Mobility

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.) A) "My line of gravity should fall outside my base of support." B) "The lower my center of gravity, the more stability I have." C) To broaden my base of support, I should spread my feet apart." D) "When I lift an object, I should hold it as close to my body as possible." E) "When pulling an object, I should move my front foot forward."

B) "The lower my center of gravity, the more stability I have." C) To broaden my base of support, I should spread my feet apart." D) "When I lift an object, I should hold it as close to my body as possible."

Which score would a nurse select from the muscle function grading scale if the client has full strength and range of motion in a given joint? A) 0 B) 5 C) 8 D) 10

B) 5 The muscle function grading scale ranges from 0 to 5. A score of 0 indicates paralysis, meaning that the client cannot contract the muscles associated with a given joint. In contrast, a score of 5 indicates that the client can move a joint through the full range of motion under full resistance.

The nurse is providing care for a client who is experiencing subjective symptoms of carpal tunnel syndrome. Which test should the nurse anticipate being performed by a provider during the physical assessment of this client? A) Bulge test B) Ballottement test C) Phalen test D) McMurray test

C) Phalen test Phalen test is a special assessment to determine whether the client is experiencing carpal tunnel syndrome. With this test, the wrists are held in acute flexion for 60 seconds. Numbness, tingling, or pain may indicate carpal tunnel syndrome.

What could happen in the joints due to a loss of elasticity? A) contractions B) fractures C) contractures D) hypotension

C) contractures

The nurse and the UAP are preparing to move a client from the bed to a chair for the first time using a hydraulic lift. What is the first thing the nurse should do prior to beginning this procedure? A) Place the canvas sling under the client's thighs. B) Place the client in the supine position. C) Lock the wheels of the client's bed. D) Demonstrate the use of the hydraulic lift to the client.

D) Demonstrate the use of the hydraulic lift to the client. Prior to using the hydraulic lift with a client for the first time, the nurse should demonstrate the use of the lift to calm any anxieties the client may have about the lift.

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A) Obtain a walker for the client to use to transfer back to bed. B) Call for additional staff to assist with the transfer. C) Use a transfer belt and assist the client back into bed. D) Determine the client's ability to help with the transfer.

D) Determine the client's ability to help with the transfer.

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include? (Select all that apply) A) A stable center of gravity increases stability and balance. B) A wide base lowers the center of gravity. C) Proper body alignment involves tightening the abdomen. D) Leaning slightly back while carrying an object equalizes the center of gravity. E) Bending at the waist when picking up objects stabilizes the spine.

A) A stable center of gravity increases stability and balance. B) A wide base lowers the center of gravity. C) Proper body alignment involves tightening the abdomen.

A nurse is caring for a client who had a stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions? A) Deep vein thrombosis B) Asthma C) Hernia D) Hypertension

A) Deep vein thrombosis The nurse should identify that the client is at risk for developing deep vein thrombosis. Blood clots can develop when a client is immobile due to an increase in blood viscosity and atrophy of the muscles. This can then result in decreased blood circulation, which can lead to blood clots and deep vein thrombosis.

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis? A) Fowler's B) Lateral C) Prone D) Supine

A) Fowler's The nurse should place the client in Fowler's position to promote lung expansion and prevent atelectasis, which is the partial or complete collapse of a lung. In this position, the client is seated in a semi-sitting position and can have their knees bent or straight.

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage? A) Lateral B) Supine C) Prone D) Fowler's

C) Prone The nurse should place the client who has pneumonia in the prone position to promote postural drainage. In this position, the client lies flat on their abdomen with their head turned to the side.

The nurse attempts to meet the developmental needs of a four-year-old child while doing range of motion (ROM) exercises by doing what with the child? A) Explaining why the ROM exercises must be done. B) Promising the child, a treat after ROM exercises are completed. C) Turning the ROM exercises into a game. D) Asking the child's parents to complete the ROM exercises.

C) Turning the ROM exercises into a game. Turning the ROM exercise experience into a game will meet the child's developmental needs and elicit the most cooperation from the child.

The cells that produce the matrix for bone formation are known as A) osteoclasts. B) sarcomeres. C) osteoblasts. D) epiphyseal plates.

C) osteoblasts. Osteoblasts are the cells that produce the matrix for bone formation, whereas osteoclasts are cells that break down bone tissue.

Which of the following is an effect of mobility occurring? A) poor circulation B) constipation C) increased peristalsis D) low blood pressure

C) increased peristalsis

The nurse is caring for a preadolescent male client who is accompanied by his mother. Which statement by the mother would be consistent with the client experiencing growing pains? A) "My son often complains that his arms and legs feel sore." B) "My son seems to get injured very easily, especially broken bones." C) "My son often doesn't want to walk because his knees hurt." D) "My son occasionally complains of pain in his lower back."

A) "My son often complains that his arms and legs feel sore." Long bones of children contain an epiphyseal plate that serves as a location for bone growth. Rapid bone growth in these long bones may produce growing pains as the lengthening bones pull on the muscles. Because this only occurs in the long bones, growing pains are most likely to be felt in the arms and legs.

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include? A) "The top of the walker should be at the level of your wrist." B) "When using the stairs, place the walker before taking a step." C) "When holding the walker, bend your elbows 30°." D) "Take a step first before moving the walker."

A) "The top of the walker should be at the level of your wrist." The nurse should instruct the client to ensure that the top of the walker is at the level of their wrist. This indicates the walker is measured at the appropriate height and prevents strain on the client's back.

The nurse is providing care for several clients. For which client should the nurse anticipate an order for administering 1000 mg of aspirin? A) A 68-year-old client with rheumatoid arthritis who is experiencing hand pain B) A 5-year-old client who is experiencing ankle pain after a fall from a horse C) A 38-year-old client who is experiencing headache pain after a skiing accident D) A 70-year-old client who is experiencing back pain after laminectomy

A) A 68-year-old client with rheumatoid arthritis who is experiencing hand pain Aspirin is appropriate for the client with rheumatoid arthritis who is experiencing hand pain, assuming there are no other contraindications.

A nurse is performing a focused assessment on an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing an age-related change to their musculoskeletal system? A) Increased curvature of the thoracic spine B) Reduced depth perception C) Narrower stance when standing D) Quick steps when ambulating

A) Increased curvature of the thoracic spine The nurse should identify that an increased curvature of the thoracic spine, along with protrusion of the neck, indicates an age-related change to the client's musculoskeletal system. This occurs due to bone loss and degeneration of vertebral discs. This can cause the client to lean forward when standing and have an unsteady gait when walking.

