Mobility

If a patient is a fall risk, they have an increased risk of....

Injury

Name the 2 parts of the skeleton.

1. Axial 2. Appendicular

The skeletal system consists of what?

1. Bones 2. Joints

What are the 3 types of muscular tissues?

1. Cardiac 2. Smooth 3. Skeletal

When palpating the bones and joints what should you be looking for?

1. Deformities 2. Tenderness 3. Pain

The nurse is preparing a teaching plan for a client about crutch walking using a two-point gait pattern. What information should the nurse include?

Advance a crutch on one side, and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side. Explanation: A two-point gait involves partial weight bearing on each foot, with each crutch advancing simultaneously with the opposing leg. Advancing a crutch on one side and then advancing the opposite foot, and repeating on the opposite side, illustrates the four-point gait. When the client advances both crutches together and follows by lifting both lower extremities to the same level as the crutches, the gait is called a "swing to" gait. When the client advances both crutches together and follows by lifting both lower extremities past the level of the crutches, the gait is called a "swing through" gait. The "swing through" gait is often used by paraplegic clients because it allows them to place weight on their legs while the crutches are moved one stride ahead

Immobility ________ blood flow to tissues; leading to an increased risk of.....

Decreases blood flow; increased risk for pressure injuries

What is an example of a premorbid physical condition that may affect mobility?

Diabetes

True or False: Bone density increases with age.

FALSE; bone density DECREASES with age.

Where 2 bones meet is a....

Joint

Where a bone is connected to another bone, this is a _____.

Ligament

Lordosis is characterized by:

Lumbar curve; sway back

It is important to encourage exercise and stretches that are both ______________ and ____________.

Passive and active

Nutrition, Obesity/Weight loss and exercise are examples of ________ risk factors.

Modifiable risk factors

If someone has a larger weight, how does the skeletal system adjust to support the structure?

More bones remodel to bare the weight.

When assisting a client to ambulate after repair of a fractured right hip, what is the best way for the nurse to be positioned to protect the nurse and the client from potential injury in the event of the client becoming weak?

On the client's left side Explanation: When ambulating a client, the nurse walks on the client's stronger or unaffected side. This provides a wide base of support and therefore increases stability during the phase of ambulation that calls for weight bearing on the affected side as the unaffected limb moves forward.

A more mobile person has more of a chance to have a ________ recovery than someone who is bedbound.

Quicker; Faster

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?

The nurse uses a rocking motion while helping the client to stand. Explanation: Rocking provides extra force when pushing or pulling. The nurse should keep any weight as close to her body as possible when lifting — not at arm's length. The nurse should keep her knees slightly bent and her feet spread apart to provide a wide base of support. Keeping the knees straight and stiff and bending at the waist and keeping the feet close together aren't examples of safe body mechanics. These positions could result in injury to the nurse or to the client.

Supporting body weight, controlling movements, providing stability and protection are all the combined outcome of what TWO systems working together?

The skeletal and muscular systems

How might immobility affect ones risk for pneumonia?

Unable to remove secretions, causing an infection

Kyphosis is characterized by:

a hunchback appearance.

Scoliosis is a _______ curvature of the spine.

lateral; S shaped

A blood clot is called

thrombus

A nurse is evaluating the proper use of crutches by a client who has fractured the right leg. Which statement indicates the client is using the correct technique?

"I feel pressure on the palms of my hands when I am walking with my crutches." Explanation: It is normal for the client to feel pressure on the palms of the hands when walking with crutches. The client should move her affected (right) leg forward first as she swings forward with the crutches. Leaning on the crutches can apply pressure to the axillae, leading to neurovascular impairment. If the client's arms are tingling after she uses her crutches, she is probably applying pressure on her axillae when walking.

Immobility affects GI mobility, putting patients at an increased risk for....

Constipation, Impaction

A client with multiple sclerosis (MS) is receiving discharge instructions from the nurse. Which of the following statements by the clien indicates that more instruction is required?

"I will walk with my feet close together." Explanation: Clients with multiple sclerosis should walk with their feet wider apart, not close together to facilitate balance and reduce the risk of falls. The other options are correct statements as watching one's feet while walking is beneficial to clients with MS. A voiding time schedule helps to prevent any episodes of incontinence. Dysphagia is a potentially serious complication and should be reported to the client's primary healthcare provider.

A nurse caring for a child with a right leg fracture should include which of the following statements when teaching the child how to bear weight on the affected leg using crutches?

"Move both crutches then your broken leg forward." Explanation: When walking with crutches, a child should be instructed to advance both crutches, then advance the affected leg. The unaffected leg then supports much of the weight associated with ambulation. It would not be effective to move the unaffected leg forward first. It would not be safe for the child to advance using only one crutch.

What are some nursing interventions to help bedrest patients prevent impaired respiratory systems?

1. Deep breathing exercises 2. Incentive Spirometers (IS) 3. Raise HOB

What are the 2 types of joints?

