FN - Unit 2 - Chapter 34: Activity

The nurse is caring for a client who works in a warehouse and has been having low back pain. Which statement by the client indicates the need for more education regarding safe lifting? "I hold the boxes away from my body so I do not drop them on my feet." "I stand with my feet apart so I have a better stance when I lift." "I bend with my knees when I pick up boxes." "I try to rest between periods of lifting."

"I hold the boxes away from my body so I do not drop them on my feet." Heavy objects should be held close to the body to distribute the weight evenly and prevent muscle strain. The other statements are correct lifting techniques.

As a part of his workout regimen, a 21-year-old college football player often engages in squats and lateral arm holds. These are examples of what type of exercise? isotonic aerobic isometric anaerobic

isometric Isometric exercise isolates a specific muscle or muscle group and exercises it by holding the muscle steady and maintaining tension.

The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include? helping the client change positions every 4 hours placing the client in good alignment with joints slightly flexed providing skin care before repositioning using a sheet to drag and lift the client

placing the client in good alignment with joints slightly flexed The inactive client should be repositioned every 2 hours with the use of a low-friction fabric or gel-filled plastic sheet and then placed in good alignment with joints slightly flexed. Skin care should be provided after repositioning.

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device? A client who has leg strength and can cooperate with the movement A client who has an abdominal incision A client with a thoracic incision A client who is confined to bed rest

A client who has leg strength and can cooperate with the movement The gait belt is used to help the client stand and provides stabilization during pivoting. Gait belts also allow the nurse to assist in ambulating clients who have leg strength, can cooperate, and require minimal assistance. A gait belt is not used on clients who have either an abdominal or thoracic incision. A gait belt would not be used on a client who is confined to bed rest.

The nurse observes a client independently move all the joints through their normal motions. Which range of motion has the client demonstrated? Active range of motion Passive range of motion Active assistive range of motion Limited range of motion

Active range of motion When the client does the exercise for himself or herself, it is referred to as active range of motion. Exercises performed by the nurse without participation by the client are referred to as passive range of motion. A client demonstrates active assistive range of motion when he or she performs the exercise exerting the muscles but also receives assistance from the nurse. Limited range of motion means that the limb involved lacks full, normal range of motion at a joint.

dorsiflexion of the feet

Assisting and observing the client perform dorsiflexion of the feet helps to reduce the risk of foot drop. Foot drop can occur if the toes of the feet are dropped downward for extended periods of time resulting in plantar flexion caused by changing the length of the muscles. Due to the gravitational pull, this position of the feet occurs naturally when the body is at rest and the toes are placed in a perpendicular position making heel-toe gait impossible. This results in altered mobility. Wearing shoes such as a high-top canvas sneaker could assist to minimize this complication of prolonged bed rest.

A nurse is promoting exercise and activities for an older adult client. Which teaching point would be appropriate for this client? Encourage the client to quickly increase the repetitions for arm and leg exercises. Encourage the client to warm up before beginning exercises and to cool down after exercising. Instruct the client to continue exercise even if feeling weak, to build up stamina. Teach the client to force joints to meet their natural limit and beyond prior to modifying exercises.

Encourage the client to warm up before beginning exercises and to cool down after exercising. The client should be encouraged to develop an exercise program that specifies warm-up and cool-down activities (walking, stretching). The client should not be encouraged to quickly increase the repetitions for arm and leg exercises. The client should not continue to exercise when feeling weak; this could lead to injury. The client should not be taught to force joints to meet their natural limit and beyond prior to modifying exercises. This could lead to injury.

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager? Equipment is positioned to the side, 50 degrees away. Chairs have firm back support and allow the feet to touch the floor. A small dolly is used to transport heavy items. Work is being carried out under sources of non-glare lighting.

Equipment is positioned to the side, 50 degrees away. Proper ergonomics promote comfort, performance, and health in the workplace. All findings support proper ergonomics, with the exception of equipment positioning. Equipment should be positioned 20 to 30 degrees away, in front, not off to the side, to avoid turning or twisting of the head, neck, and shoulders.

The nurse is assisting with client transfer. Which guideline(s) will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply. Ensure that the client's bedrails are up prior to transfer. Lower the bed to the lowest position allowing the client's soles to contact the floor. Provide the client with nonskid slippers to put on prior to standing up. Make sure the client's weaker leg is nearest to the chair. Provide step-by-step instructions to the client before the transfer begins.

Lower the bed to the lowest position allowing the client's soles to contact the floor. Provide the client with nonskid slippers to put on prior to standing up. Provide step-by-step instructions to the client before the transfer begins. Lowering the bed to the point where the client is able to touch the ground allows the client to be as stable as possible prior to standing up. Having the client wear nonskid slippers prevents the client from slipping and falling during the transfer. Providing step-by-step instructions to the client allows the nurse to solicit the client's help as much as possible. This action informs the client, encourages self-help, and reduces the workload/burden on the nurse. The nurse should ensure the bedrails are down prior to starting the transfer. Having these up will obstruct movement and make the transfer more difficult. Since the client is not lying in bed, the bedrails do not need to be up for client safety. The client's strongest leg should be positioned closest to the chair to provide stability and prevent a fall as the client moves to lower oneself into the chair.

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight? Shift their weight back and forth from the legs to the back muscles. Rock the client back and forth to raise the client up in bed. Turn the client from side to side while pushing upward. Shift their weight back and forth, from back leg to front leg.

Shift their weight back and forth, from back leg to front leg. The nurses would use a rocking motion to counteract the client's weight. The nurses would shift their weight back and forth, from back leg to front leg, count to three, and then move the client up toward the head of the bed. Rocking the client or turning the client from side to side is not used to move a client.

