Fundamentals mobility ch. 44

The nurse has documented that the client has orthostatic hypotension. Which assessment findings would support this assessment? (Select all that apply.) 1. Decrease in blood pressure when moving from supine to standing 2. Decrease in heart rate when moving from supine to sitting 3. Pale color in the legs when lying in bed 4. Complaints of dizziness when first sitting up 5. Increased respiratory rate on exertion

. Increased respiratory rate on exertion Correct Answer: 1 Rationale 1: Orthostatic hypotension occurs when the normal vasoconstriction reflex in the legs is dormant and the client's central blood pressure drops when moving from supine to sitting or to standing. Rationale 2: Orthostatic hypotension is a drop in blood pressure not a drop in heart rate. Rationale 3: Paleness of the legs is not significant. Rationale 4: The blood pressure drops, the heart rate increases, and the client may complain of dizziness or may faint upon arising. Rationale 5: Increased respiratory rate on exertion is more related to diminished cardiac reserves, not orthostatic hypotension, as it can occur even when the client is lying flat in bed and moving.

What is the priority action of the nurse prior to transferring a client from bed to wheelchair? 1. Place the bed in its lowest position. 2. Place the wheelchair parallel to the bed. 3. Lock the brakes on the bed. 4. Place a transfer belt on the client

4. Place a transfer belt on the client. Correct Answer: 3 Rationale 1: This is not the most important action of the nurse. Rationale 2: This is not the most important action of the nurse. Rationale 3: While all of these activities are important safety issues, the most important is to lock the wheels on the bed. If the wheels are not locked and the bed moves out from under the client, none of the other safety actions will likely prevent a fall or near fall. Rationale 4: This is not the most important action.

The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed is parallel to the stretcher and: 1. Slightly higher 2. Slightly lower 3. At the same height 4. At least 2 inches lower

Correct Answer: 1 Rationale 1, 4: When transferring a client from bed to gurney, the bed should be parallel to the stretcher and slightly higher. It is easier for the client to move down a slant to the new surface than to move up to a higher surface or to an even surface. Rationale 2, 3: It is easier for the client to move down a slant to the new surface than to move up to a higher surface or to an even surface.

What should the nurse do first when assisting the client to a lateral position for placement of a bedpan? 1. Perform hand hygiene. 2. Move the client to the side of the bed. 3. Place the client's arm over the chest. 4. Raise the opposite side rail.

Correct Answer: 1 Rationale 1: Even though the intervention being performed is placing the client on a bedpan, the nurse should first perform hand hygiene. This prevents cross-transmission of infection from one client to another. Performing this hygiene in front of the client also increases the client's perception of the quality of care being provided and the nurse's concern about infection control. Rationale 2: This action is done later in the procedure. Rationale 3: This action is done later in the procedure. Rationale 4: This action is done later in the procedure.

The client who is unconscious is developing foot drop. What nursing action is indicated? 1. Place high-topped shoes on the client while in bed. 2. Keep the linens on the end of the bed turned back to expose the feet. 3. Use only the prone and Sims positions for client positioning. 4. Use a device to elevate the linens off the feet.

Correct Answer: 1 Rationale 1: High-topped shoes will place the client's feet in the anatomical position of dorsal flexion. Rationale 2: Turning the linens back will keep the weight of the linens off of the feet but will not prevent foot drop. Rationale 3: The prone and Sims positions are implicated in the development of foot drop. Rationale 4: A device to elevate the linens off of the feet will not prevent foot drop.

The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should: 1. Include what mobility is impaired. 2. Use Level 1, 2, 3, or 4 to describe immobility. 3. Describe what happens when the client attempts mobility. 4. Add strength assessment data.

Correct Answer: 1 Rationale 1: In order to make this broad nursing diagnosis more specific to the client, the nurse should include what mobility is impaired. For example, if the client cannot transfer from bed to chair, a more specific nursing diagnosis is Impaired Transfer Mobility. Rationale 2: There are NANDA levels of activity intolerance, but not of immobility. Rationale 3: Describing what happens when the client attempts mobility might be used in the "as manifested by" section of the nursing diagnosis, but not in the problem statement section. Rationale 4: Strength assessment data might be used in the "as manifested by" section of the nursing diagnosis, but not in the problem statement section.

The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client? 1. Institute an exercise plan that includes weight-bearing activities. 2. Increase the amount of calcium in the client's diet. 3. Protect the client's bones with strict bed rest. 4. Provide the client with assisted range of motion exercising twice daily.