1. Fibrous 2. Cartilaginous

The muscular system consists of what?

1. Ligaments 2. Tendons 3. Cartilage

A traveling blood clot is called...

An embolism

Canes, walkers and crutches are examples of what?

Assistive devices

Immobility affects the metabolism of what 3 macronutrients?

Fats, Proteins, Carbohydrates

Immobility ________ workload on the heart.

Increases workload

An increased workload ______ blood pressure due to the increased effort to pump blood to immobile _______.

Increases BP, to pump blood to immobile muscles

Where a muscle is connected to a bone, this is a ______.

Tendon

Which cells are involved in bone resorption?

Osteoclasts Explanation: Osteoclasts carry out bone resorption by removing unwanted bone while new bone is forming in other areas. Chondrocytes are responsible for forming new cartilage. Osteoblasts are bone-forming cells that secrete collagen and other substances. Osteocytes, derived from osteoblasts, are the chief cells in bone tissue.

What are the 5 P's of neurovascular assessment?

Pain Pulses Pallor (pale) Paresthesia (change in sensation) Paralysis (ability to move body parts)

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do?

Remove any unsafe items from the area in which the infant is mobile. Explanation: Safety is the priority in caring for this infant. Infants adapt easily, increasing mobility even with a splint in place. Therefore, the mother needs to ensure that the area in which the infant is mobile is safe. There is no need to contact the HCP to alter the treatment plan. Confining the infant to one room may not allow the child to achieve normal development. The child needs different environments for maximum development. The infant needs to wear the splint as prescribed by the HCP to ensure optimal healing.

As calcium absorption decreases with age, how does this affect bone healing?

Slows down regeneration and rehealing

Quadriplegia and paraplegia are examples of ________ injuries.

Spinal cord injuries

How do we develop a shorter stature/posture as we age?

Spinal disks lose fluid and become thinner

True or False: Remodeling and strength/mobility of our bones decreases with age.

TRUE

What factor has the potential to lead to chronic respiratory acidosis in older adults?

Thoracic skeletal changes Explanation: Poor respiratory exchange as the result of chronic lung disease, inactivity, or thoracic skeletal changes may lead to chronic respiratory acidosis. Decreased renal function in older adults can cause an inability to concentrate urine and is usually associated with fluid and electrolyte imbalance. A poor appetite, erratic meal patterns, inability to prepare nutritious meals, or financial circumstances may influence nutritional status, resulting in imbalances of electrolytes. Overuse of sodium bicarbonate may lead to metabolic alkalosis.

A male client underwent a lumbar spinal fusion yesterday. Which nursing assessment should alert the nurse to the development of a possible complication?

clear yellowish fluid on the dressing Explanation: Clear yellowish fluid on the dressing may be cerebrospinal fluid (CSF). This fluid must be tested for glucose to determine whether it is CSF. If so, the client is at great risk for an infection of the central nervous system, which has a high mortality rate. The client should be able to laterally rotate the head and neck, which is above the surgical site in the spinal column. During the nursing postoperative neuromuscular-vascular assessment of movement of the head and neck, the nurse should find results consistent with the preoperative baseline status. Using the standing position to void is normal for a male client. Coughing is the body's defense mechanism to help clear the lungs of the anesthetic agents and to ventilate the lungs in response to a sustained deep inspiration for ventilation of the lower lobes of the lungs. A frequent cough could place a strain on the incision site and should be avoided. Also, a productive cough of thick, yellow sputum would indicate the complication of a respiratory infection.

Four days after surgery for internal fixation of a C3-C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which features of the wheelchair are appropriate for the needs of this client?

• back and head that are high • seat that is lower than normal • chair controlled by the client's breath Explanation: The client with a C3-C4 fracture has neck control but may tire easily using sore muscles around the incision area to hold up the head. Therefore, the head and neck of the wheelchair should be high. The seat of the wheelchair should be lower than normal to facilitate transfer from the bed to the wheelchair. When a client can use the hands and arms to move the wheelchair, the placement of the back to the client's scapula is necessary. This client cannot use the arms and will need an electric chair with breath, chin, or voice control to manipulate movement of the chair. A firm or hard cushion adds pressure to bony prominences; the cushion should instead be padded to reduce the risk of pressure ulcers.

Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis? 1. Risk for injury related to altered mobility 2. Impaired urinary elimination related to effects of aging 3. Ineffective breathing pattern related to immobility 4. Imbalanced nutrition: Less than body requirements related to effects of aging

1. Risk for injury related to altered mobility Typically, a client with osteoarthritis has stiffness in large, weight-bearing joints, such as the hips. This joint stiffness alters functional ability and range of movement, placing the client at risk for falling and injury. Therefore, Risk for injury is the most appropriate nursing diagnosis. The other options are incorrect because osteoporosis doesn't affect urinary elimination, breathing, or nutrition.

A nurse is preparing to help a client with weakness in his or her right leg move from the bed to a chair. Where should the nurse place the chair?