The nurse is planning care for a client who is experiencing an alteration in mobility. Which would the nurse include as an independent nursing intervention? A) Instructing on the importance of proper nutrition and an active lifestyle B) Administering a prescribed nonsteroidal anti-inflammatory drug (NSAID) C) Identifying necessary modifications to the home environment D) Prescribing a skeletal muscle relaxant

A) Instructing on the importance of proper nutrition and an active lifestyle An appropriate independent nursing intervention for a client who is experiencing an alteration in mobility is providing instruction on the importance of proper nutrition and an active lifestyle. Administering a prescribed NSAID is an example of a collaborative intervention that the nurse can implement.

The nurse is caring for a client with limited movement who weighs 415 pounds and will plan to use which assistive device when moving this client up in bed? A) Mechanical lift B) Turn sheet C) Fiction-reducing device D) Pull sheet

A) Mechanical lift A mechanical lift is necessary to move an obese client up in the bed because the client's weight and immobility will require the nurse to lift more than 35 pounds of the client's weight.

The nurse is preparing to do pin site care for a client in skeletal traction. It is noted that the site appears red and feels warm to the touch. What actions will the nurse perform in taking care of this situation? Select all that apply. A) Notify the healthcare provider. B) Refrain from disturbing the crusts around the pin until the healthcare provider can observe it. C) Expect to obtain a culture and sensitivity specimen from the pin site. D) Remove the client's traction weights until the healthcare provider sees the client. E) Check the client's vital signs.

A) Notify the healthcare provider. C) Expect to obtain a culture and sensitivity specimen from the pin site. E) Check the client's vital signs. The healthcare provider should be notified immediately once an infection is suspected. A culture and sensitivity of the drainage is obtained so antibiotic sensitivity can be determined. The nurse should take the client's temperature to monitor for signs of systemic infection.

The nurse will stand where when preparing to ambulate a client who uses crutches? A) On the client's affected side and slightly behind. B) On the client's strong side and slightly ahead. C) On the client's affected side and directly next to the client. D) On the client's strong side and directly next to the client.

A) On the client's affected side and slightly behind. The nurse stands behind the client and toward the affected side to provide support if the client loses balance.

The nurse has completed discharge teaching about range-of-motion exercises with an elderly client that are to be completed at home. The nurse explains that these exercises are important to complete for what reason? A) ROM exercises will help the client maintain necessary muscle mass. B) ROM exercises prevent the elderly client from becoming depressed. C) ROM exercises increase the elderly client's dependent behaviors. D) ROM exercises causes an elderly client to use proper body mechanics.

A) ROM exercises will help the client maintain necessary muscle mass. ROM exercises will help prevent a loss of muscle mass which could lead to difficulties performing activities requiring strength.

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.) A) Request assistance when repositioning a client. B) Avoid twisting your spine or bending at the waist. C) Keep your knees slightly lower than your hips when sitting for long periods of time. D) Use smooth movements when lifting and moving clients. E) Take a break for repetitive movements every 2 to 3 hours to flex and stretch your joints and muscles.

A) Request assistance when repositioning a client. B) Avoid twisting your spine or bending at the waist. D) Use smooth movements when lifting and moving clients.

A nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks? A) Sit on the edge of the bed for 1 min B) Stand in place for 5 seconds C) Walk in place D) Step forward and backward

A) Sit on the edge of the bed for 1 min The nurse should identify that the client who is at Level 1 Mobility of the MAT requires maximum assistance. The client should be able to sit on the edge of the bed for 2 min and extend their arms across their chest to shake hands with the nurse before advancing to the next level. If the client is unable to complete both tasks, they remain at Level 1 Mobility of the MAT.

The nurse observes the unlicensed assistive person (UAP) perform range-of-motion (ROM) exercises to a client's leg. The nurse knows that UAP is correctly performing abduction of the hip when which set of motions is completed? A) The UAP moves the leg to the side away from the body. B) The UAP moves the leg from the side of the body across and in front of the other leg. C) The UAP bends the knee and brings the heel toward the back of the thigh. D) The UAP moves the foot down and away from the leg.

A) The UAP moves the leg to the side away from the body. Abduction is the movement of a limb away from the medial plane of the body so abduction of the leg would be movement to the side away from the body.

A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL? A) Toileting B) Writing C) Ambulating D) Talking

A) Toileting The nurse should include that toileting is an ADL that the AP can assist the client to perform. Other ADLs include dressing, bathing, and feeding.

A 16-year-old has had a full leg cast in place for 2 months, and it is being removed today. Which of the following assessment findings would be expected following the removal of the cast? (Select all that apply.) A. Popliteal pulse equal in both legs B. Slight footdrop noted on affected leg C. Swelling noted at ankle on affected leg D. Weight bearing less stable on affected leg E. Calf circumference greater in unaffected leg F. Greater range of motion of knee of unaffected leg

A, D, E, F A. Popliteal pulse equal in both legs D. Weight bearing less stable on affected leg E. Calf circumference greater in unaffected leg F. Greater range of motion of knee of unaffected leg

The nurse caring for a 73-year-old female client who has been hospitalized with a stroke instructs the client's daughter to continue to do passive range-of-motion exercises with her mother on her affected side to prevent contractures. The nurse explains to the daughter that this is very important in an immobile older adult client because contractures can form in as little as: A. 8 hours B. 24 hours C. 1 week D. 1 month

A. 8 hours Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. When a contracture occurs, the joint cannot obtain full ROM. Contractures sometimes leave a joint or joints in a nonfunctional position, as seen in clients who are permanently curled in a fetal position. Early prevention of contractures is key; they can begin to form after only 8 hours of immobility in the older adult client.

Which of the following clients is most at risk for losing his or her balance? A. A woman who is 9 months pregnant walking down a flight of stairs B. A 16-year-old skate boarding down a 15-degree slope C. A 45-year-old taking hypertensive medication D. A 4-year-old riding a tricycle

A. A woman who is 9 months pregnant walking down a flight of stairs Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced.

The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to: A. Measure the calf and thigh circumferences B. Attempt to elicit Homans' sign C. Palpate the temperature of the feet D. Observe for a loss of hair and skin turgor in the lower legs

A. Measure the calf and thigh circumferences Calf and thigh circumferences should be measured daily. Unilateral increases in calf or thigh circumference can be an early indication of thrombosis.