Correct Answer: 1 Rationale 1: Osteoporosis is a demineralization of the bone in which calcium leaves the bone matrix. One causative factor is lack of weight-bearing activity. Weight bearing helps to move calcium back into the bone, thereby strengthening them. A standard intervention for those attempting to prevent or reverse osteoporosis is beginning an exercise plan that includes weight-bearing activities. Rationale 2: Additional calcium in the diet after osteoporosis has begun is not thought to be effective. Rationale 3: Strict bed rest may well make the osteoporosis worse because there is no weight-bearing activity. Rationale 4: Assisted range of motion exercises are not weight bearing and do not help delay or reverse osteoporosis.

The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse? 1. Percuss for flatness over the liver. 2. Palpate for bladder fullness. 3. Use the prn order to medicate the client with an antacid. 4. Inspect the sacral area for edema.

Correct Answer: 2 Rationale 1: Flatness is the normal percussion sound over the liver. Rationale 2: The nurse should palpate for bladder fullness that could cause this discomfort. Rationale 3: The nurse should not medicate the client until assessment is complete. Rationale 4: Sacral edema may occur with the bed-bound client, but should not be a contributor to abdominal pain.

How should the nurse position a client who is complaining of dyspnea? 1. High Fowler's position with two pillows behind the head 2. Orthopneic position across the overbed table 3. Prone position with knees flexed and arms extended 4. Sims position with both legs flexed

Correct Answer: 2 Rationale 1: High Fowler's position should not be used with more than one pillow or with overly large pillows. Rationale 2: The orthopneic position across the overbed table facilitates respiration by allowing maximum chest expansion. Rationale 3: The prone position places the client on the abdomen and makes chest expansion difficult. Rationale 4: Sims position is a side-lying position and does not support full chest expansion as much as the orthopneic position.

The nurse is organizing a wellness project to educate teenagers about keeping their bodies healthy. Which information about diet and exercise should be included? 1. Diet is the most important predictor of health. 2. The most important factors for maintaining health are diet and activity. 3. Increase in exercise is sufficient to manage most people's weight gain. 4. Obese women who remain active have a low mortality rate.

Correct Answer: 2 Rationale 1: Research shows that diet and activity are the most important factors for maintaining health. People who follow a sedentary lifestyle have an increased chance of becoming overweight as well as developing a number of chronic diseases. Although diet is an important predictor of health, activity level appears to be more predictive of future health. Increase in exercise without change in diet will not be sufficient to manage most weight gain and is considered an unhealthy trend in today's society. While obese women who are active are generally healthier than their sedentary counterparts, they still have a higher mortality rate than women who are lean and active.

The nurse is assisting a newly delivered mother ambulate to the nursery to see the baby. The client complains of light-headedness and begins to faint. What is the nurse's most important action? 1. Ensure the client's modesty as she falls. 2. Be certain the client does not hit the head on anything. 3. Call for immediate assistance. 4. Check the vital signs and for excessive vaginal bleeding.

Correct Answer: 2 Rationale 1: This is not the priority for the nurse at this time. Rationale 2: All of these actions are important, but the priority is ensuring the client does not strike her head on anything when falling. The nurse should ease the client down while supporting her body against the nurse, protecting the head and laying it gently on the floor. Rationale 3: This is important however does not address that the client is falling. Rationale 4: This is important to do after the client has been assisted to the floor.

The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? 1. The UAP 2. A licensed practical (vocational) nurse 3. A registered nurse 4. It makes no difference

Correct Answer: 3 Rationale 1, 2, 3, 4: Since this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. The registered nurse must assess and evaluate the client's response to the ambulation. Once the client has successfully ambulated, any nursing staff member can assist. The registered nurse should make assistive personnel aware of potential untoward effects of ambulation and of what to report to the nurse.

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care? 1. Frequent position changes to reverse the contractures 2. Exercises to strengthen flexor muscles 3. Range of motion exercises to prevent worsening of contractures 4. Weight-bearing activities to stimulate joint relaxation

Correct Answer: 3 Rationale 1: Frequent position changes will not reverse contractures. Rationale 2: The contracture occurs because the flexor muscles are stronger than the extensor muscles. This imbalance in strength pulls the inactive joint into a flexed position, and a permanent shortening of the muscle occurs. Rationale 3: Once contractures occur they are irreversible except by surgical intervention. The best nursing intervention is to keep the contractures from getting tighter (or worse) by providing range of motion exercises. Rationale 4: Weight bearing activities will not reverse contractures.