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? supine prone Sims' Fowler's

Sims' Sims' position, a semi-prone position, can be used for certain examinations of the rectum and vagina. The other positions do not allow adequate examination of this area.

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education? When I lift and carry a heavy box of supplies I will keep it at arm's length from my body. When lifting an object, I will keep my feet shoulder width apart. When lifting an object, I will bend at the knees instead of the waist. When I lift an object, I will get close to the object being lifted.

When I lift and carry a heavy box of supplies I will keep it at arm's length from my body. The nurse teaching a group of UAPs about proper body mechanics recognizes the need for additional education when a class participant states that, when lifting and carrying a heavy box of supplies, the UAP will keep it at an arm's length from body. This motion will result in injury and the UAP should be instructed to keep items close to the body. The UAPs should lift an object with feet shoulder width apart by bending at the knees instead of the waist and getting close to the object being lifted. These actions reflect the correct understanding of proper body mechanics.

The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change? reports of pain in the lower back decrease in flexibility stumbling gait unequal pupil size

decrease in flexibility A decrease in the flexibility of joints is a normal age-related finding. Pain in the lower back, stumbling gait, and unequal pupil can be indicators of pathology and are not normal age-related findings.

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: uses the sides of the walker to rise from a chair. places the walker far in front when walking. steps into the walker when walking. leans over the walker when walking.

steps into the walker when walking. A walker is mechanical aid that enhances the client's balance and ability to bear weight. Education is usually done by physical medicine or physical therapy, but the nurse should continue to assess the client's ability to use the walker properly. The client should step into the walker when walking rather than walking behind it. When the client is rising from a seated position, the arms of the chair, not the walker, should be used for support. The client should be cautioned to avoid pushing the walker out too far in front. Also, the client should avoid leaning over the walker but should instead stay upright while moving.

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep? supine lateral prone Sims'

supine Supine position is recommended as a way to reduce the incidence of sudden infant death syndrome (SIDS) among newborns. The other positions are inappropriate for placing an infant to sleep.

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response? "To preserve the client's functional ability to grasp and pick up objects." "To prevent foot drop." "To help client to turn independently." "To prevent the legs from rotating outward."

"To preserve the client's functional ability to grasp and pick up objects." Trochanter rolls prevent the legs from rotating outward. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop. Side rails help a weak client turn independently and protect the client from falling out of bed.

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response? "To preserve your functional ability to grasp and pick up objects." "To prevent foot drop." "To avoid contractures." "To prevent your legs from rotating outward."

"To prevent your legs from rotating outward." Trochanter rolls prevent the client's legs from rotating outward. The other statements do not describe trochanter rolls. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop.

An older adult client is transferring from a supine position to a sitting position in a chair. The client reports dizziness when transferring. Which teaching by the nurse is most appropriate? "Place your head lower than your heart if you begin to feel dizzy." "Move slowly and sit on the edge of the bed before transferring to the chair." "Place feet firmly on the floor when rising to maintain balance." "Drink a glass of water before attempting to stand to promote circulation."

"Move slowly and sit on the edge of the bed before transferring to the chair." The nurse should allow extra time when older adults are changing their positions, such as from supine to sitting or standing, to prevent orthostatic hypotension. The most important thing is to teach the client is to wait until any dizziness has resolved before moving, thereby decreasing the risk for falls. While lowering the head below the level of the heart is common practice, it is not appropriate for an older client with hypotension. Planting the feet firmly on the floor before standing is to prevent falls, not to address orthostatic hypotension. Drinking water will help fluid volume, but not reduce risk of orthostatic hypotension.

The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include? "Picture yourself with good posture standing; that is how good lying posture works." "Keep knees and legs very straight." "Your feet should be at 45-degree angles from the legs." "Sleep with your head tilted to one side to take pressure off your neck."

"Picture yourself with good posture standing; that is how good lying posture works." The best posture lying down will be the same as standing posture, except the client is horizontal. Knees should be slightly flexed; feet should be at a right angle from the legs; the head and neck muscles should be in a neutral position, centered between the shoulders. It is not correct to say to keep the knees and legs very straight, to position feet at a 45-degree angle from the legs, or to sleep with the head tilted to one side.

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client? "Put on your shirt." "Don't put on your shoes yet." "Put your arm in this sleeve." "Put your pants on and zip the zipper."

"Put your arm in this sleeve." When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions. "Put your arm in this sleeve" gives one step in the process of getting dressed. "Put on your shirt" involves many steps and should be broken down into the steps of putting on a shirt. "Put your pants on and zip the zipper" should be broken down into steps and given in clear, short sentences. Furthermore, putting on pants and zipping a zipper involves many steps and may be too complicated for the client with dementia to follow. Instructions should be phrased positively as the client may not register the "Don't"; the client may put the shoes on if the nurse states "Don't put on your shoes yet."

The unlicensed assistive personnel (UAP) is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response? "You are free to move onto the stretcher without assistance, but I will supervise for your safety." "I can only allow you to transfer without assistance with a health care provider's order, so I will help you now." "You may not transfer without my help, because you need a friction-reducing device to prevent harm to your skin." "That is fine if you want to transfer without my help; ring your call bell after you have transferred and are ready to go."

"You are free to move onto the stretcher without assistance, but I will supervise for your safety." If the client is fully able to assist in the transfer, the nurse should allow the client to complete the movement independently, with supervision for safety. A health care provider order is not necessary for a transfer from a stretcher to a bed. The client can move independently and, therefore, does not need a friction-reducing device. A nurse should remain at the bedside to monitor the transfer.