Which demonstration by the patient below shows that the patient knows how to properly ambulate a cane? A. The patient holds the cane on the strong side and moves the cane and weak side forward together, and then moves the strong side. B. The patient holds the cane on the strong side and moves the cane forward, then moves the weak side, and then moves the strong side. C. The patient holds the cane on the weak side and moves the cane forward, then moves the weak side, and then moves the strong side. D. The patient holds the cane on the weak side and moves the cane and weak side forward together, and then moves the strong side.

A. The patient holds the cane on the strong side and moves the cane and weak side forward together, and then moves the strong side. The patient holds the cane on the strong side and moves the cane and weak side forward TOGETHER, and then moves strong side.

Your patient attempts to sit down in the bedside chair after ambulating in the hallway with crutches. What finding requires you to re-educate the patient on how to sit down in the chair correctly while using crutches? A. The patient places both crutches on the non-injured side before sitting down in the chair. B. The patient backs up to the chair's seat until he feels it with his non-injured leg and stops. C. The patient keeps the injured leg extended out in front of him while sitting down. D. The patient holds both crutches on one side and reaches for the hand grips on the crutches and places weight on them while sitting down.

A. The patient places both crutches on the non-injured side before sitting down in the chair. This requires re-education because the patient should place both crutches on the INJURED SIDE (NOT the non-injured side) before sitting down in the chair. The crutches will help provide weight support to the injured side while sitting down.

The nurse is caring for a client who is 28 weeks pregnant. The client says she has recently begun to experience frequent lower back pain and asks the nurse what can be done to control this pain. What is the nurse's best response? A) "Back pain is common during pregnancy and can usually be managed by taking nonsteroidal anti-inflammatory drugs (NSAIDs)." B) "Let's talk about some postural adjustments that might help alleviate your pain." C) "Back pain during pregnancy is often related to kidney infection. Have you experienced any recent urinary problems, including pain when voiding?" D) "The physician will likely order an x-ray to investigate potential causes of your pain."

B) "Let's talk about some postural adjustments that might help alleviate your pain." Back pain is common during pregnancy due to strain on the back from the growing uterus and fetus; abdominal weakness from stretched abdominal muscles; and hormonal changes that loosen the ligaments in the joints of the pelvis.

The nurse is aware that which client would best be able to handle a three-point gait using crutches? A) A 76-year-old client who complains of pain in both knees. B) A 25-year-old client with a broken right ankle. C) A 19-year-old client with a broken right tibia and a sprained left foot. D) A 55-year-old client with a fractured left patella and a right foot laceration.

B) A 25-year-old client with a broken right ankle. The three-point gait requires that the client must bear the entire body weight on the unaffected leg. A young person whose only injury is a broken right ankle would be able to do this.

The nurse is caring for a client who is experiencing limited mobility related to a musculoskeletal alteration. Which laboratory tests would be useful to diagnose the client appropriately? Select all that apply. A) Magnetic resonance imaging (MRI) B) Alkaline phosphatase (ALP) C) Human leukocyte antigen-B27 (HLA-B27) D) Rheumatoid factor (RF) E) Electromyography (EMG)

B) Alkaline phosphatase (ALP) C) Human leukocyte antigen-B27 (HLA-B27) D) Rheumatoid factor (RF) ALP, HLA-B27, and RF are all laboratory tests that are used to diagnose clients with musculoskeletal disorders that can cause alterations in mobility. ALP is produced by bone and other organs. Increased ALP may indicate bone disease, bone fracture, bone tumors, osteomalacia, Paget disease, or rickets. Decreased ALP may indicate Wilson disease. The presence of HLA-B27 indicates an increased risk for ankylosing spondylitis and arthritis. Elevated levels of RF may indicate rheumatoid arthritis, scleroderma, lupus erythematosus, and adult Still disease.

An adult client is diagnosed with a degenerative bone disease that is impairing mobility. Based on this information alone, which of the following actions should be the nurse's first priority? A) Implementing a low-level exercise program for the client B) Assessing the client's pain management C) Teaching the client relaxation techniques D) Referring the client to a dietitian

B) Assessing the client's pain management When caring for a client with a degenerative bone disease that is impairing mobility, the nurse should assess pain management prior to implementing an exercise program, teaching relaxation exercises, or referring to a dietitian.

A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing? A) Atrophy B) Foot drop C) Joint contracture D) Disuse osteoporosis

B) Foot drop The nurse should suspect the client is experiencing foot drop. Foot drop occurs when the joint of the foot becomes contracted and results in the inability to perform dorsiflexion, or pulling the toes upward. This is due to nerve damage that causes shortening of the muscle. The foot is left with the toes pointing downward and in a dropped position.

Within the human body, which type of connective tissue connects bones to other bones to form a joint? A) Tendon B) Ligament C) Cartilage D) Myelin

B) Ligament Ligaments, tendons, and cartilage are all connective tissues. Ligaments connect bones to other bones to form a joint.

A nurse is caring for a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client? A) Gait belt B) Mechanical lift C) Cane D) Sit-to-stand lift

B) Mechanical lift The nurse should identify that, according to the MAT, a client who requires total assistance requires the use of a mechanical lift or slide board, along with assistance from one to two personnel, to transfer the client.

A nurse is caring for a client who requires maximum assistance to transfer from the bed to the chair. Which of the following pieces of equipment should the nurse use? A) Pivot disc B) Mechanical lift C) Sit-to-stand lift D) Gait belt

B) Mechanical lift The nurse should use a mechanical lift, along with assistance from two or more health care staff, to transfer a client who is unable to assist. The use of a mechanical lift decreases the risk of injury to both the staff and the client.

A preadolescent client who fell from a balance beam in physical education class injured her ankle. Given this information, which action by the nurse is appropriate? A) Referring the client to physical therapy B) Placing an ice pack on the client's ankle C) Planning for a corticosteroid injection D) Ordering an x-ray of the ankle

B) Placing an ice pack on the client's ankle An appropriate intervention for a client who experiences an ankle injury is placing ice on the ankle to limit swelling.

The nurse is caring for an adult client who sustained a right distal radial fracture and a left tibia fracture. Which mobility aid does the nurse anticipate being used for this client? A) Lofstrand crutches B) Platform crutches C) Walker D) Axillary crutches

B) Platform crutches This client has fractures in both the leg and wrist. Platform crutches are used for clients who are unable to bear weight on their wrists.

