Chapter 8 Quiz 4

Alignment

The relationship of various body parts to each other.

Dorsiflexion

To bend or flex backward.

Which assistive device *allows patients to pull with the upper extremities to raise their trunk off the bed, to assist in transfer from bed to wheelchair, and to perform upper arm exercises?*

Trapeze bar

Active assisted ROM

When patient uses the strong arm to exercise the weaker or paralyzed arm.

Musculoskeletal disorder (MSDs)

Work injuries due to improper body mechanics, back injuries prominent among healthcare workers

Which of the following would NOT be used to promote venous circulation and prevent the development of deep vein thrombosis in the legs? Sequential Compression Device Thromboembolic Disorder stockings (TEDs) ACE wraps to the lower extremities An abductor wedge

An abductor wedge

The nurse explains to the patient that the log-rolling technique will be used to help the patient change position. The patient asks why this is necessary. Which response is accurate?

"It is important to keep your neck and spine in straight alignment while we help you move onto your side." (maintains body alignment, preventing stress on any part of the body)

what instructions should the nurse give to a new home health aid about helping the patient who has problems with immobility

-Assist the patient to make slow, gradual position changes -If the patient has orthostatic hypotension, assist him to return to bed and call the provider -If the patient becomes dizzy or faint when walking, ease him to the floor or chair - Be sure the home is free of clutter, wet areas or rugs that may slide

What is a necessary safety precaution when helping a patient who has an unsteady gait to ambulate? (Select all that apply)

-Have patient wear well-fitting nonskid shoes or slippers -Have at least two people present to assist the patient -Use a gait belt when assisting the patient to stand and to ambulate (nonskid shoes or slippers help maintain balance, having two people there to help if the patient begins to fall, gait belt help to assist with balance)

Correct use of body mechanics

-Maintain appropriate body alignment -Maintain wide base of support- feet apart -Bend knees and hips -Do not bend at the waist -Hold objects close to you -Face the object Head erect

What is a major benefit of *active ROM exercises?* (Select all that apply)

-Preventing contractures -Maintaining joint movement and mobility -Preventing atrophy of muscle near the joints -Increasing the patient's self-esteem and motivation (Active ROM- preformed by patients)

A patient becomes faint sitting on the side of the bed. To prevent injury to the patient and nurse, which action should the nurse take? (Select all that apply)

-The nurse should call for assistance -The nurse should lay the patient straight back and support the head (assist to the floor and call for help)

For an older female who is at risk for *osteoporosis*, which associated complication can be minimized by participating in a regular exercise program as prescribed by the health care provider? 1. Bone loss that results in fractures 2. Immobility secondary to joint degeneration 3. Tissue ischemia and pressure ulcers 4. Thrombophlebitis secondary to blood clots

1. Bone loss that results in fractures Patients who are at risk for osteoporosis should be encouraged to exercise. This strengthens bones and reduces the risk for fractures. The other complications are more related to mobility

Which patient has a *contracture*? 1. Patient has abnormal extension of a finger joint 2. Patient's wrist is abnormally flexed and joint is fixed 3. Patient's knee is hyperextended 4. Patient has abnormal lateral movements of ankle joint

2. Patient's wrist is abnormally flexed and joint is fixed (Abnormal shortening of muscle tissue. The wrist can not be flexed like a normal wrist. Frequent stretching of joints and muscles decreases contractures)

The patient has had a surgical procedure and is getting up to ambulate for the first time. While ambulating down the hallway, the patient says "I'm going to faint". What should the nurse do first? 1. Call out for someone to obtain a wheelchair 2. Pull the patient close and lower him gently to the floor 3. Lean the patient against the wall until the episode passes 4. Support the patient and move quickly back to the room

2. Pull the patient close and lower him gently to the floor (never try to prevent the fall, assist them to the floor and then call for help)

When assessing the neurovascular status of a patient, what is an expected finding? 1. Capillary refill after 8 seconds 2. Pulses strong and easily palpated 3. Loss of sensation to an affected area 4. Mild localized discomfort