The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response? "If you recently fell, you might have a fractured hip." "Osteoarthritis is painful and very common as you age." "Because you lose muscle tone with age, it hurts to walk." "You have lost the padding in your joints and the friction causes pain."

"You have lost the padding in your joints and the friction causes pain." Osteoarthritis is a common disorder as people age. It is a noninflammatory, progressive disorder of movable joints (particularly weight-bearing joints) characterized by the deterioration of articular cartilage and pain with motion. Cartilage acts as a shock absorber and provides a smooth surface that reduces friction between the moving parts of the joint. If the client experienced a fall and subsequent hip fracture, mobility would be more impaired. The client would have difficulty walking. Also, this does not address the client's question of why pain accompanies osteoarthritis. Although it is true that osteoarthritis is painful and common as people age, this response does not answer the client's question of why there is pain. Furthermore, while it is also true that loss of muscle tone is common as people age, it may cause weakness, but does not necessarily cause pain with walking.

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly." "Your elbows will be slightly bent when you are using your crutches." "When your crutches fit right, most of your body weight will be supported by your armpits." "We will have the unlicensed assistive personnel watch you while you walk around the unit the first time."

"Your elbows will be slightly bent when you are using your crutches." When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel. The client should stop ambulating and sit down, if fatigued.

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? Adduction Abduction Circumduction Extension

Adduction Adduction is a lateral movement of a body part toward the midline of the body. An example of adduction is when a person's arm is moved from an outstretched position to a position alongside the body. Abduction is a lateral movement of a body part away from the midline of the body. An example of abduction is when a person's arm is moved away from the body. Circumduction is turning in a circular motion. This motion combines abduction, adduction, extension, and flexion. An example of this movement is the circling of the arm at the shoulder, as in bowling or a serve in tennis. Extension is the state of being in a straight line. An example of extension is when a person's cervical spine is extended, the head is held straight on the spinal column.

Which nursing actions would the nurse perform when assisting clients with passive ROM exercises? Select all that apply Raise the bed to the highest position. Adjust the bed to the flat position or as low as the client can tolerate. Begin ROM exercises at the client's head and move down one side of the body at a time. Perform each exercise 10 to 15 times. Move each joint in a smooth, rhythmic manner. Use a flat palm to support joints during ROM exercises.

Adjust the bed to the flat position or as low as the client can tolerate. Begin ROM exercises at the client's head and move down one side of the body at a time. Move each joint in a smooth, rhythmic manner. The nurse would adjust the bed to the flat position or as low as the client can tolerate. The nurse would begin ROM exercises at the client's head and move down one side of the body at a time. The nurse would move each joint in a smooth, rhythmic manner. The nurse would not raise the bed to the highest position, but to a position that is waist-high to the nurse. The nurse would not perform each exercise 10 to 15 times, rather 2 to 5 times. The nurse would not use a flat palm, rather a cupping hold to support joints during ROM exercises.

The nurse is preparing to apply compression stockings for a client that is at risk for the development of deep vein thrombosis. What action(s) by the nurse demonstrate to the client the appropriate way to apply the stockings? Select all that apply. Estimate the size of the client's legs, and obtain the stockings. Assess the skin and neurovascular status of the legs and feet before applying. Have the client lie down with legs and feet elevated for at least 15 minutes before applying. Massage the client's legs before applying. Apply the stockings in the evening.

Assess the skin and neurovascular status of the legs and feet before applying. Have the client lie down with legs and feet elevated for at least 15 minutes before applying. The nurse needs to measure the client's legs to determine the proper size of stocking. Each leg should have a correct fitting stocking; if measurements are different, then two different sizes of stocking need to be ordered to ensure correct fitting on each leg. The size should not be estimated. The nurse will apply the stockings in the morning before the client is out of bed and while the client is supine. If the client is sitting or has been up and about, the nurse will have the client lie down with legs and feet elevated for at least 15 minutes before applying the stockings. Otherwise, the leg vessels are congested with blood, reducing the effectiveness of the stockings. The nurse will not massage the client's legs before applying the stockings. If a clot is present, massaging the leg may break it away from the vessel wall and it can circulate in the bloodstream.

A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply. Exercise increases resting heart rate and blood pressure. Exercise increases intestinal tone. Exercise increases efficiency of the metabolic system. Exercise increases blood flow to kidneys. Exercise decreases appetite. Exercise decreases rate of carbon dioxide excretion.

Exercise increases intestinal tone. Exercise increases efficiency of the metabolic system. Exercise increases blood flow to kidneys. The benefits of exercise include increasing intestinal tone, increasing efficiency of the metabolic system, and increasing blood flow to the kidneys. Exercise decreases resting heart and blood pressure. Exercise increases appetite. Exercise increases the rate of carbon dioxide excretion.

The nurse assists a client who has had a stroke affecting the left side causing difficulty moving the hand and fingers. Which range-of-motion exercise(s) will the nurse use? Select all that apply. Extension of fingers Flexion of fingers Adduction of fingers Abduction of fingers Hyperextension of fingers

Extension of fingers Flexion of fingers Adduction of fingers Abduction of fingers The standard range-of-motion exercises for the fingers of the left hand that will assist the client are extension, flexion, adduction, and abduction of the fingers. Hyperextension of the fingers is not appropriate and may cause injury to the client.

The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply. Fowler Semi-Fowler Upright Supine Modified supine

Fowler Semi-Fowler Upright The Fowler position is a sitting position, also known as upright, that raises the client's head 80 to 90 degrees and benefits the client by preventing aspiration, promoting ventilation, facilitating eating, and improving cardiac output. The semi-Fowler position is a 45-degree angle, which also allows for ventilation without aspiration. The supine and modified supine (pillow under knees) would not be appropriate for facilitation ventilation and preventing aspiration.