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take? A) Reposition the client every 2 hr while in bed. B) Remind the client to use the incentive spirometer. C) Obtain the client's weight daily. D) Encourage the client to eat foods that are high in fiber.

B) Remind the client to use the incentive spirometer. The nurse should remind the client who is at risk for developing atelectasis to use the incentive spirometer. Using the incentive spirometer prevents atelectasis from occurring because the client takes slow, deep breaths to promote lung expansion.

The nurse is caring for a client who uses a hydraulic lift to be moved out of the bed. What is the nurse's first action prior to starting this procedure? A) Perform hand hygiene. B) Request help from another staff member. C) Roll the client to the side to position the sling. D) Demonstrate the use of the hydraulic lift to the client.

B) Request help from another staff member. A minimum of 2 healthcare workers is required to safely move a client with a hydraulic lift. The nurse should first obtain assistance.

The nurse is caring for a client who is complaining of esophageal reflux symptoms. After administering the prescribed medication, the nurse will place the client in what bed position to assist in providing comfort to this client? A) Semi-Fowlers B) Reverse Trendelenburg C) Trendelenburg D) High-Fowler

B) Reverse Trendelenburg Reverse Trendelenburg places the client in position with the bed tilted down starting at the head of the bed. This allows gravity to assist with keeping gastric contents in the stomach and out of the esophagus.

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? A) Supine B) Semi-Fowler's C) Semi-prone D) Trendelenburg

B) Semi-Fowler's

The nurse is preparing to conduct an hourly assessment of a client who was placed in skin traction approximately 6 hours ago and has been stable since that time. The plan is to check the client's vital signs, pain level and complete what other assessments? Select all that apply. A) Neurovascular assessment of the unaffected leg. B) Skin integrity of both heels. C) Massage the skin of the buttocks with a dry washcloth. D) Ensure traction weight is correctly placed. E) Ensure client's shoulders and hips are in alignment.

B) Skin integrity of both heels. D) Ensure traction weight is correctly placed. E) Ensure client's shoulders and hips are in alignment. Check the skin integrity of any area exposed to the surface of the bed like the heels. The nurse should ensure that the weights are hanging properly, not sitting on the floor. The body alignment shoulders and hips in alignment) should be checked often.

A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include? A) Cartilage is always remodeling and changing. B) Tendons connect muscle to bone. C) Ligaments are flexible connective tissue that coat bony areas. D) Synovial joints attach to the skeleton to maintain posture.

B) Tendons connect muscle to bone. Tendons and ligaments are both made of fibrous connective tissue. Tendons attach muscle to bone while ligaments attach bones to other bones.

The nurse is observing an unlicensed assistant person (UAP) make an occupied bed and will provide correction if the UAP uses which technique with body mechanics? A) The UAP stands close to the bed while making it. B) The UAP pulls the client to move him in the bed. C) The UAP distributes weigh evenly between both feet. D) The UAP carries the clean sheets and blankets close to the body.

B) The UAP pulls the client to move him in the bed. Pulling an object (or client) to move it puts a strain on a person's back. The UAP should push to move the object using the legs.

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint? A) Synovial joints contain sensory receptors that trigger flexion. B) The contraction of a muscle results in flexion of a joint. C) Neurotransmitters coordinate with cartilage to initiate flexion. D) Ligaments extend to enable flexion of a joint.

B) The contraction of a muscle results in flexion of a joint. When muscles contract, they shorten and pull against the bone they are attached to. This results in flexion at the joint.

________ occurs as a result of fluid retention in the lungs due to the chest muscles getting weak. A) contractures B) hypostatic pneumonia C) orthostatic hypotension D) muscle weakness

B) hypostatic pneumonia

A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident (stroke). In planning care for this client, the nurse implements which one of the following as an appropriate intervention? A. Encourage an even gait when walking in place. B. Assess the extremities for unilateral swelling and muscle atrophy. C. Encourage holding the breath frequently to hyperinflate the client's lungs. D. Teach the use of a two-point crutch technique for ambulation.

B. Assess the extremities for unilateral swelling and muscle atrophy. Because edema moves to dependent body regions, assessment of the immobilized client should include the sacrum, legs, and feet. Unilateral increases in calf diameter can be an early indication of thrombosis.

The nurse recognizes that a client who is inactive is at a risk for decreased muscle mass as a result of increased muscle atrophy and: A. Decrease metabolic rate B. Catabolic tissue breakdown C. Inactivity-induced depression D. Anorexia caused by decreased peristalsis

B. Catabolic tissue breakdown Weight loss, decreased muscle mass, and weakness result from tissue catabolism (tissue breakdown)

To promote respiratory function in the immobilized client, the nurse should: A. Change the client's position every 4 to 8 hours B. Encourage deep breathing and coughing every hour C. Use oxygen and nebulizer treatments regularly D. Suction the client's secretions every hour

B. Encourage deep breathing and coughing every hour The nurse should actively work with the immobilized client to deep breathe and cough every 1 to 2 hours to promote chest expansion.

Two nurses are standing on opposite sides of the bed to move the client up in bed with a drawsheet. Where should the nurses be standing in relation to the client's body as they prepare for the move? A. Even with the thorax B. Even with the shoulders C. Even with the hips D. Even with the knees

B. Even with the shoulders The nurses should be standing even with the client's shoulders when they prepare to move the client up in bed.

To reduce the chance of plantar flexion (footdrop) in a client on prolonged bed rest, the nurse should implement the use of: A. Trapeze bars B. High-top sneakers C. Trochanter rolls D. Thirty-degree lateral positioning

B. High-top sneakers High-top tennis shoes or an ankle-foot orthotic may be used to help maintain dorsiflexion and prevent footdrop.

As the nurse, how would you correctly demonstrate to the patient the proper gait while using a walker? A. Hold onto the walker's hand grips, take a step forward with the strong side, then move walker forward, and then take a step with the weak side. B. Hold onto the walker's hand grips, move walker forward, then take a step forward with the weak side, and then take a step forward with the strong side. C. Hold onto the walker's hand grips, move walker forward, then take a step forward with the strong side, and then take a step forward with the weak side. D. Hold onto the walker's hand grips, take a step forward with the weak side, then move walker forward, and then take a step with the strong side.

B. Hold onto the walker's hand grips, move walker forward, then take a step forward with the weak side, and then take a step forward with the strong side. The correct gait with a walker is to: Hold onto the walker's hand grips, move walker forward, then take a step forward with the weak side, and then take a step forward with the strong side.