45 degrees to the bed on the left side Explanation: The nurse should place the wheelchair at a 45 degree angle or parallel to the bed on the client's strong side to help prevent a fall. The nurse should not place the chair perpendicular to the bed because the client won't be able to support his weight on his right leg.

Using the Morse Fall Scale (see chart), place the clients in order from lowest to highest fall risk. All options must be used.

50-year-old client admitted for chest pain while running. The client has been healthy and has no history of falling; she is alert and oriented, has IV access, and has been cleared to ambulate independently. 38-year-old client who has been blind since birth, admitted for abdominal pain and nausea with IV in place. The client has steady gait and no history of falling and requires cuing and assistance due to unfamiliar surroundings. 56-year-old client with diabetes admitted with osteomyelitis of right ankle, receiving IV antibiotics per peripherally inserted central catheter. The client is alert and cooperative, is non-weight bearing on the right lower extremity but may stand pivot into a wheelchair. The client has no history of falling. Elderly client admitted from assisted living facility with new-onset confusion secondary to urinary tract infection. The client has a history of hypertension and diabetes; gait is weak due to illness, but the client has no known history of falling. The client may be up with assistance using a walker and is receiving intravenous (IV) antibiotics. Explanation: The 50-year-old client has the lowest risk for falling with points assigned for IV access only (20); this client should be monitored regularly for changes that would increase the client's risk, and interventions should be instituted if they become necessary to ensure safety. The 38-year-old blind client is medium risk for falling with 35 points (secondary diagnosis and IV access); due to unfamiliar surroundings, the nurse may need to provide extra attention to cuing and providing assistance to keep this client safe. The client admitted with osteomyelitis is a high fall risk with points assigned for secondary diagnosis of diabetes (15), impaired gait (20), and IV access (20) to a total of 55; the nurse should institute high fall precautions and reassess need regularly. The elderly client with new-onset confusion is at highest risk for falling, acquiring points for a history of falling (25), secondary diagnosis (15), IV access (20), weak gait (10), and confusion (15) to a total of 85 points; the nurse should institute fall precautions, taking care to identify this client to all health care team members as high fall risk.

True or False: Bones stop growing at a certain age.

FALSE; some bones continue to grow with age

The nurse advises the client who has had a femoral head prosthesis placement on the type of chair to sit in during the first 6 to 8 weeks after surgery. Which chair would be the correct type to recommend?

a high-backed chair with armrests Explanation: A high-backed straight chair with armrests is recommended to help keep the client in the best possible alignment after surgery for a femoral head prosthesis placement. Use of this type of chair helps to prevent dislocation of the prosthesis from the socket. A desk-type swivel chair, padded upholstered chair, or recliner should be avoided because it does not provide for good body alignment and can cause the overly flexed femoral head to dislocate.

There are ______ total bones.

206

The sticking or uninflation of alveoli, due to the lack of deep breathing, is called...

Atelectasis

Flexible connective tissue throughout the body is _____

Cartilage

Muscles ________ causing the movement of _______.

Contract, causing movement of skeletal bones.

Which is not a typical clinical manifestation of multiple sclerosis (MS)?

sudden bursts of energy Explanation: With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS.

A client is scheduled to have a graded exercise test. The nurse explains to the client that the test will determine how:

well the body reacts to controlled exercise stress. Explanation: Graded exercise testing is a diagnostic and prognostic tool used to determine the physiologic responses to controlled exercise stress. Information gained from a graded exercise test can achieve diagnostic, functional, and therapeutic objectives for the client. Graded exercise tests involve the use of a treadmill, stationary bicycle, or arm ergometry. The information obtained from this test is not used to set the incline on the treadmill, and measuring the distance walked and the duration of the walk are not the purpose of a graded exercise test.

A nurse is caring for a client who had hip pinning surgery 6 hours ago to treat inter-trochanteric fracture of the right hip. What assessment finding requires further investigation by the nurse?

Client is anxious and confused Explanation: The client is anxious and confused is the appropriate answer. Postoperative complications of hip fractures include hemorrhage, pulmonary emboli, and fat emboli. Anxiety and confusion may be indicative of hypoxia as a result of any of above these complications and needs further investigation. Capillary refill of 2-3 seconds is an expected finding, edema is present from both the injury and the surgical intervention. 100 milliliters of bright red drainage 6 hours after surgery should be watched, but is not of immediate concern.

A nurse is admitting a client scheduled for a laminectomy of the L1 and L2 vertebrae. Indicate where the nurse assesses the surgical incision following completion of the procedure.

Explanation: In a laminectomy, one or more of the bony laminae that cover the vertebrae are removed. The incision for the surgery is at the site of the vertebrae. There are five lumbar vertebrae that are numbered from top to bottom. L5 is the closest to the sacrum. Count up from the sacrum to locate L1 and L2.