The nurse is providing discharge teaching to a family member of a client who has recently developed right sided weakness post-stroke. Which information will the nurse provide when educating the family member on how to assist the client to mobilize? Select all that apply. Have the client dangle legs on the side of the bed before standing. Support the client on the stronger side of the body when preparing to stand. Rock the client to standing position based on an agreed signal. Have the client stand for 1 minute before trying to take steps. Encourage the client to slowly take small steps.

Have the client dangle legs on the side of the bed before standing. Rock the client to standing position based on an agreed signal. Have the client stand for 1 minute before trying to take steps. Encourage the client to slowly take small steps. The caretaker should have the client sit on the side of the bed prior to ambulation to help prevent significant drops in blood pressure and help ensure that the client is safely moved to a standing position. Then, the client should stand for a few minutes to ensure blood pressure has stabilized and balance will not be lost. Rocking the client in the sitting position before assisting them to stand provides momentum and reduces the need to lift the client. The client should also move slowly and take small steps to avoid falls. Moving the legs and feet prior to standing may feel comfortable but is not needed to assist in ambulation. The client should always be assisted on the weaker side in order to allow them to use the stronger side to lead. This promotes independence with a focus on the client's ability rather than on their deficits.

A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction? Lean into the cane as it supports you. Hold your cane on the right side. Hold the cane 6 in (15 cm) in front of you. You may switch hands with your cane if you become tired.

Hold your cane on the right side. Because this client is using the cane due to weakness, it should be placed on the "strong" side, in this case the right side. The client should stand tall and not lean into the cane. The cane should be 4 in (10 cm) outside the stronger foot. This client should not switch hands with the cane.

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings? Apply the stockings at night when the client is going to bed. Apply the stockings after the client has been sitting up for an hour. If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Avoid the use of powders on the legs before applying stockings.

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Be prepared to apply the stockings in the morning before the client is out of bed. Assist the client to a supine position. If the client has been sitting or walking, have him or her lie down with legs and feet well elevated for at least 15 minutes before applying the stockings. Powder the leg lightly unless client has a breathing problem, dry skin, or sensitivity to the powder. If the skin is dry, a lotion may be used. Powders and lotions are not recommended by some manufacturers; check the package material for manufacturer specifications.

The nurse assesses a 68-year-old client being treated for heart failure who reports dyspnea with mild activity, sitting at a desk most of the day while working, and preferring an orthopneic position. Recognizing that the client is at risk for disuse syndrome, which intervention(s) will the nurse initiate? Select all that apply. Instruct the client to sit upright to prevent dyspnea. Offer activity options and their benefits that match the client's interests and address the client's needs. Collaborate with physical, occupational, and recreational therapists to implement an individually tailored exercise program. Encourage active range-of-motion exercises. Encourage the client to elevate legs instead of standing up at times in the day.

Instruct the client to sit upright to prevent dyspnea. Offer activity options and their benefits that match the client's interests and address the client's needs. Collaborate with physical, occupational, and recreational therapists to implement an individually tailored exercise program. Encourage active range-of-motion exercises. The consequences of inactivity are referred to as disuse syndrome and, because the client is at risk for the condition, the nurse will teach the client to initiate a high Fowler position when dyspnea occurs. This will help alleviate the dyspnea and allow the client better oxygenation and energy to increase activity level. The nurse also offers activity options and their benefits to the client that match the client's interest and address the client's needs, so the client can understand the reasons for the activities and make good choices. The nurse collaborates with physical, occupational, and recreational therapists to implement an individually tailored exercise program, so that each professional can contribute from his or her area of expertise and the different types of activities that can motivate the client and enhance adherence to the program. Whenever possible, it is important to encourage the client to stand up from the sitting position even for brief periods throughout the day, as repositioning can improve circulation that prevents disuse syndrome. Although elevating the legs is an effective way to prevent edema of the lower legs, it is not as effective as standing to prevent muscle atrophy associated with disuse.

The nurse is assisting a client from a bed to a wheelchair. Which nursing action is appropriate? Discourage the client from helping with the transfer. Administer pain medication following the transfer. Grab and hold the client by the arms. Lock the wheelchair prior to moving the client.

Lock the wheelchair prior to moving the client. When transferring the client from a bed to a chair, the wheelchair must be locked. The nurse would encourage the client to help with the transfer if the client is able and can safely assist. Pain medication would not be indicated after the transfer unless a pain assessment indicated this action. The nurse would not grab and hold the client by the arms. This action could cause injury to the client.

A nurse is providing care for a frail older adult client with chronic obstructive pulmonary disease (COPD). The client always remains in a sitting position, leaning forward to improve oxygenation. Which assessment(s) provide data of possible impaired tissue integrity? Select all that apply. Monitor skin integrity of heels. Monitor ischial tuberosities for pressure injury. Evaluate the client's awareness of pressure sensation. Assess for edema. Evaluate nutritional status.

Monitor skin integrity of heels. Monitor ischial tuberosities for pressure injury. Evaluate the client's awareness of pressure sensation. Assess for edema. When in a sitting position, the hips and knees are flexed at 90 degrees and the body's weight is borne by the pelvis, particularly the ischial tuberosities, which are bony protuberances of the lower portion of the ischium that are at great risk for impaired skin integrity and pressure injuries. The client's heels, balls of feet, and elbows are also at great risk for impaired skin integrity because the client continuously leans forward to facilitate easier breathing. The nurse would assess for edema because swelling can contribute to the breakdown of skin due to excess friction. The nurse would also evaluate the client's awareness of pressure sensation to determine if the client is capable of reporting issues that would contribute to a breakdown in the skin. Although poor nutrition can affect skin integrity, there is no evidence that the client is not eating properly. Evaluating nutritional status would be a nursing intervention in the event there is an additional increased risk factor that has been determined.