2. Pulses strong and easily palpated (other expected findings: normal skin color, warm skin, ability to move, no numbness or tingling, no loss of sensation, normal cap refill and no pain)

The nurse is working with a patient who has poor balance to move from the bed to the chair. What is included in the correct technique for assisting the patient to stand and pivot the chair? 1. Keep the knees slightly bent 2. Maintain a narrow base with the feet 3. Keep the stomach muscles loose 4. Stand arm's length from he patient

1. Keep the knees slightly bent (Prevents hyperextension. All other options are bad body mechanics)

Which position would be most comfortable for the patient and provide the best access for the nurse to *insert a rectal suppository?* 1. Sims 2. Lithotomy 3. Trendelenberg 4. Orthopneic

1. Sims (lies on side with knee and thigh up towards the chest)

The range of motion (ROM) that can be safely performed on the neck includes: (select all that apply) 1. flexion 2. supination 3. lateral flexion 4. rotation 5. hyperextension

1. flexion 3. lateral flexion 4. rotation ( Flex: chin to chest, lateral flex: ear to shoulder, Rotation: head in a circle)

The patient experienced a cerebrovascular accident (CVA) that left her with severe left-sided paralysis and very limited mobility. Which device would *prevent plantar flexion?* 1. Footboard 2. Bed board 3. Trapeze bar 4. Trochanter roll

1. footboard (Maintain the foot in dorsiflexion position)

Which patient behavior should be corrected to reduce the risk of thrombophlebitis? 1. Patient gets out of bed and forgets to put on slippers 2. Patient sits in a chair and crosses legs while reading a book 3. Patient forgets to rise slowly when getting out of bed 4. Patient sits in a slouched position on a soft couch

2. Patient sits in a chair and crosses legs while reading a book. (Inflammation of the Thrombo- blood clot in the Phleb- vein. Blood clot- avoid crossing legs and prolonged immobility)

Patients who are immobilized in health care facilities require that their psychosocial needs be met along with their physiologic needs. Which statement by the nurse acknowledges these needs? 1. "Visiting hours will be limited so you can rest." 2. "We will help you do everything so you don't have to worry." 3. "Let's talk about what you used to do at home during the day." 4. "A private room can be arranged for you."

3. "Let's talk about what you used to do at home during the day." (Theyre physical needs are being met by the help of the nurse- ADLs- and theyre emotional and mental- wellbeing needs are being met by talking about what theyre usual routine is)

Which medications are most likely to contribute to *orthostatic hypotension?* 1. Medications used to treat osteoporosis 2. Medications to prevent thrombophlebitis 3. Medication to reduce high blood pressure 4. Medications to treat arthritis pain

3. Medication to reduce high blood pressure ( patients who use meds to reduce BP are at greater risk for Orthostatic Hypotension)

The nurse is preparing to assist the patient to transfer from the bed to the chair. Which action demonstrates the proper use of body mechanics? 1. Stands by the chair and reaches out to guide the patient towards the chair 2. Stands by the side of the patient and pulls up on the stronger arm 3. Stands directly in front of the patient and places hands at the patients waist level 4. Stands to the side of patient and assists as the patient pivots

3. Stands directly in front of the patient and places hands at the patient's waist level (Face your work area- prevents unnecessary twisting)

The patient will be immobilized for an extended period due to extensive injuries. Which intervention will the nurse use to prevent *respiratory* complications? 1. Suction the airway every hour 2. Change the patient's position every 4-8 hours 3. Use oxygen and nebulizer treatments regularly 4. Encourage deep breathing and coughing every hour

4. Encouraging deep breathing and coughing every hour. (This promotes chest expansion and will get any mucous out of the chest)

A nurse walks into a patients room and notices that the patient is having trouble breathing. Which position will the nurse immediately use to help relieve the patients respiratory distress? 1. Lower the head of the bed and place the patient in a supine anatomical position. 2. Position the patient on the side with the knee and thigh drawn up towards chest. 3. Lower the patient's head and place the body and legs on a slightly inclined plane. 4. Raise the head of the bed to 45-60 degrees and with the head in an anatomical position.

