nurse is caring for a client who requires maximum assistance transfer from the bed to a chair. which of the following pieces of equipment should the nurse use? -pivot disc -mechanical lift -sit-to-stand lift -gait belt

mechanical lift

a nurse is assisting w/preparing a poster presentation about the musculoskeletal system. the nurse should include that which of the following is responsible for body posture -center of gravity -bones -muscles synovial joints

muscles

a nurse is caring for a client who has pneumonia. in which of the following positions should the nurse place the client to promote postural drainage? -lateral -supine -prone -fowler's

prone

A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL? -toileting -writing -ambulating -talking

toileting