The emergency room nurse is caring for a client who fell breaking the tibia. The nurse determines that a client understands the risk of compartment syndrome when knowing to report which early symptom following treatment? Paresthesia

Paresthesia Explanation: Compartment syndrome is the compression of the nerves, blood vessels, and muscle inside a closed space. Paresthesia is the earliest sign of compartment syndrome. Pain, heat, and swelling are also signs but occur after paresthesia. Skin pallor is not a sign of compartment syndrome.

Why is it important to do a ROM assessment?

To see where ones physical limits are upon admission; to prevent deterioration of muscles and joints (contractures)

To assess the joints, a nurse asks a client to perform various movements. As the client moves his arm away from the midline, the nurse evaluates his ability to perform:

abduction. Explanation: A client performs abduction when moving a body part away from the midline. Protraction refers to drawing out or lengthening of a body part. Retraction, the opposite of protraction, refers to drawing back or shortening of a body part. Adduction, the opposite of abduction, is movement of a body part toward the midline

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. The nurse should:

explain how to overcome a freezing gait by telling the client to march in place. Explanation: Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bed rest. A muscle relaxant is not indicated.

A nurse is assessing a client for neurologic impairment after a total hip replacement. Which finding would indicate impairment in the affected extremity?

inability to move Explanation: Being unable to move the affected leg suggests neurologic impairment. A decrease in the distal pulse, diminished capillary refill, and coolness to touch of the affected extremity suggest vascular compromise.

True or False: Some bones fuse during infancy.

TRUE

A nurse is educating a client with chronic back pain about the use of the fentanyl patch. Which statement by the nurse is appropriate?

"The desired effect may take up to 24 hours."

A client with respiratory complications of multiple sclerosis (MS) is admitted to the intensive care unit. Which equipment is most important for the nurse to keep at the client's bedside?

Suction machine with catheters Explanation: MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade is an appropriate seizure precaution, but should not be used in this client because its large size could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen delivery; this client requires a mechanical ventilator.

Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment?

free, easy movement of the joints Explanation: ROM exercises help preserve joint motion and stimulate circulation. Contractures develop rapidly in clients with spinal cord injuries, and the absence of this complication indicates treatment success. Range of motion will keep the ankle joints freely mobile. Footdrop, however, is prevented by proper positioning of the ankle and foot, which is usually accomplished with high-top sneakers or splints. External rotation of the hips is prevented by using trochanter rolls. Local ischemia over bony prominences is prevented by following a regular turning schedule.

A nurse notes that a client has kyphosis and generalized muscle atrophy. Which problem is a priority when the nurse develops a nursing plan of care?

ineffective coughing and deep breathing Explanation: In kyphosis, the thoracic spine bends forward with convexity of the curve in a posterior direction, making effective coughing and deep breathing difficult. Although the client may develop other problems because respiratory status deteriorates when pulmonary secretions are not adequately cleared from airways, ineffective coughing and deep breathing should receive priority attention.

After surgery and insertion of a total hip prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse interprets these findings as indicating:

joint dislocation. Explanation: The joint has dislocated when the client with a total joint prosthesis develops severe sudden pain and an inability to move the extremity. Clinical manifestations of an infection would include inflammation, redness, erythema, and possibly drainage and separation of the wound. Bleeding could be external (e.g., blood visible from the wound or on the dressing) or internal and manifested by signs of shock (e.g., pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in the operating room, when the glue is still in the liquid form. The glue dries into the hard, fixed form before the wound is closed.

The client with an above-the-knee amputation is to use crutches while the prosthesis is being adjusted. Which exercises will best prepare the client for using crutches?

triceps strengthening exercises Explanation: Use of crutches requires significant strength from the triceps muscles. Therefore, efforts are focused on strengthening these muscles in anticipation of crutch walking. Bed and wheelchair push-ups are excellent exercises targeted at the triceps muscles. Abdominal exercises, range-of-motion and isometric exercises of the shoulders, and quadriceps and gluteal setting exercises are not helpful in preparing for crutch walking.

When planning home care for the child with Legg-Calvé-Perthes disease, what should be the primary focus for family teaching?

management of the corrective appliance Explanation: Because most of the child's care takes place at home, the primary focus of family teaching would be on the care and management of the corrective device. Devices such as an abduction brace, a leg cast, or a harness sling are used to protect the affected joint while revascularization and bone healing occur. As long as the child is eating a well-balanced diet, there is no need for an intake of protein-rich foods. The parents can encourage range of motion in the unaffected leg, but motion in the affected leg is limited until it heals. Once therapy has been initiated, pain is usually not a problem. The key is management of the corrective device.

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply.