The bed-bound client complains of pain and burning in the right calf area. What action should be taken by the nurse? 1. Deeply palpate the area for rebound tenderness. 2. Percuss over the area for change in tone. 3. Measure the calf and compare to the opposite calf. 4. Medicate the client for pain and reassess in 30 minutes.

Correct Answer: 3 Rationale 1: Palpating the area is contraindicated because injury to the vein may induce a thrombus. Rationale 2: Percussing the area is contraindicated because injury to the vein may induce a thrombus. Rationale 3: The nurse should measure the calf and compare it to the opposite calf. The client may be developing a deep vein thrombosis or thrombophlebitis. Rationale 4: Medicating the client and reassessing in 30 minutes might allow a worsening of the client's condition.

During a prenatal visit, the nurse is instructing a newly pregnant client in regard to exercise. What advice is best for the nurse to give this client? 1. Pregnant clients can exercise if exercise was a part of their life prior to pregnancy. 2. Due to the stress of a growing fetus, exercise should be limited to no more than 10 minutes per day. 3. Healthy pregnant women should exercise at least 30 minutes on most if not all days. 4. The pregnant woman's exercise should actually increase above normal recommended levels to prevent water weight gain.

Correct Answer: 3 Rationale 1: Pregnant clients should be encouraged to exercise, regardless if exercise was a part of life prior to being pregnant. Rationale 2: Exercise should be done 30 minutes on most days. Rationale 3: The current recommendation of the American College of Obstetricians and Gynecologists is for healthy pregnant women to get as much exercise as the general population (30 minutes on most if not all days). This is a change from their previous recommendation that pregnant women can exercise.

The nurse is providing range of motion exercising to the client's elbow when the client complains of pain. What action should the nurse take? 1. Stop immediately and report the pain to the client's physician. 2. Discontinue the treatment and document the results in the medical record. 3. Reduce the movement of the joint just until the point of slight resistance. 4. Continue to exercise the joint as before to loosen the stiffness.

Correct Answer: 3 Rationale 1: Stopping the treatment is not justified until an assessment occurs. Rationale 2: Stopping the exercises is not justified until an assessment occurs. Rationale 3: Range of motion exercising should never cause discomfort. In this case, the best action is to reduce the movement of the joint just until the point of slight resistance is felt and evaluate the pain response at that level. If there is no pain, the exercise can be continued. Rationale 4: Continuing at the same level of intensity may cause damage to the joint as well as cause the client pain.

The client's chief complaint is, "I just can't get around like I used to. I have to stop halfway up the stairs to the bedroom, and just walking to the bathroom makes me so tired." Which nursing diagnosis is most likely appropriate for this client? Activity Intolerance: 1. Level 1 2. Level 2 3. Level 3 4. Level 4

Correct Answer: 3 Rationale 1: The NANDA diagnosis Activity Intolerance is further individualized to the client's level of intolerance. Level 1 indicates normal activity with slightly more shortness of breath. Rationale 2: The NANDA diagnosis Activity Intolerance is further individualized to the client's level of intolerance. Level 2 indicates ability to walk about one level city block without difficulty or to climb one flight of stairs without stopping. Rationale 4: The NANDA diagnosis Activity Intolerance is further individualized to the client's level of intolerance. Level 4 indicates dyspnea and fatigue at rest.

When planning care, the nurse would identify which client as needing logrolling for position changes? 1. A client with documented pneumonia 2. The client who has had abdominal surgery 3. The client who fell from a house, sustaining a fractured tibia 4. A client who has a severe headache from hypertensive crisis

Correct Answer: 3 Rationale 1: There is no physiological reason why a client recovering from abdominal surgery would need to be logrolled. Rationale 2: There is no physiological reason why a client recovering from abdominal surgery would need to be logrolled. Rationale 3: Logrolling technique is used in moving any client who may have sustained a spinal injury. Of these clients, the most concern is for the client who fell from a house. Rationale 4: There is no physiological reason why the client with a headache would need to be logrolled.

While assisting the client with a bath, the nurse encourages full range of motion in all the client's joints. Which activity would best support range of motion in the hand and arm? 1. Give the client a washcloth to wash the face. 2. Move the wash basin farther toward the foot of the bed so the client must reach. 3. Have the client brush hair and teeth. 4. Move each of the client's hand and arm joints through passive range of motion.