The nurse caring for a 38-year-old female client with multiple fractures in the trauma intensive care unit knows that this client is at high risk for pulmonary complications such as atelectasis from her immobility. One of the interventions that the nurse can do to help prevent this from occurring is to: A. Keep the PaO2 level at or above 94% B. Instruct the client to deep breathe and cough every hour while awake C. Turn the client every 2 hours D. Keep the client on the ventilator as long as possible

B. Instruct the client to deep breathe and cough every hour while awake In atelectasis, secretions block a bronchiole or a bronchus, and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. The site of the blockage affects the severity of atelectasis. Sometimes an entire lung lobe or a whole lung collapses. At some point in the development of these complications, there is a proportional decline in the client's ability to cough productively.

A client has sequential compression stockings in place. The nurse evaluates that they are implemented appropriately by the new staff nurse when the: A. Initial measurement is made around the client's calves B. Intermittent pressure is set at 40 mm Hg C. Stockings are wrapped directly over the leg from ankle to knee D. Stockings are removed every hour during application

B. Intermittent pressure is set at 40 mm Hg Inflation pressures average 40 mm Hg.

A client is getting up for the first time after a period of bed rest. The nurse should first: A. Assess respiratory function B. Obtain a baseline blood pressure C. Assist the client with sitting at the edge of the bed D. Ask the client if he or she feels light-headed

B. Obtain a baseline blood pressure When getting the client up for the first time after a period of bed rest, the nurse should document orthostatic changes. The nurse first obtains a baseline blood pressure.

When a patient uses a cane to ambulate, the patient will hold the cane on the? A. Weak side B. Strong side C. It does not matter. The patient should choose what side is the most comfortable for them.

B. Strong side The patient will hold the cane on the strong side (non-injured side).

A patient will be using a walker for the first time. You adjust the walker to fit the patient. Which finding below demonstrates that the walker properly fits the patient? A. There is a 2-3 finger width distance between the hand grips of the walker and the wrists. B. The elbows bend at about a 15-30 degree angle when the patient holds onto the hand grips of the walker. C. The patient's back is mid-line with the crossbar of the walker. D. The crossbar of the walker is even with the greater trochanter.

B. The elbows bend at about a 15-30 degree angle when the patient holds onto the hand grips of the walker. When a patient holds the hand grips of the walker, the elbows should slightly bend at a 15-30 degree angle.

A patient needs to go up the stairs while using crutches. What finding by the nurse demonstrates the patient understands how to ambulate upstairs with crutches? A. The patient moves the crutches forward up the step, then the injured and non-injured leg. B. The patient moves the non-injured leg forward onto the step and then the moves the injured leg and crutches up. C. The patient moves the injured leg forward onto the steps, then moves the crutches, and then moves the non-injured leg. D. The patient moves the crutches and non-injured leg forward to the step together, and then the non-injured leg.

B. The patient moves the non-injured leg forward onto the step and then the moves the injured leg and crutches up. The patient will move the non-injured leg forward onto the step and then will move the injured leg and crutches up.

Your patient is using a cane for the first time. Before using the cane, you assess that the cane properly fits the patient. Which findings below demonstrate the cane properly fits the patient? Select all that apply: A. The arm that is holding the cane is flexed at about a 40 degree angle. B. The top of the cane is at the level of the greater trochanter. C. When the patient dangles their arms, the top of the cane is even with the crease of the wrist closest to the hand. D. There is a 1.5 inch gap between the top of the cane and the axillae.

B. The top of the cane is at the level of the greater trochanter. C. When the patient dangles their arms, the top of the cane is even with the crease of the wrist closest to the hand. Option B and C are correct because these are the two methods used to determine a proper fit for a cane.

While your patient is ambulating with crutches he moves both crutches forward along with the injured leg and then moves the non-injured forward. When you document you will note that the patient used what type of gait while ambulating with crutches? A. Two-point gait B. Three-point gait C. Four-point gait D. Swing-to-gait

B. Three-point gait The answer is B. This describes the three-point gait while using crutches.

The nurse and a nursing assistive personnel (NAP) are going to move an older adult client up in bed. Before moving the client, the nurse explains to the NAP that they will need to lift the client off the bed with an assistive device instead of using the drawsheet. The most important reason for using the assistive device is: A. To avoid frightening the client B. To avoid shearing the client's skin C. To avoid getting "written up" for not following lift procedures D. Because the nurse is tired

B. To avoid shearing the client's skin The greater the surface area of the object that is moved, the greater the friction. A larger object produces greater resistance to movement. To decrease surface area and reduce friction when clients are unable to assist with moving up in bed, nurses use an ergonomic assistive device, such as a full body sling. It mechanically lifts the client off the surface of the bed, thereby preventing friction, tearing, or shearing of the client's delicate skin.

Your patient will be using crutches for mobility. After educating the patient on how to adjust the crutches to fit correctly, you assess how well the patient understood the instructions. What findings demonstrate that the crutches were adjusted correctly by the patient? Select all that apply: A. The hand grips of the crutches are even with the mid-forearm. B. When the patient grips the hand grips of the crutches the elbow bends at about 30 degrees. C. The patient has a 2-3 finger width distance between the axillae and crutch rest pad. D. The patient places weight on the axillae rather than the hands while ambulating.

B. When the patient grips the hand grips of the crutches the elbow bends at about 30 degrees. C. The patient has a 2-3 finger width distance between the axillae and crutch rest pad. Properly fitted crutches should be a 2-3 finger width (about 1-1.5 inches) distance between the axillae (armpit area) and the crutch rest pads during ambulation. This prevents damaging the nerves that are located in the axillae during ambulation. In addition, when the patient grips the hand grips of the crutches the elbow should slightly bend at about 30 degrees.

While going down the stairs with crutches the patient will move the crutches down onto the step followed by? A. moving the non-injured leg down onto the step. B. moving the injured leg down onto the step. C. moving both legs down onto the step.

B. moving the injured leg down onto the step. When going down the stairs with crutches, the patient will move the crutches down first onto the step followed by moving the INJURED leg and then the patient will move the non-injured leg down.

A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? A) "Lie on your back with your head and shoulders supported by a pillow." B) "Have your head turned to the side while you lie on your stomach." C) "Have a table beside your bed so you can sit on the bedside and rest your arms on the table." D) "Lie on your side with your top arm resting on the bed and your weight on your hip."