• A client who is on complete bed rest following extensive spinal surgery. • A client who has a large venous stasis ulcer on the right ankle area. • A client who has recently been admitted with a broken femur and is awaiting surgery. • A client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy. Explanation: Bed rest, poor venous circulation, fractures, and hormone replacement therapy can cause formation of a thromboembolus, placing these clients at risk for developing a PE. A deep vein thrombosis could break loose in the leg and travel to the lungs as a pulmonary embolus. The clot would then lodge in the pulmonary arteries or arterioles and impede blood flow. The client who is on complete bed rest is at risk for venous stasis, and the client who has a venous stasis ulcer is already demonstrating this condition. The client with a broken femur is at risk for a fat embolus, another form of PE. The client on estrogen replacement therapy is at increased risk for thromboembolic disorders. Pleural effusion and infection usually have no effect on thrombus formation, and oxygen therapy does not cause venous stasis or increase the risk of a pulmonary embolism.

The nurse is caring for a 17-year-old male client with Duchenne muscular dystrophy. When assisting the client during a hospitalization for pneumonia, which anticipated nursing interventions would reflect client specific care? Select all that apply.

• Assisting the client to a Fowler's position for a breathing treatment • Clearing a path to the bathroom for safe and easy access • Providing directions to the client's educational level Explanation: Duchenne muscular dystrophy typically occurs in males with symptoms appearing in the preschool years. The course of the disease is fairly predictable with weakness occurring in the voluntary muscles of the legs and trunk. By the teens, the heart and respiratory muscles can also be affected. Nursing interventions anticipated include assisting the client to an upright position for breathing treatments as the client has difficulty sitting up. Clearing a path to the bathroom is important as the client has an unsteady gait with possible braces and is unable to safely step over and around medical equipment. If wheelchair bound, a clear path is important for navigating to the bathroom.

The nurse is instructing a client following right-knee replacement on how to use crutches. Which instructions are included? Select all that apply.

• Have your elbows bent when holding the crutch handles • Place crutches one foot in front of you • Pivot on your left leg • Swing your left leg forward Explanation: It is very important to instruct a client to safely use crutches. Additional damage to the injured knee may result with improper crutch use. When using crutches, instruct the client to, "place the crutches about 1 foot (0.3 meters) in front of your feet, slightly wider apart than your body. Next, lean on the handles of your crutches (not armpit) and move your body forward. Use the crutches for support. Do not step forward on the weak leg. Finish the step by swinging your left leg forward. Repeat steps to move forward. Turn by pivoting on the strong left leg, not the right leg. The armpits should not support your body weight."

A client is admitted to the trauma center with a spinal cord transection at T4. Which of the physical limitations does the nurse anticipate when planning care? Select all that apply.

• The client will be unable to independently ambulate. • The client will have no control of the bladder. Explanation: The client with a spinal cord transection (complete tear) at the thoracic 4 location will be a paraplegic with no control of the body below mid chest. The client will need assistance to ambulate (wheelchair) and assistance with urination. The client will be able to breathe independently, speak, feed themselves and have normal cognitive function

A nurse should perform passive range-of-motion (ROM) exercises on which clients? Select all that apply.

• a client who has temporary loss of sensation • a client who is unconscious Explanation: Passive ROM exercises are used to move the client's joints through as full a ROM as possible. Passive ROM exercises improve or maintain joint mobility and help prevent contractures. These exercises are indicated for the client with temporary or permanent loss of mobility, sensation, or consciousness. Exercises help with joint mobility, strength, and endurance. Plantar flexion of the foot and supination of the hand may be normal joint movements if the client can do active ROM. Septic joints have infection that may be spread either hematogenously or through trauma.

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help?

"Obtain the sliding board or two other people to assist us." Explanation: To successfully move an obese client from the stretcher to the bed without incurring injury, at least four staff members must perform the transfer. If only two people are available, the nurse should use the sliding board. The hydraulic lift isn't the appropriate equipment to use with a sedated patient. The nurse shouldn't place the client in a semi-Fowler's position unless he has a head injury or other complicated medical condition. To perform a safe transfer using a drawsheet, the nurse must place the sheet directly under the client's body.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? 1. Elevating the stump for the first 24 hours 2. Maintaining the client on complete bed rest 3. Applying heat to the stump as the client desires 4. Removing the pressure dressing after the first 8 hours

1. Elevating the stump for the first 24 hours Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

A client has been receiving radiation therapy for 3 weeks to treat cancer and has fatigue. The nurse should consider which factor when planning to help the client cope with the fatigue?

A balance of activity and rest will help manage the fatigue. Explanation: The plan of care to treat fatigue associated with radiation therapy should include encouraging the client to remain active and to plan scheduled rest periods as necessary before activity. Engaging in activities, such as walking, has been shown to decrease the cycle of fatigue, anxiety, and depression that can occur during treatment. Fatigue is a very common side effect of radiation therapy that typically begins during the third or fourth week of treatment and persists until after treatment ends. The presence of fatigue does not mean that the cancer is not responding to treatment or that the client has developed another health problem.

A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation below, which laboratory result is the priority for the nurse to report to the physician?