4. Raise the head of the bed to 45-60 degrees and with the head in an anatomical position. (Put the bed in Fowler's position so theyre sitting up in bed)

What is the most likely complication if an elderly patient gets pulled across the bed when changing wet linens? 1. Dislocation of the joint 2. Increased stress to the joints 3. Abnormal hyperextension of a joint 4. Shearing or tearing of the skin

4. Shearing or tearing of the skin (older adults skin is very fragile and susceptible to injury. Pulling them across a bed will cause a skin tear or shearing)

Which of the following can cause acute compartment syndrome (SELECT ALL THAT APPLY)? A cast applied to treat a fractured wrist Excessive bleeding into the tissue The client's legs being kept in abduction A tightly wrapped dresssing applied to the leg Placing loose fitting stockinette on the client's arms to protect fragile skin

A cast applied to treat a fractured wrist Excessive bleeding into the tissue A tightly wrapped dresssing applied to the leg

The nurse is assigned to care for an 82-year-old patient who weighs 252 lb and has undergone a bilateral below-the -knee amputation. Which transfer method is the safest for the patient and the nurse?

A mechanical lift with a sling (For full weight lifting of patients, because she had an amputation, who cannot assist in helping must use a mechanical lift)

Base of support

A stance with feet shoulder width apart.

Physical disuse syndrome

A state in which an individual is at risk for deterioration of body systems due to prescribed or unavoidable inactivity.

Mobility

Ability to move around freely in his or her environment.

contracture

Abnormal, usually permanent condition of a joint characterized by flexion and fixation and caused by atrophy and shortening of muscle fibers.

A client who had a cerebrovacular accident (CVA or stroke) has weakness in his right arm but his left arm was not affected. The physical therapist instructs the client to use his right arm to provide range-of-motion (ROM) exercises to his weaker left arm. What type of ROM does this describe?

Active assisted ROM

Joint

Any one of the connections between bones.

The patient has a cast on the left lower leg. Which assessment is performed to prevent compartment syndrome?

Asses skin color, temperature, movement, sensation, pulses, capillary refill, and pain

A 56-year-old patient had an open cholecystectomy (removal of gallbladder). The nurse is going to assist the patient with *dangling* on the side of the bed before ambulation. After sitting him on the edge of the bed, which nursing intervention should the nurse perform before proceeding with the ambulation?

Assessment of his pulse and respirations (Provide baseline for assessing patients response to dangling)

The nurse weighs 106 pounds. According to the National Institute for Occupational Safety and Health (NIOSH) Division of Safety research, what is the maximum weight she should safely lift? 1. Depends on the nurse's health and personal strength 2. No more than 35 pounds of the patient's weight 3. No more than 35% of her own 106 pounds 4. Maximum of 50 pounds regardless of patient's or nurse's weight

B. No more than 35 pounds of the patient's weight. (no matter what the nurse weighs)

Compartment syndrome

Compression from external devices, such as casts and bulky dressings which has the potential to cause extensive tissue damage. (pressure in a given part of the body that disrupts circulation and function of tissues in that compartment)

It is the patient's first night after an abdominal hysterectomy. She has not voided for 9 hours, and the nurse is to insert a 16Fr. Foley catheter into her bladder. What patient position best allows insertion of the catheter?

Dorsal recumbent (lying on back with head and shoulder extremities flexed and sometimes legs flexed)

In order to prevent footdrop, the client should wear some sort of a splint/brace that keeps the foot in which position?

Dorsiflexion

An 82-year-old patient has had a cerebrovascular accident that affects her right side, placing a pillow between her legs and another to her back. What is the primary purpose of this intervention?

Ensuring the patient's proper body alignment. (Pillows between the legs and along her back will provide support of body or extremity and keep the body aligned)

A 72-year-old patient with a stroke has slid to the foot of the bed. With use of appropriate body mechanics, the nurse maintains a *wide base of support and faces the patient in the direction of movement.* What do these actions allow the nurse to do?

Exert less physical effort

Hyperextension

Extreme or abnormal extension.