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body? The wrist is classified as an irregular bone. Short bones contribute to movement. Long bones are relatively thin and contribute to shape. Flat bones are found in the spinal column.

Short bones contribute to movement. Short bones contribute to movement and are located in the wrist and ankle. The wrist is classified as a short bone. Long bones, such as the femur and humerus, are located in the upper and lower extremities and contribute to height and length. The flat bones are relatively thin and contribute to shape. The flat bones are found in the ribs and several of the skull bones and contribute to shape (structural contour).

A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take? Tell the client he can remove them for 20 or 30 minutes during this shift. Instruct the client to not remove them until the primary care provider writes a prescription to discontinue them. Explain that the stockings must be worn 48 hours straight before they may be removed temporarily. Permit the client to remove the stockings indefinitely and speak to the health care provider about the necessity of having the client wear them.

Tell the client he can remove them for 20 or 30 minutes during this shift. Antiembolism stockings should be removed once every shift for 20 to 30 minutes to allow for assessment of circulatory status and the condition of the skin on the lower extremity and for skin care. The nurse should not disregard the health care provider's prescription and allow the client to remove the stockings indefinitely, as this could endanger the client's health.

At a well-child visit, the nurse is observing siblings at play. Which observed behaviors would be of concern to the nurse and would require additional assessment? Select all that apply. The 5-year-old is jumping off a step pretending to fly. The 3-year-old sits by as the 5-year-old stacks a tower of blocks. The 3-year-old does not join the 5-year-old in the jumping game. The 3-year-old runs circles while the 18-month-old chases. The 18-month-old does not follow the others up a set of three stairs.

The 3-year-old sits by as the 5-year-old stacks a tower of blocks. The 3-year-old does not join the 5-year-old in the jumping game. A 3-year-old should be able to build a tower with blocks and should be able to jump. The 18-month-old should be able to run, but climbing steps is not an expected behavior.

When assessing correct body alignment when the client is standing, the nurse would document which abnormal findings? Select all that apply. The head is held erect. The feet are at right angles to the lower legs. The arms are bent at the elbows. The chest is held upward and forward. The knees are bent.

The arms are bent at the elbows. The knees are bent. Correct alignment permits optimal musculoskeletal balance and operation and promotes optimal physiologic function. With the client standing, the nurse would be concerned if the arms were bent at the elbows. The arms should hang comfortably at the sides. Also, the nurse would be concerned if the knees were bent. The knees should be in a slightly flexed position, not bent and not in the knee-locked position. It is a normal finding for the head to be held erect and in the midline position. It is also a normal finding for the feet to be at right angles to the lower legs. It is a normal finding for the chest to be held upward and forward.

The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table? The brain is sending impulses to the muscles to avoid the table. The client is aware of spatial relationships to avoid the table. The client's muscles are being stretched to walk around the table. The cerebellum is responding to impulses from the inner ear.

The client is aware of spatial relationships to avoid the table. The client has awareness of spatial relationships (where objects are located in space). This ability comes from the visual or optic reflexes. The labyrinthine sense relates to the sensory organs in the inner ear and provides a sense of position, orientation, and movement. It does not contribute to where objects are in space. When the extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture (e.g., when the knee buckles under, the reflex contraction aids the person to straighten the knee). This does not contribute to perception of where objects are in space.

An adult has been admitted to the intensive care unit following a cerebrovascular accident. The client is uncounscious and the plan of care includes passive range-of-motion exercises. Drag words from the choices below to fill in each blank in the following sentence.

The nurse should move each joint both internally and externally, which results in prevention of overlooking a joint . When performing range-of-motion exercises each joint should be moved to the point of resistance. This action avoids damage caused by pain and helps to maintain the maximum mobility of the associated joint. When each joint is moved to the point of resistance repetitively twice daily by range-of-motion exercises, it ensures the full limitation of the joint is achieved. When performing range-of-motion exercises, it is not possible to move each joint internally and extenally, because all joints are not capapble of this type of movement. Some joints require other movements, such as flexion, extension, rotation, abduction, and adduction. Range-of-motion exercises should be performed 3 to 5 times with each joint; 10 repititions is excessive and may cause fatigue or cardiopulmonary stress to the client. Nonverbal signs of discomfort main indicate tissue damage and movement to this point should be avoided. When these signs are noted, the exercises should be stopped and reported to the health care provider for further instructions. To prevent overlooking a joint when performing range-of-motion exercises, the nurse should move systematically with repetitive patterns. A sufficient cardiopulmonary response is not associated with moving a joint to the point of resistance. The nurse should expect respiratory and cardiac rates to increase during range-of-motion exercises and return to normal within 3 minutes following completion. Spasticity may be a result of moving a joint to far or too fast. If spasticity developes, movement of the related joint should be stopped, at least temporarily.

Using proper body mechanics, which motions would the nurse make to move an object? The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. The nurse uses the muscles of the back to help provide the power needed in strenuous activities. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity.

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The internal girdle is made by contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward. It is helped further by making a long midriff by stretching the muscles in the waist. The nurse would not relax the stomach muscles or use the muscles of the back when moving an object. The nurse would not lift an object when it can be safely slid, rolled, pushed, or pulled.

The nurse is caring for a client who is ordered to be in the Fowler position. When assessing the client's position in bed, the nurse will adjust the client in bed if what is observed? Select all that apply. There is a large pillow under the client's head. The client's forearms are supported on pillows. The knee gatch on the bed is engaged. The client's foot is in the plantar flexion position. There is a rolled towel beside the client's hips.