Blood culture Explanation: Osteomyelitis is a bacterial infection of the bone and soft tissue that occurs by extension of soft tissue infection, direct bone contamination following surgery, or spreading from other infection sites in the body. A positive blood culture would be reported immediately to the physician so that specific antibiotic therapy can begin or be adjusted based on the positive culture. A negative rheumatoid factor would be expected in a possible diagnosis of osteomyelitis. An alkaline phosphatase level of 60 IU/L (1.0 nkat/L) is within the normal range, and an ESR of 10 mm/hour is also within the normal range.

After undergoing surgery the previous day for a total knee replacement, a client states that he doesn't feel ready to ambulate yet. What should the nurse do?

Discuss the complications that the client's may experience if he doesn't cooperate with the care plan. Explanation: The nurse should discuss the care plan and its rationale with the client. Calling the physician to report the client's noncompliance won't alter the client's degree of participation and shouldn't be used to force the client to comply. Doing nothing isn't acceptable. Although the client does have the right to make choices, it's the nurse's responsibility to provide education to help the client make informed decisions. Although the nurse should ultimately document the client's refusal, she should first discuss the care plan with the client.

When performing an assessment, the nurse identifies the following signs and symptoms: discoordination, decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms indicate which nursing diagnosis?

Impaired physical mobility Explanation: This client demonstrates the limitation of physical movement defined as Impaired physical mobility. Health-seeking behavior is a state in which a client in stable health actively seeks ways to alter personal health habits or his environment in order to move toward optimal health. Disturbed sensory perception indicates changes in the characteristics of incoming stimuli. Deficient knowledge exists when the client requires further teaching.

A client is being discharged following an open reduction and internal fixation of the left ankle, and is to wear a non-weight-bearing cast for 2 weeks. What should the nurse teach the client to do when using crutches?

Maintain two to three finger widths between the axillary fold and underarm piece grip. Explanation: The nurse instructs the client to maintain two finger widths between the axillary fold and the underarm piece grip of the crutches to prevent pressure on the brachial plexus. The client is advised to use the three-point gait; in the four-point and two point-gait there is partial weight bearing of both feet. The client is also advised to keep the affected leg elevated when sitting to prevent swelling, and to use the arms, not the axillae, to maintain balance and support

A client is being discharged following an open reduction and internal fixation of the left ankle, and is to wear a non-weight-bearing cast for 2 weeks. What should the nurse teach the client to do when using crutches?

Maintain two to three finger widths between the axillary fold and underarm piece grip. Explanation: The nurse instructs the client to maintain two finger widths between the axillary fold and the underarm piece grip of the crutches to prevent pressure on the brachial plexus. The client is advised to use the three-point gait; in the four-point and two point-gait there is partial weight bearing of both feet. The client is also advised to keep the affected leg elevated when sitting to prevent swelling, and to use the arms, not the axillae, to maintain balance and support.

Which home care activity should the nurse tell a client who underwent a laryngectomy to do?

Participate in activities such as walking and golfing. Explanation: The client should be encouraged to participate in activities such as walking, golfing, and other moderate recreational sports. It is not necessary to keep the stoma covered at all times, although a gauze bib can be used to protect the clothes from mucus and to keep irritants from entering the stoma. Clients with a new laryngectomy may find air-conditioning too cool and dry at first, so they should avoid such environments. It is not necessary to remain in air-conditioning in the summer.

A nurse is caring for a client who is recovering from an illness requiring prolonged bed rest. Based on the nursing documentation above, which procedures would the nurse implement next?

Performing active range-of-motion exercises of the legs Explanation: Active range-of-motion exercises involve moving the client's joints through their full range of motion; they require some muscle strength and endurance. The client should have received passive range-of-motion exercises since admission to maintain joint flexibility and should have been taught isometric exercises to build strength and endurance for transfers and ambulation. Walking to the bathroom would be unsafe without the ability to first dangle the legs over the bedside and transfer from bed to chair.

Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis?

Risk for injury related to altered mobility Explanation: Typically, a client with osteoarthritis has stiffness in large, weight-bearing joints, such as the hips. This joint stiffness alters functional ability and range of movement, placing the client at risk for falling and injury. Therefore, Risk for injury is the most appropriate nursing diagnosis. Impaired urinary elimination, Ineffective breathing patterns, and Imbalanced nutrition: Less than body requirements are incorrect because osteoarthritis doesn't affect urinary elimination, breathing, or nutrition.

Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. In which position should the nurse place the client?

Side-lying Explanation: Lethargy puts the post-tonsillectomy client at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he's fully awake is best. The semi-Fowler's, supine, and high-Fowler's positions don't allow for adequate oral drainage of a lethargic post-tonsillectomy client and increase the risk of blood aspiration.

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?

When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight. Explanation: To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the walker should be level with the client's waist, not below it. If one leg is weaker than the other, the walker and the weak leg move together while the stronger leg bears the client's weight. To use a standard walker correctly, a client should pick it up to move it. However, some walkers have wheels and can glide across the floor.