C) "Have a table beside your bed so you can sit on the bedside and rest your arms on the table."

The nurse is preparing to assist a client with ambulation and knows a gait belt may not be appropriate to use for a client with which condition? A) A client wearing a knee brace. B) A client who uses a walker for ambulation. C) A client who has a large abdominal incision. D) A client who has vertigo.

C) A client who has a large abdominal incision. A gait belt may not be appropriate for a client who has an abdominal incision because of the pressure is may put on the incision.

A nurse in a long-term facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing? A) Sarcopenia B) Disuse osteoporosis C) Atrophy D) Joint contracture

C) Atrophy The nurse should suspect the client is experiencing atrophy of their muscles. Atrophy occurs when the muscles of the body become smaller and weaker. This can occur with prolonged immobility or disuse of a limb.

The nurse is aware that clients who use the swing-to-gait for ambulation on a regular basis are at risk for development of which problem? A) Atrophy of the arm muscles B) Fractures of the feet C) Atrophy of the leg muscles D) Sciatic nerve injury

C) Atrophy of the leg muscles Prolonged use of the swing-to-gait can cause atrophy of unused muscles, the legs.

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the would is in which of the following stages of damage? A) Deep damage through the skin and tissue B) Damage beyond the skin layer C) Damage into the skin layer D) Damage with the skin intact

C) Damage into the skin layer The nurse should identify that the client's wound indicates damage into the skin layer. In this stage, the wound can be lighter in color than the client's skin tone, along with temperature differences and an intact or open blister.

The nurse is caring for a client who was placed in skeletal traction 48 hours ago for treatment of a serious femur fracture. The nurse will check the client's neurovascular status of the client's affected foot how often? A) Every 30 minutes B) Every 1 hour C) Every 4 hours D) Every 24 hours

C) Every 4 hours The client's neurovascular status is checked every 4 hours while the client remains in traction.

The nurse and the UAP are preparing to logroll a client who has a spinal injury. The nurse will ask the UAP to obtain what assistive device prior to beginning the procedure? A) Trochanter roll B) Hydraulic lift C) Friction-reducing device D) Foot board

C) Friction-reducing device A friction-reducing device is necessary to pull the client to the side of the bed prior to logrolling the client.

The UAP is caring for a 79-year-old client who is immobilized and is preparing to complete range-of-motion (ROM) exercises. The nurse cautions the UAP to avoid which motion in an elderly client? A) Flexion B) Extension C) Hyperextension D) Abduction

C) Hyperextension Hyperextension should be avoided in the elderly because joints become joints become less flexible with age and hypertension may cause pain or nerve damage.

The nurse is conducting a gait and posture assessment for a client who is experiencing mobility issues. Which action by the nurse is appropriate during this assessment? A) Assessing the client's muscle mass and strength B) Measuring the length and circumference of the client's extremities C) Inspecting the client's spine for curvature D) Palpating the client for tenderness and pain

C) Inspecting the client's spine for curvature When assessing a client's gait and posture, the nurse should be sure to inspect the client's spine for curvature. Assessing muscle mass and strength, measuring the length and circumference of the extremities, and palpating for tenderness and pain are part of the physical assessment performed by the nurse for clients who are experiencing mobility issues.

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture? A) Center of gravity B) Bones C) Muscles D) Synovial joints

C) Muscles Skeletal muscles are attached to the skeleton. They maintain body posture and position.

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include? A) Muscles store calcium and magnesium. B) Muscles produce red blood cells and platelets. C) Muscles assist with thermoregulation in the body. D) Muscles provide protection of internal organs.

C) Muscles assist with thermoregulation in the body. Contracting muscles generate heat that assists in maintaining body temperature. Shivering is an example of the muscles working to produce heat.

The nurse is preparing to place a client with COPD in the orthopneic bed position and will place what item in front of this client that is necessary to maintain this position? A) Wheelchair B) Stationary chair C) Over the bed table D) Client's urinal

C) Over the bed table An overbed table is necessary when the client is in the orthopneic position because it assists the client with exhalation.

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include? A) The use of ergonomics improves blood circulation in the body. B) The use of ergonomics eliminates costs related to workers' compensation. C) The use of ergonomics increases job satisfaction. D) The use of ergonomics maintains the body's balance and a lower center of gravity.

C) The use of ergonomics increases job satisfaction. The use of ergonomics increases job satisfaction along with productivity of staff members. When staff members can work safely and effectively, they can perform at a higher level.

The nurse is preparing to transport a six-month-old infant to the radiology department. What measures will the nurse institute to safely complete this procedure? Select all that apply. A) Ensure the parents stay in the infant's room. B) Unhook all monitors and IV lines prior to transporting the infant. C) Use a high-top crib for transporting. D) Cover the infant with a blanket. E) Ensure the infant's hands are washed before transport begins.

C) Use a high-top crib for transporting. D) Cover the infant with a blanket. A high-top crib ensures the infant can't fall during transport. Infant is kept covered to prevent hypothermia from occurring.

Which of the following statements regarding physical activity and its effect on activity tolerance made by a client shows the most informed knowledge regarding the connection between the two? A. "I know I need to walk more if I want to get stronger." B. "I don't like walking, but I do it because I know it will make me stronger." C. "I try to walk a little farther each afternoon so I can dance at my grandson's wedding." D. "I walk with my son three evenings a week because it's good for his weight and for my bones."

C. "I try to walk a little farther each afternoon so I can dance at my grandson's wedding." Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. The better the muscle tone, the more stamina the client will experience.

A 16-year-old had a full leg cast for 4 months, and it is being removed today. Which of the following statements made by the client shows the most informed understanding of the effects of immobilization of a muscle on its strength and stamina? A. "I'm hoping to be back at soccer practice in 3 weeks." B. "Walking and riding my bike will help regain the muscle." C. "I'll practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring." D. "There was a good bit of muscle and strength loss, but I'll work at getting it back like it was before the break."

C. "I'll practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring." Even this temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. This answer shows the greatest insight because it provides both a plan and a time line for recovery.

To provide for the psychosocial needs of an immobilized client, an appropriate statement by the nurse is which of the following? A. "The staff will limit your visitors so that you will not be bothered." B. "A roommate can be a real bother. You'd probably rather have a private room." C. "Let's discuss the routine to see if there are any changes we can make." D. "I think you should have your hair done and put on some makeup."