There is a large pillow under the client's head. The knee gatch on the bed is engaged. The client's foot is in the plantar flexion position. In the Fowler position, the client's head should be against the mattress or supported by a small pillow only. Using a large pillow may cause flexion contracture of the neck. The knee gatch should be avoided to prevent pressure on the popliteal artery that could compromise lower extremity circulation. When the client's foot is in the plantar flexion position, the client is at risk for foot drop. A foot board, high-top sneakers, or improvised firm foot support should be used. It is appropriate to place the client's forearms on pillows. This will prevent pull on the shoulders and help prevent dislocation of the shoulder. A rolled towel or trochanter roll will help prevent external rotation of the hips.

A nurse is providing care for a client recovering from a stroke and teaches the spouse about caring for the client. Which strategy(ies) does the nurse include about how the spouse can maintain proper body mechanics and prevent injury to oneself? Select all that apply. When supporting your spouse during dangling, tighten your gluteal and abdominal muscles to avoid back strain or self-injury. Grip the gait belt as your spouse walks so that you can provide aid if your spouse begins to fall. Use a gait belt to help your spouse transfer from bed to chair. Always keep your spouse close to your body during the transfer. Use the hip flexors to rotate the client to the designated position. Use the muscles in your legs to lift and/or pull.

When supporting your spouse during dangling, tighten your gluteal and abdominal muscles to avoid back strain or self-injury. Grip the gait belt as your spouse walks so that you can provide aid if your spouse begins to fall. Use a gait belt to help your spouse transfer from bed to chair. Always keep your spouse close to your body during the transfer. Use the muscles in your legs to lift and/or pull. When teaching the spouse about his or her safety while providing care for the client who had a stroke, the nurse will explain that when the caregiver supports the spouse during dangling, the caregiver should tighten the gluteal and abdominal muscles to avoid back strain or self-injury. In addition, the nurse will tell the caregiver to use a gait belt to help the spouse transfer from bed to chair to prevent the caregiver injuring one's own shoulders and back. The caregiver will also be advised to always keep the spouse close to one's body to prevent shoulder and back strain to self. The caregiver will be told to use the muscles in the legs to lift and/or pull rather than using the shoulders and back. When transferring a client, the body should turn with the client and there should not be a rotation movement as this will cause back injury.

A nurse is teaching a client who has unilateral weakness how to walk with a cane. Which guideline promotes safe use of this device? The client should hold the cane in the hand on the same side as the leg with the most severe deficit. The client should stand with as much weight as possible placed on the feet, using the cane for balance. When taking a step, the client should advance the stronger leg forward ahead of the cane and follow with the weaker leg. When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane.

When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane. When stepping forward, the heel should be slightly beyond the tip of the cane. The client should hold the cane on the opposite side of the foot with the deficit and evenly distribute weight between the feet and the cane. The client should step first with the weaker leg.

A client's job requires moving heavy objects from one surface to another. The nurse will provide which anticipatory guidance to help this client avoid a back injury? Select all that apply. Standing with your feet close together will improve your balance. Pull objects toward you rather than pushing them away. Work as closely to the objects you are moving as possible. Flex the knees to improve balance and strength. Face in the direction in which you are moving the load.

Work as closely to the objects you are moving as possible. Flex the knees to improve balance and strength. Face in the direction in which you are moving the load. Standing with the feet apart and knees flexed will improve balance. Objects should be pushed, not pulled, if possible. Working close to the object and facing in the direction of movement improve strength.

Which type of mobility aid would be most appropriate for a client who has poor balance? a cane with four prongs on the end (quad cane) a single-ended cane with a half-circle handle a single-ended cane with a straight handle axillary crutches

a cane with four prongs on the end (quad cane) Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold but are not recommended for clients with poor balance. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.

The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply. hold his breath only when lifting heavy objects adjust the height of the work area face in the direction of the activity he is performing use a wide stance and lift with the large leg muscles

adjust the height of the work area face in the direction of the activity he is performing use a wide stance and lift with the large leg muscles Breath holding is a sign of muscle strain and an inefficient use of body mechanics.

The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher? alongside the bed 2 in (5 cm) lower alongside the bed 1 in (2.5 cm) either lower or higher alongside the bed at the same height alongside the bed 2 in (5 cm) higher

alongside the bed at the same height By placing the bed and the stretcher at the exact same height, it makes for easier transfer and decreases risk of potential injury. If the stretcher were lower or higher, it would not make for a smoother transfer and the client could be injured during transfer.

The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse correctly documents the presence of: ataxia. tremors. chorea. athetosis.

ataxia. Ataxia refers to a lack of muscle coordination. Tremors are rhythmic, repetitive movements. Chorea is spontaneous, brief, involuntary muscle twitching of the limbs or facial muscles. Athetosis refers to movement characterized by slow, irregular, twisting motions.

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate? bed trapeze foot board bed cradle trochanter roll

bed trapeze A trapeze bar is a handgrip suspended from a frame near the head of the bed. A client can grasp the bar with one or both hands and raise the trunk from the bed. The trapeze makes moving and turning considerably easier for many clients and facilitates transfers into and out of bed. A foot board helps reduce the risk of foot drop. A bed cradle is usually a metal frame that supports the bed linens away from the client while providing privacy and warmth. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward.

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity? pull the shoulder blade forward and out from under the client place the call bell within reach cover the client with the bed linens assess for pain

pull the shoulder blade forward and out from under the client Positioning the shoulder blade in this manner removes pressure from the bony prominence and thus helps decrease the risk of impaired skin integrity. The other actions should also be performed but do not decrease the risk of impaired skin integrity.