When assessing the client with Parkinson's disease, the nurse should observe the client for:

a stiff, masklike facial expression. Explanation: Typical signs of Parkinson's disease include drooling; a low-pitched, monotonous voice; and a stiff, masklike facial expression. Dry mouth is not associated with Parkinson's disease. Aphasia is not a symptom of Parkinson's disease. An exaggerated sense of euphoria would not be typical; more likely, the client would exhibit depression, probably related to the progressive nature of the disease and the client's difficulties dealing with it.

When the client who has had a hip replacement is lying on the side, the nurse should place pillows or an abductor splint between the legs to prevent:

adduction of the hip joint. Explanation: After hip replacement surgery, the client should be positioned on the nonoperative side with pillows or an abductor splint between the legs to help prevent adduction of the operative leg. This positioning places the hip in proper alignment. Dislocation of the hip can occur if the leg on the affected side is allowed to adduct. Flexion of the knees is not contraindicated. Abduction of the legs is the correct position. Placing a pillow between the legs will not result in hyperextension of the knee. Hyperextension of the knee is to be avoided in any case because it can result in injury.

The nurse is teaching an older adult how to prevent falls. The nurse should tell the client to:

instruct the client to rise slowly from a supine position. Explanation: Normal age-related changes can predispose older adults to falling and include vision, hearing, cardiovascular, musculoskeletal, and neurological changes. One of the most common problems facing older adults is the loss of tissue elasticity that affects the arteries. This loss of elasticity results in a decrease in tissue recoil and leads to changes in blood pressure with position changes. When they rise too quickly from a supine position, they feel light-headed and dizzy and can fall. The nurse should instruct clients to change positions slowly and to dangle the legs a few minutes when arising from a supine position. When aging, the lens of the eye becomes sensitive to very bright light which can causes a glare and visual disturbances that can lead to falls. Rooms should be well lit, but not with bright lights that cause a glare. Neurological changes are seen in impaired reflexes and thus postural instability. This loss of postural stability leads to falls. The need of assistive devices (hand rails, cane, walkers) helps reduce falls and promote independence. If joint pain develops and remains untreated, it can cause older adults to become sedentary or immobile. This disuse of muscles contributes to muscle weakness and falls. Nursing interventions should be directed at encouraging regular ambulation and joint movement (range of motion).

An older adult is admitted with a fracture of the femur. The nurse should first assess:

mechanism of injury. Explanation: The nurse first assesses the mechanism of injury to help determine related injuries, tests needed, and potential treatment options. The next step is to assess the location, type, quality, and intensity of the pain. Neurovascular stasis of the injured site is assessed after pain; therefore, the nurse checks for functional ability or changing positions. Although the nurse can also determine the extent of anxiety while assessing the injury and can use communication strategies to minimize anxiety, it is not the first priority for assessing this client.

The nurse is caring for an adult with a grade III compound fracture of the right femur; the client has been placed in skeletal traction. The intended outcome of the traction is to:

reduce and immobilize the fracture. Explanation: Skeletal traction is often used to regain normal length of the bone, but in this situation the main purpose of the traction is to reduce and immobilize the fracture. This type of traction allows the client to move in bed without dislocating the fracture. This client has an open fracture, but skeletal traction will not prevent further skin breakdown.

A client is scheduled to undergo transurethral resection of the prostate. The procedure is to be done under spinal anesthesia. Postoperatively, the nurse should assess the client for:

respiratory paralysis. Explanation: If paralysis of vasomotor nerves in the upper spinal cord occurs when spinal anesthesia is used, the client is likely to develop respiratory paralysis. Artificial ventilation is required until the effects of the anesthesia subside. Seizures, cardiac arrest, and renal shutdown are not likely results of spinal anesthesia.

The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which activity is contraindicated?

sitting all afternoon in the room Explanation: After a lumbar laminectomy, a client should not sit for prolonged periods in a chair because of the increased pressure against the nerve root and incision site. Assisting with daily hygiene is an appropriate activity during the initial postoperative period because, as with any surgical procedure, the client needs to return to an optimal level of functioning as soon as possible. There is no limitation on the client's participation in daily hygiene activities except for individual responses of pain, nausea, vomiting, or weakness. Lying flat in bed is appropriate because it does not cause stress on the spinal column where the laminectomy was performed and the disc tissue was removed. Positions that should be avoided are those that would cause twisting and flexion of the spine. Walking in the hall is an acceptable activity. It promotes good postoperative ventilation, circulation, and return of peristalsis, which are needed for all surgical clients. In addition, walking provides the postoperative lumbar laminectomy client an opportunity to build up endurance and muscle strength and to promote circulation to the operative and incision sites for healing without twisting or stressing them.