C. "Let's discuss the routine to see if there are any changes we can make." To meet the psychosocial needs of immobilized clients, the nurse should encourage clients to be involved in their care whenever possible. Asking the client if there are changes the staff can make in routine care is an appropriate question.

It has been determined that all of the following clients are at risk for falling. Which one requires the nurse's priority for ambulation? A. A 16-year-old with a sprained ankle being discharged from the emergency department B. A 54-year-old who has taken the initial dose of an antihypertensive medication C. A 45-year-old postoperative client up for the first time since knee surgery D. An 81-year-old who is asthmatic and had a hip replaced 18 months ago

C. A 45-year-old postoperative client up for the first time since knee surgery Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility also affect balance. Although all the options represent a potential risk for falling, the postoperative client has both prolonged immobility and physical injury (surgery) and so is at greatest risk.

Antiembolic stockings (thromboembolic device [TED] hose) are ordered for the client on bed rest following surgery. The nurse explains to the client that the primary purpose for the TEDs is to: A. Keep the skin warm and dry B. Prevent abnormal joint flexion C. Apply external pressure D. Prevent bleeding

C. Apply external pressure The primary purpose of antiembolic stockings is to maintain external pressure on the muscles of the lower extremities and thus promote venous return.

An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as: A. Harsh crackles B. Wheezing on inspiration C. Diminished breath sounds D. Bronchovesicular whooshing

C. Diminished breath sounds Atelectasis is the collapse of alveoli. In atelectasis, secretions block a bronchiole or a bronchus, and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. If the client were suspected of having atelectasis, the nurse would expect diminished breath sounds in the area of hypoventilation.

Your patient is prescribed to use crutches for ambulation. The patient can bear partial weight and needs to be taught how to use the two-point gait while using crutches. Which description below best describes this type of gait with crutches? A. The patient moves both crutches forward and then moves both legs forward to the same point as the crutches. B. The patient moves the right crutch (injured side), then moves the left foot (non-injured side), then moves the left crutch (non-injured side), and then moves the right foot (injured side). C. The patient moves both the right crutch (injured side) and left foot (non-injured side) forward together, and then moves the left crutch (non-injured side) and right foot (injured side) forward together. D. The patient moves both crutches and injured leg forward together, and then moves the non-injured leg forward.

C. The patient moves both the right crutch (injured side) and left foot (non-injured side) forward together, and then moves the left crutch (non-injured side) and right foot (injured side) forward together. The two-point gait is where the patient moves both the right crutch (injured side) and left foot (non-injured side) forward TOGETHER, and then moves the left crutch (non-injured side) and right foot (injured side) forward TOGETHER.

The charge nurse is making assignments for the nursing unit and knows that which healthcare worker is responsible for ensuring that staff use proper body mechanics in caring for assigned clients? A) The charge nurse B) The education director C) The client's healthcare provider D) All healthcare personnel

D) All healthcare personnel All healthcare personnel are responsible for using proper body mechanics when caring for clients.

The nurse is observing a UAP assist a client with a vascular problem back into bed. The nurse would intervene if the UAP placed this client in what position in the bed? A) Low-Fowler B) Semi-Fowler C) Orthopneic position D) Elevate knee-gatch position

D) Elevate knee-gatch position The elevate knee-gatch bed position is contraindicated in clients with vascular problems because it will put pressure on the blood vessels at the back of the knee.

A client presents with an alteration in mobility. Which finding would suggest damage to the muscle? A) Increased PTH levels B) Decreased PTH levels C) Decreased CK levels D) Increased CK levels

D) Increased CK levels Creatine kinase (CK) is used to detect muscle damage, muscle inflammation, rhabdomyolysis, polymyositis, and muscular dystrophy. Thus, increased CK levels are suggestive of increased muscle inflammation.

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include? A) Kyphosis is when the upper back extends posteriorly to the lower back. B) Kyphosis is an inward curvature of the lower back. C) Kyphosis is a sideways curvature of the spine. D) Kyphosis is a rounded upper back with the pelvis tilted forward.

D) Kyphosis is a rounded upper back with the pelvis tilted forward. Kyphosis is when the upper back is abnormally rounded with the pelvis tilted forward.

A nurse is preparing to transfer a client from bed to a wheelchair. Which of the following actions by the nurse demonstrates proper use of body mechanics? A) Twisting the torso when transferring the client B) Bending at the waist when transferring the client C) Placing the bed in the high position before transferring the client D) Looking at the client face-to-face when transferring the client

D) Looking at the client face-to-face when transferring the client The nurse should look at the client face-to-face when transferring. This prevents twisting or turning of the torso, which can cause back injuries.

The nurse is teaching a group of newly hired UAP's about proper body mechanics and instructs them to use which most important piece of equipment to ensure that proper body mechanics are used? A) Gait belt B) Assistive moving device C) Additional staff D) No special equipment is required

D) No special equipment is required No special equipment is required to do proper body mechanics but the healthcare worker must know what equipment is available to assist with safe movement of a client.

A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client? A) Speech therapist B) Physical therapist C) Respiratory therapist D) Occupational therapist

D) Occupational therapist The nurse should recommend a referral for an occupational therapist to assist the client with ADLs. An occupational therapist assists clients who have impaired function to perform ADLs, such as bathing and brushing their teeth.

The nurse is watching an unlicensed assistive person (UAP) prepare to move an eighteen-month-old toddler from the pediatric unit to the radiology unit. The nurse will stop the UAP if the UAP chooses which form of transport? A) The child's crib B) Pediatric wheelchair C) Walking while holding the mother's hand D) Stretcher

D) Stretcher A stretcher is not a safe form of transport because a mobile toddler could possibly fall off of it.

The nurse has asked the unlicensed assistive person (UAP) to provide personal care to the client who is in skin traction and will ensure that UAP knows to place the client in what position? A) Semi-Fowler B) Low-Fowler C) Lateral D) Supine

D) Supine The client in skin traction must be maintained in the supine position to maintain body alignment and proper traction.

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches? A) The hand grips of the crutches are at the level of the client's umbilicus. B) The client's elbows are bent 45° when holding the crutches. C) The client places their weight on their axilla when using the crutches. D) The client has the crutches resting 5 cm (2 in) below their axilla.

D) The client has the crutches resting 5 cm (2 in) below their axilla. The nurse should identify that the client is using the crutches properly when they rest the crutches 5 cm (2 in) below their axilla.