Correct Answer: 3 Rationale 1: This activity does not utilize all of the major joints in the hands and arms. Rationale 2: The wash basin should be close to the client to prevent overreaching and possible falls. Rationale 3: Brushing the hair and teeth includes more of the joints of the hands and the arms than does washing the face. Rationale 4: Passive range of motion is a second best choice after normal use of the joints.

The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? 1. Toward the nearest corner of the head of the bed 2. Toward the side of the bed 3. Toward the far corner of the foot of the bed 4. Directly toward the client

Correct Answer: 3 Rationale 1: This position could cause the nurse's trunk to twist. Rationale 2: This position could cause the nurse's trunk to twist. Rationale 3: The nurse should face the far corner of the foot of the bed because this is the direction in which movement will occur. Rationale 4: This position could cause the nurse's trunk to twist.

The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. The nurse should employ which techniques to best protect the back? (Select all that apply.) 1. Place the feet together to provide a strong base of support. 2. Flex the knees to lower the center of gravity. 3. Face the box, pick it up, and rotate the upper body toward the table. 4. Hold the box as close to the body as possible. 5. Bend over and use a jerking motion to pull the box to waist level.

Correct Answer: 4 Rationale 1: Placing the feet together makes the body more unstable and more likely to fall. Rationale 2: In order to pick up this box as safely as possible, the nurse should flex the knees to lower the center of gravity. Rationale 3: After picking up the weight, the body should not be rotated, but should be turned to face the table. Rationale 4: In order to pick up this box as safely as possible, the nurse should hold the box as close to the body as possible. Rationale 5: The nurse should squat to pick up the box and should lift smoothly with no jerking motions.

The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? 1. Nurses must wear back belts when lifting clients. 2. All nursing personnel must attend annual body mechanics education. 3. In order to prevent injury, nurses must strive to become physically fit. 4. No solo lifting of clients is permitted in the facility.

Correct Answer: 4 Rationale 1: Wearing a back belt does not prevent injury Rationale 2: Body mechanics training does not prevent injuries. Rationale 3: Physical fitness does not prevent back injury. Rationale 4: Research has shown that the only option that has any influence on frequency of back injury is a policy prohibiting solo lifting.

The client has a history of postural hypotension. Which activities would the nurse advise this client would be likely to cause postural hypotension? (Select all that apply.) 1. Hot baths 2. Heavy meals 3. Use of a rocking chair 4. Valsalva maneuvers 5. Bending down to the floor

Correct Answer: 5 Rationale 1: Hot baths can cause venous pooling in the lower extremities. Rationale 2: Heavy meals divert blood to the gastrointestinal organs. Rationale 3: Use of a rocking chair can be good for the client as the rocking action exercises the legs. Rationale 4: Valsalva maneuvers slow the heart rate, which lowers blood pressure. Rationale 5: Bending to the floor can cause rapid changes in blood pressure upon standing up again.

The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? (Select all that apply.) 1. Place a turn sheet on the bed. 2. Always use two personnel to move the client. 3. Stand at the head of the bed to pull the client up. 4. Slide the client toward the head of the bed. 5. Encourage the client to assist as possible.

Correct Answer: 5 Rationale 1: Placing a turn sheet on the bed will help overcome inertia and friction during moving. Rationale 2: Using two personnel will allow a "lift and move" rather than pulling or sliding the client over linens. Rationale 3: The personnel should stand on either side of the bed and use the turn sheet to move the client. Rationale 4: Sliding the client causes friction. The client should be moved using the turn sheet. Rationale 5: Encouraging the client to assist as much as possible will lighten the workload.

The nurse is evaluating the proper fit of crutches for a client who is to be discharged home. What portion of this client's body should support the weight?

Correct Answer: Arms Rationale : The weight of the body should rest on the arms, not the axilla. Weight on the axilla can cause radial nerve damage. Crutches that are too long will divert weight to the axilla. Crutches that are too short will cause the client to hunch over to walk and will alter the center of gravity, perhaps causing a fall.

The nurse is teaching a client how to use a cane while rehabilitating from a left leg injury. The nurse should advise this client to place the cane on which side of the body?

Correct Answer: Right Rationale : The cane should be placed on the stronger side of the body, in this case the right side. This provides maximum support and the best body alignment.