A resident at a long-term care facility has difficulty transferring and needs one assist to stand-pivot to a wheelchair. Which device should the staff member use when transferring this resident in order to be safe during the transfer?

Gait belt

Which health care facility is using evidence based practice to protect patients and health care workers from musculoskeletal injuries

Has a mechanical lift available for use; there is at least an 80% compliance rate and nurses and UAP are trained in the use of devices

Supination

Kind of rotation that allows palm of hand to turn up.

Prone

Lying face down in horizontal position.

When using a lift sheet to assist in moving a patient in bed, what should the nurse ask the patient to do?

Maintain a straight body position

Foot boards

Maintain feet in dorsiflexion, which prevents plantar flexion (foot drop)

**The student nurse demonstrated principles of good body mechanics with which activity?

Maintaining a wide base of support and bending at the knees.

Flexion

Movement of certain joints that decreases angle between two adjoining bones.

Extension

Movement of certain joints that increases angle between two adjoining bones.

Abduction

Movement of limb away from body.

Adduction

Movement of limb toward axis of body.

Range of motion

Movement of the body that involves the muscles and joints in natural directional movements.

Which nurse is using the key factor in body mechanics

Nurse D keeps head erect and aligns and balances weight on both feet when assisting a patient stand up (maintenance of appropriate body alignment is the key factor in proper body mechanics)

Passive assisted ROM

Nurse assists patient with full ROM

Two-point gait

One crutch and opposite extremity move together followed by opposite crutch and extremity

The nurse is assigned to care for a 64-year-old patient who was admitted for exacerbation of chronic obstructive pulmonary disease and pneumonia. He has dyspnea and is *unable to rest in a supine position.* The nurse elevates the head of the bed to *90 degrees, places a pillow on the overbed table, and assists the patient to lean forward, placing his head on the pillow.* What position should the nurse document the patient as being in?

Orthopneic. difficult or painful breathing except in an erect sitting or standing position. (position assumed by the patient sitting up in bed. Facilitates ease of breathing- COPD)

Pronation

Palm of hand turned down.

Which patient us the most likely candidate for active assisted ROM

Patient C has right side weakness in the upper body due to stroke

Genupectoral

Patient kneels so that weight of body is supported by knees and chest, with abdomen raised, head turned to one side, and arms flexed. (Genu- means knees and Pectoral- means chest. Patient puts all their weight on their knees and chest while in prone position)

Lithotomy

Patient lies supine with hips and knees flexed and thighs abducted and rotated externally. (GYNO and child birth

Trendelenburg's

Patient's head is low and the body and legs are on inclined plane. Used to assist in venous distention during central line placement

The nurse receiving a report on a patient. The nurse giving the report states that the patient has *foot drop*. The nurse receiving the report knows that which is the correct terminology for foot drop?

Plantar flexion of the foot (foot drop boots keep the foot in dorsiflexion position to prevent this)

platform walker

Platform walkers are used for patients who cannot grasp the handlebars or bear their weight on their hands. With some platform walkers, patients' rest their forearms on a support table. With other platform walkers, patients' forearms are strapped into platforms that are attached to the sides of the walker. With both types of platform walkers, patients bear their weight on their forearms.

Sims'

Position in which patient lies on side with knee and thigh drawn upward toward chest. Left position is appropriate for enema procedure and administration of rectal suppository

Dorsal (supine)

Position lying flat on the back.

Fowler's

Posture assumed by patient when head of bed is raised 45 to 60 degrees.

Semi-Fowler's

Posture assumed by patient when head of bed is raised approximately 30 degrees.

Orthopneic

Posture assumed by the patient sitting up in bed at a 90-degree angle, or sometimes resting in forward tilt while supported by pillow on over bed table.

Trochanter roll

Prevents external rotation of legs when patient is in supine position; possible to make with a towel

In which position is the patient *lying face down or chest down?*

Prone

A patient has been immobilized for 5 days because of extensive abdominal surgery. When the patient is helped out of bed for the first time, which nursing diagnosis related to safety applies to this patient?