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from: decubitus ulcers. pooling of blood. blood pressure changes. foot drop.

foot drop. A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Foot drop is a contracture in which the foot is fixed in plantar flexion.

When moving a client up in bed with the assistance of another caregiver, the nurse should: ask another nurse about the plan of care. elevate the head of the bed. maintain a pillow under the client's head. have the client fold the arms across the chest.

have the client fold the arms across the chest. Positioning the arms across the chest improves assistance, reduces friction, and prevents hyperextension of the neck. Before attempting to move a client up in bed, the nurse should review the medical record and the nursing plan of care. This validates the correct client and correct procedure, identification of limitation, and ability. Reviewing the medical record and plan of care also identifies use of an algorithm to prevent injury and assists in determining the best plan for client movement. The head of the bed should be flat or as low as the client can tolerate; this will help to decrease the gravitational pull of the upper body. If tolerated, a slight Trendelenburg position aids in movement. Pillows should be removed from under the client's head; this facilitates movement.

An infant develops one extremity that is shorter than the other. This occurs with: bone tumors. hip fractures. loss of calcium. hip dislocation.

hip dislocation. Hip dislocation/subluxation can occur any time during the first year of life. Assessing all infants for hip abnormalities during well-infant examinations is crucial.

The nurse observes an older adult client walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating? should have an orthopedic consultation. is demonstrating a common gait for the older adult. requires a better walking shoe. requires crutches for mobility.

is demonstrating a common gait for the older adult. Many older people have more difficulty overcoming inertia and using gravity efficiently. One contributing factor is the shift in the center of gravity. To compensate for this shift, the knees flex slightly for support.

A nurse is interviewing a client about the client's usual activity level. The client states, "I swim laps 2 to 3 times a week and walk 1 to 2 miles twice a week. The nurse interprets this activity as which type of exercise? isometric isokinetic isotonic range-of-motion

isotonic Isotonic exercise involves muscle shortening and active movement. Examples include carrying out ADLs, independently performing range-of-motion exercises, and swimming, walking, jogging, and bicycling. Isometric exercise involves muscle contraction without shortening (i.e., there is no movement or only a minimal shortening of muscle fibers). Examples include contractions of the quadriceps and gluteal muscles, such as that which occurs when someone holds a yoga pose. Isokinetic exercise involves muscle contractions with resistance. The resistance is provided at a constant rate by an external device that has a capacity for variable resistance. Examples include rehabilitative exercises for knee and elbow injuries and lifting weights. Range-of-motion exercise refers to the maximum degree of movement of which a joint is normally capable.

The nurse is caring for a bedbound client who reports not being able to rest comfortably on their back. In which position will the nurse place the client to improve sleep? supine lateral prone Sims

lateral Because many people routinely fall asleep in the side-lying position or lateral position, this is a comfortable alternative to the supine position for the client on bed rest. Supine is on the back, prone is lying face down, and Sims is halfway between lateral and prone positioning. Sims position places the body out of alignment, which can be more uncomfortable for the client. Sims is the position utilized for the administration of enemas. Prone positioning is lying face down and may not be a comfortable alternative due to the torsion pressure applied to the neck when lying prone.

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene? lowering the height of the bed prior to moving the client turning the client as a complete unit to avoid twisting the spine placing the client in good alignment with joints slightly flexed replacing pillows and positioning devices

lowering the height of the bed prior to moving the client Lowering the height of the bed is an incorrect action that would require the nurse to intervene. The bed should be raised to the height of the caregiver's elbow, or to a comfortable working height before the client is positioned. All other options are appropriate positioning techniques.

The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action? push the client to the opposite side of the bed push the client to the edge of the bed to which the client will be turning pull the client to the edge of the bed to which the client will be turning move the client to edge of the bed opposite the side that client will be turning

move the client to edge of the bed opposite the side that client will be turning When turning a client in bed, the nurse would use a friction-reducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Pushing the client to the opposite side of the bed is not good for back safety. Consult a Safe Patient Handling algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client.

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed? near the client's hip, with legs together near the client's hip, with legs shoulder width apart and one foot near the head of the bed to the dominant side of the client, with legs together and one foot near the head of the bed to the nondominant side of the client, with legs together and one foot near the head of the bed.

near the client's hip, with legs shoulder width apart and one foot near the head of the bed When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight to assist the client to a sitting position safely. The dominant or nondominant side is not relevant when moving a client with equal strength but would be helpful with a client who has had a stroke.

A nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program? obtain a pre-exercise medical examination for clearance pick an activity the client enjoys to promote adherence choose a specific single-exercise activity understand that the activity will have positive benefits.

obtain a pre-exercise medical examination for clearance The client has underlying medical conditions and should obtain a pre-exercise medical examination before beginning any exercise program. Picking an enjoyable activity and understanding that the activity will have positive benefits will help promote success. Variety is preferable to a single-exercise activity to promote success.

The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement? instruct the client to place arms on the side rails place a small pillow under each arm elevate the head of the bed place a trochanter roll under the arms

place a small pillow under each arm A small pillow may be used to elevate the extremities, shoulders, or incisional wounds. Instructing the client to place the arms on the side rails will place pressure on the arms and affect circulation to the extremity. Elevating the head of the bed (Fowler) will not elevate the arms. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward.

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate? contacting the primary health care provider placing a small towel under the neck administering a muscle relaxer positioning the client on the stomach

placing a small towel under the neck Kyphotic changes can cause pressure on cervical vertebrae when someone is in a supine position. Effects of this can be minimized by placing a small towel or cervical pillow under the neck. Placing the client on the stomach is incorrect, and a muscle relaxer will not help reduce the pressure caused by the kyphosis. Contacting the health care provider is unnecessary.