When the nurse is conducting a preoperative interview with a client who is having a vaginal hysterectomy, the client states that she forgot to tell her surgeon that she had a total hip replacement 3 years ago. The nurse communicates this information to the perioperative nurse because:

the client should not have her hip externally rotated when she is positioned for the procedure. Explanation: The nurse should notify the surgery department and document the past surgery in the medical record in the preoperative notes so that the client's hip is not externally rotated and the hip dislocated while she is in the lithotomy position. The prosthesis should not be a problem as long as the perioperative nurse places the return electrode away from the prosthesis site. The perioperative nurse will inform the rest of the team, but the primary reason to inform the perioperative nurse is related to safe positioning of the client. The surgeon should enter this information on the client's medical record at this time.

Which information should the nurse include when performing discharge teaching with a client who had an anterolateral approach for a total hip replacement? Select all that apply. • Avoid turning the toes or knee outward. • Use an elevated toilet seat and shower chair. • Do not extend the operative leg backwards.

• Avoid turning the toes or knee outward. • Use an elevated toilet seat and shower chair. • Do not extend the operative leg backwards. Explanation: A client who has had a total hip replacement via an anterolateral approach has almost the opposite precautions as those for a client who has had a total hip replacement through the posterolateral approach. The hip joint should not be actively abducted. The client should avoid turning the toes or knee outward. The client should keep the legs side by side without a pillow or wedge. The client should use an elevated toilet seat and shower chair and should not extend the operative leg backwards. The client should perform range-of-motion exercises as directed by the physical therapist.

The nurse is caring for a client who is experiencing an exacerbation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply.

• Eat a low-purine diet. • Limit alcohol intake. Explanation: Gout is characterized by an abnormal metabolism of uric acid. Individuals either produce too much uric acid or their body is unable to metabolize and excrete it. Purines are metabolized into uric acid. The client who suffers from gout would be placed on a low-purine diet with foods such as peanut butter, cherries, rice, pasta, fruits, and vegetables. Fluids do not have to be limited. Alcohol intake would be limited as it is thought to trigger an exacerbation.

A 20-year-old seeks treatment at a local emergency care center after spraining his ankle while playing football with friends. The ankle is painful and swollen. Which actions should the nurse perform, as ordered by the physician? Select all that apply.

• Initially apply cold pack. • Instruct the client to elevate the ankle for 48 to 72 hours. • Provide crutch-gait training. • If needed, apply an elastic bandage from the toes to midcalf. Explanation: Pain caused by an injury is best treated initially with cold applications. Cold reduces localized swelling and decreases vasodilation. Decreasing vasodilation prevents pain-producing chemicals from entering the circulation. The client should be instructed to call the physician if pain worsens or persists. Additional radiographs may be necessary to detect a fracture that might have originally been missed. The client should also be instructed to elevate the joint for 48 to 72 hours after the injury. If an elastic bandage is needed, the nurse should wrap the bandage from toes to midcalf, forming a figure eight, and teach the client how to reapply it. The nurse should ensure that the client also receives crutch-gait training.

When preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which information in the discharge plan? Select all that apply.

• Report signs of infection to health care provider (HCP). • The physical therapist will encourage progressive ambulation with use of assistive devices. Explanation: After a total knee replacement, efforts are directed at preventing complications, such as thromboembolism, infection, limited range of motion, and peroneal nerve palsy. The nurse should instruct the client to report signs of infection, such as an increased temperature. To prevent edema, the affected leg must remain elevated when the client sits in a chair. The client will wear antiembolism stockings at all times, including when sleeping. After discharge, the client may undergo physical therapy on an outpatient basis per HCP prescription. The client should leave the dressing in place until the follow-up visit with the surgeon.

Four days after surgery for internal fixation of a C3-C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which features of the wheelchair are appropriate for the needs of this client? Select all that apply.

• back and head that are high • seat that is lower than normal • chair controlled by the client's breath Explanation: The client with a C3-C4 fracture has neck control but may tire easily using sore muscles around the incision area to hold up the head. Therefore, the head and neck of the wheelchair should be high. The seat of the wheelchair should be lower than normal to facilitate transfer from the bed to the wheelchair. When a client can use the hands and arms to move the wheelchair, the placement of the back to the client's scapula is necessary. This client cannot use the arms and will need an electric chair with breath, chin, or voice control to manipulate movement of the chair. A firm or hard cushion adds pressure to bony prominences; the cushion should instead be padded to reduce the risk of pressure ulcers.

A client is being admitted with a spinal cord transection at C7. Which assessments take priority upon the client's arrival? Select all that apply.

• temperature • respirations • blood pressure Explanation: The nurse should assess the client for spinal shock, which is the immediate response to spinal cord transection. Hypotension occurs, and the body loses core temperature to environmental temperature. The nurse must treat the client immediately to manage hypotension and hypothermia. The nurse should also ensure that there is an adequate airway and respirations; there may be respiratory compromise due to intercostal muscle involvement. Once the client is stable, the nurse should conduct a complete neurologic check. The nurse should take all precautions to keep the client's head, neck, and spine position in straight alignment. If the client is conscious, the nurse should briefly assess major reflexes, such as the Achilles, patellar, biceps, and triceps tendons, and sensation of the perineum for bladder function.