Risk for activity intolerance. (the patient may be too weak to tolerate the actions of getting out of bed)

the nurse has a previous back injury and knows that she should avoid twisting her spine as she cares for patients. What is the best strategy for the nurse to use

Stand directly in front of the person or object being worked with

Dorsal recumbent

Supine position with patient lying on back, head, and shoulder with extremities moderately flexed; legs are sometimes extended. (THIGHS ARE NOT ABDUCTED)

The nurse helps ambulate an 84-year-old female patient who has peripheral vascular disease that caused a severe stasis ulcer. The patient becomes very weak, reports feeling faint, and begins to fail. What is the most appropriate action to prevent injury to the patient?

Support her while she is falling and allow her to sit on the floor. (Easing the patient to the floor allows the nurse to break the fall, control its direction and protect the patients head. Never try to prevent the fall because you will get hurt)

Body mechanics

The area of physiology for the study of muscle action and how muscles function in maintaining the posture of the body and prevention of injury during activity.

Immobility

The inability to move around freely.

The patient accidentally knocks the emesis basin to the floor. When picking up the emesis basin, which movement demonstrates *proper body mechanics* by the nurse?

The nurse lowers the body by flexing the knees and bending the hips. (Picking something up.)

An older adult patient has been lying in the supine position for 3 hours and tells the nurse that she is too uncomfortable to move right now. What is the best response by the nurse?

The nurse should assess the patient's need for pain medication before helping her change position. (she doesn't want to move because shes in pain)

The physical therapist instructs a client on the use of crutches for ambulation. The client is able to bear weight on both lower extremities, but has bilateral lower extremity weakness and pain. Which crutch gait pattern would NOT be necessary for the physical therapist to teach to this client? two-point gait A swing-to approach A four-point gait A three-point gait

a three point gait

abductor wedge

designed to separate the legs of a patient. It is often used after hip surgery to prevent the new hip from "popping out".

The nurse and a UAP are to move a *dependent patient* from the supine to the lateral position (back to side position). Which action should be performed first?

ensure that the upper arm and leg are supported with pillows (Pillows under the arm and leg will provide support of body or extremity and keep the body aligned)

Continuous Passive Motion

flex and extend joints for passive mobilization without the strain of active exercises; frequently used after total knee replacement surgery

Straight Cane

minimal assistance

Early sign of acute compartment syndrome

pain upon stretching (other symptoms: tingling and burning or a feeling of pins and needles in affected area, full or tight feeling in the muscle)

The nurse is helping plan an activity schedule for an older adult resident at a long term care facility who is at risk fir disuse syndrome. which plan is the nurse most likely to suggest

patient participate in ADLs for 10-15 minutes every 2-3 hours while awake for a total of 2 hours of activity per 24 hours (the amount of activity require to prevent disuse syndrome- a state in which an individual is at risk for deterioration of body systems as a result of inactivity- is only 2 hours for every 24 hour period)

A 65 year old female client sustained multiplier fractures in a motor vehicle crash. She fractured bones in both wrists and in her right lower leg. Her weight bearing status has been changed from non-weight bearing to the right lower extremity and both upper extremities after having a follow up appointment with the orthopedic surgeon. The new weight bearing status is to be weight bearing as tolerated to the right lower extremity and weight bearing through the forearms/ elbows for her upper extremities. Which assistive device would allow the client to be able to walk with these restrictions being maintained?

platform walker

Standard crutches

remove weight from one leg. Patients who must transfer more weight to their arms than is possible with a cane

three point gait

requires the patient to bear all of the weight on one foot. The patient bears weight on both crutches then on the uninvolved leg, repeating the sequence.

standard walker

requires the person to have fair balance and the ability to lift device with upper extremities to advance

Ergonomics

the design of work tasks to best suit the capabilities of workers. (example: using mechanic lifts for patients who cant assist to prevent back injuries)

a swing to approach (crutch)

used by patients whose lower extremities are paralyzed or who can wear supporting brace on their legs. it requires ability to partially bear weight on both legs

Four-point gait

used when both legs can bear some weight; right foot, left crutch, left crutch, right foot