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? standing at the top of the bed and having a colleague stand at the bottom of the bed placing the bed in its lowest position to reduce the client's risk for falls positioning a friction-reducing sheet under the client to facilitate movement using back muscles to gently and gradually pull the client to the side

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.

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? increase in the movement of secretions in the respiratory tract increase in circulating fibrinolysin predisposition to renal calculi increased metabolic rate

predisposition to renal calculi In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.

The nurse is caring for a client with multiple areas of skin breakdown on the back. In which position will the nurse choose to place the client to improve arterial oxygenation? supine prone Sims' Fowler's

prone Placing the client in prone position allows for better arterial oxygenation, which may assist in healing of skin breakdown. The other positions place pressure on the areas of skin breakdown and are therefore incorrect.

The nurse is caring for a client who has a lower-body injury and who is able to partially assist with transfers. The nurse should: use a pull sheet whenever moving the client. manually roll the client to the side of the bed. provide the client with an overhead trapeze. teach the client to pull up with the headboard.

provide the client with an overhead trapeze. Overhead trapezes may provide handholds for clients to assist with transfers and repositioning. The headboard should not normally be used for this purpose. A pull sheet may be unnecessary if the client can partially assist.

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor installing hardwood floors

removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor Removing clutter from the floor, placing nightlights in the bathroom and hallways, and moving the bedroom to the ground floor will reduce the risk of falling and encourage the client to increase his mobility. Installing hardwood floors may induce falls due to the smooth surface; wall-to-wall carpeting would provide traction.

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group? kyphosis shifted center of gravity increased need for calcium and vitamin D scoliosis

scoliosis Numerous factors, including growth and development, influence a person's posture, movement, and daily activity level. The adolescent should be assessed for scoliosis (curvature of the spine). Kyphosis is increased convexity in the thoracic spine from disk shrinkage and decreased height, common in older adults. A shifted center of gravity occurs during pregnancy (in the adult) because of the developing fetus. Older adults have an increased need for calcium and vitamin D related to the risk for osteoporosis.

The nurse is planning care for a client with the identified activity intolerance. What assessment concerns the nurse for a clien with this health issue? a change in pulse from 80 to 84 beats/min after walking up 20 stairs shortness of breath after walking up five stairs joint stiffness after sitting for 1 hour walking with a slow and uncoordinated movement

shortness of breath after walking up five stairs Activity intolerance may result from any condition that interferes with the transport of oxygenated blood to tissue. The altered response to activity includes exertional dyspnea, shortness of breath. Shortness of breath after walking up five stairs would be included in this nursing concern. Another altered response would be excessive increase in pulse rate. After walking up 20 stairs, a change in pulse of 4 beats/min is not excessive. Joint stiffness is a defining characteristic of the nursing concern of altered physical mobility. Walking with a slow and uncoordinated movement is another defining characteristic of altered physical mobility.

The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client? supine slight Trendelenburg Sims' prone

slight Trendelenburg Placing a client in slight Trendelenburg position may help keep the client from sliding down toward the foot of the bed. Placement into the other position choices does not accomplish the same purpose.

The nurse is assessing an older adult client who is having difficulty with mobility. Assessment reveals that the client has stiff and awkward muscle movements. The nurse identifies this as: hemiparesis. ataxia. spasticity. disequilibrium.

spasticity. Spasticity refers to stiff or awkward muscle movements. Hemiparesis refers to weakness on one side of the body. Ataxia refers to impaired muscle coordination. Disequilibrium would lead to balance problems.

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow? under the client's head supporting the client's back in front of the client's abdomen under the client's feet

supporting the client's back The nurse would place the pillow under the client's back to provide support and help maintain the proper position. A pillow can also be placed between the knees. More than one pillow under the client's head is not necessary. Placing a pillow in front of the client's abdomen would be helpful for a client who has undergone abdominal surgery. Placing a pillow under the client's feet is not helpful for the side lying position.

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? the 24-month-old child who is unable to walk unassisted the 3-month-old child who is unable to raise the head when prone the 6-month-old child who is unable to roll over the 18-month-old child who is unable to stack blocks

the 24-month-old child who is unable to walk unassisted At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raise the head, but this is not expected at this age. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month-old infants. Stacking blocks is accomplished by most 3-year-olds, but doing so at 18 months is considered early.

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? transfer belt transfer boards mechanical lift roller sheet

transfer belt A transfer belt is designed for clients who can bear weight and help with the transfer but are unsteady. The other options are inappropriate for this client.

The nurse is working to increase functional ability of a client who is bedbound. Which assistive technique should the nurse prioritize in the plan of care? trapeze bar log rolling pull sheets trochanter rolls

trapeze bar Promoting client independence with movement and activity is an important intervention for clients who are bedbound, especially ones with musculoskeletal problems. Unlike log rolling, trochanter rolls, and pull sheets, which are nurse-initiated methods, the overhead trapeze is used by the client.

A nurse is conducting an in-service education program for a group of staff nurses about ways to reduce their risk for injuries incurred while working with clients. Which action(s) would contribute to this risk? Select all that apply. using uncoordinated lifts using assistive devices lifting when tired engaging in repetitive movements standing for long periods

using uncoordinated lifts lifting when tired engaging in repetitive movements standing for long periods Variables that can lead to back injuries or back pain for health care workers include performing uncoordinated lifts, manual lifting and transfer of clients without assistive devices, lifting when fatigued, repetitive movements, and standing for long periods.