Which of the following statements made by ancillary staff reflects the most informed knowledge regarding the benefit of having a client assist with his or her own activities of daily living (ADLs) to that client's activity tolerance? A. "The more he does for himself, the more he will be able to do for himself." B. "He doesn't like washing and dressing himself, but it makes him stronger." C. "Doing for himself makes him tired, but in the long run he has more energy and strength when he does." D. "By washing and dressing himself he is building muscle strength that lets him actually walk a little better."

D. "By washing and dressing himself he is building muscle strength that lets him actually walk a little better." Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. ADLs require muscle action and help maintain muscle tone.

Which of the following is the most important to consider when assisting the client in passive range-of-motion exercises? A. Flex the joint to the point of discomfort. B. Work from the proximal joints to the distal joints. C. Quickly work through the range of motion. D. Support the distal joints while performing range-of-motion exercises.

D. Support the distal joints while performing range-of-motion exercises. While performing range-of-motion exercises, support should be provided for the distal joints.

A client recovering from hip surgery tells the nurse that she wants to get better so she can walk down the aisle to her seat at her granddaughter's wedding. Which of the following nursing interventions will have the greatest impact on achieving that goal? A. Informing physical therapists that the client has expressed that goal B. Reminding the ancillary staff to offer to walk with the client after her bath C. Regularly praising the client for the efforts she is making to reach her goal D. Walking with the client to and from the dining room where she eats her meals

D. Walking with the client to and from the dining room where she eats her meals Although all the interventions are appropriate, actually walking with the client will have the greatest impact on her ability to achieve the goal.

While the patient ambulates in the hallway with a walker, the nurse will make it priority to? A. stand on the patient's strong side. B. stand behind the patient. C. stand in front of the patient. D. stand on the patient's weak side.

D. stand on the patient's weak side. The nurse should stand on the patient's weak side while the patient ambulates with a walker.

The nurse recognizes that facilitating correct body alignment for a dependent client may well result in which of the following positive client outcomes? (Select all that apply.) A. A comfortable night's sleep B. Minimized activity intolerance C. Muscle tone that promotes ambulation D. Reduction of falls caused by general weakness E. Minimal strain placed on the spinal column F. Increased socialization, resulting in peace of mind

A, B, C, D, E A. A comfortable night's sleep B. Minimized activity intolerance C. Muscle tone that promotes ambulation D. Reduction of falls caused by general weakness E. Minimal strain placed on the spinal column Correct body alignment reduces strain on musculoskeletal structures, aids in maintaining adequate muscle tone, promotes comfort, and contributes to balance and conservation of energy.

To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse should implement the use of a: A. Footboard B. Trochanter roll C. Trapeze bar D. Bed board

B. Trochanter roll A trochanter roll prevents external rotation of the hips when the client is in a supine position.

What is peristalsis? A) When a person is no longer mobile. B) Circular, wave like contractions C) Contractions that cause the heart to beat D) When muscles won't contract

B) Circular, wave like contractions

While using crutches the patient moves both crutches forward and then moves both legs forward past the placement of the crutches. This is known as the: A. Two-point gait B. Swing-to-gait C. Swing-through-gait D. Three-point gait

C. Swing-through-gait

The nurse chooses to use a mechanical lift to move an obese immobile client. The nurse recognizes that the positive outcomes for both the client and the staff resulting from this intervention will be: (Select all that apply.) A. Less of the client's body will be dragged along the sheets during the transfer B. There will be less chance of injuring the skin on the client's elbows and buttocks C. The staff involved in the transfer will have less likelihood of self-injury D. The staff will have a greater degree of control over the move E. The client will feel physically safer during the transfer F. The move will be accomplished more quickly

A, B, C, D A. Less of the client's body will be dragged along the sheets during the transfer B. There will be less chance of injuring the skin on the client's elbows and buttocks C. The staff involved in the transfer will have less likelihood of self-injury D. The staff will have a greater degree of control over the move

Which of the following factors has an impact on the severity of physical impairment a client will experience from a period of immobility? (Select all that apply.) A. The client's age B. Prior overall health C. Length of immobility D. The degree of immobility E. Situation requiring the inactivity F. Client's mental attitude about the limitations

A, B, C, D A. The client's age B. Prior overall health C. Length of immobility D. The degree of immobility

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following? A) Restricted movement due to abnormal fixation of a joint B) A drop in blood pressure that occurs with a change in position C) Altered gait with dragging of the toes while ambulating D) Diminished awareness of body position and balance

D) Diminished awareness of body position and balance Proprioception, or kinesthesia, is a sense of self-awareness and body position. It is the result of feedback from nerve sensory receptors that alert the brain to fine-tune muscle movement in order to regulate balance, coordination, and movement.

The nurse is discussing joint mobility exercises with a client who experienced a stroke and now has left-sided weakness. Which of the following statements made by the client reflects the greatest insight regarding the best method for him to maintain mobility of the joints on his left side? A. "My wife knows how to do those exercises for the joints on my left side." B. "Physical therapy really exercises my left side when I go there every afternoon." C. "I'll remind the staff to exercise my left side when they come to help me with my bath and getting dressed." D. "I will do those passive range of motion exercises you taught me to my left side at least 3 times a day."

D. "I will do those passive range of motion exercises you taught me to my left side at least 3 times a day." If one extremity is paralyzed, teach the client to put each joint independently through its ROM.

A client is leaving for surgery and because of preoperative sedation needs complete assistance to transfer from the bed to the stretcher. Which of the following should the nurse do first? A. Elevate the head of the bed. B. Explain the procedure to the client. C. Place the client in the prone position. D. Assess the situation for any potentially unsafe complications.

D. Assess the situation for any potentially unsafe complications. Before transferring the client from the bed to the stretcher, the nurse should assess the situation for any potentially unsafe complications.

The nurse assesses that the client has torticollis and that this may adversely influence the client's mobility. This individual has a(n): A. Exaggeration of the lumbar spine curvature B. Increased convexity of the thoracic spine C. Abnormal anteroposterior and lateral curvature of the spine D. Contracture of the sternocleidomastoid muscle with a head incline

D. Contracture of the sternocleidomastoid muscle with a head incline. Torticollis is inclining of the head to the affected side, in which the sternocleidomastoid muscle is contracted.

A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the client, the nurse is alert to a(n): A. Increased blood pressure B. Decreased heart rate C. Increased urinary output D. Decreased peristalsis

D. Decreased peristalsis Immobility causes gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.