mobility and immobility prepU

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

27-year-old client with acute pancreatitis receiving morphine sulfate IV every 2 hours as needed for pain; has no significant medical history, smokes two packs of cigarettes per day, may be up independently and has steady gait. 48-year-old who is quadriplegic admitted for wound care of a stage IV pressure ulcer, receiving IV antibiotics per a peripherally inserted central catheter (PICC); the client is alert and oriented. 84-year-old client with non-insulin-dependent diabetes admitted with new-onset confusion, and forgets about limitations of activity. The client reportedly fell at home last week, is currently on bed rest, and has normal saline infusing per saline lock. 62-year-old client with Parkinson's disease, admitted for pneumonia and receiving IV antibiotics. The client reports falling at home but continues to ambulate with a cane. During this hospitalization, the client has gotten out of bed without calling for assistance.

The older client asks the nurse how best to maintain strong muscles. The best response by the nurse is:

"Weight-resistance exercises can strengthen muscles." Weight-resistance exercises maintain and strengthen muscles. Cardio-training is important for heart health and weight maintenance/reduction. Weight-bearing exercises maintain bone mass. Range of motion exercises are essential for joint mobility.

The nurse is conducting a community education program on hip fracture risk. The nurse evaluates that the participants understand the program when the participants determine that client at highest risk for a hip fracture is a(n)

80-year-old man recently widowed.

Which term refers to a grating or crackling sound or sensation?

Crepitus

A client is experiencing chronic arthritis and active range of motion is ordered. The nurse understands that the goal is to do which of the following?

Increase muscle strength.

What instructions should the nurse include in the discharge teaching for the client following an arthroscopy?

"The pain should be well-controlled with Tylenol."

Which of the following assessment findings indicate to the nurse that a client may have peripheral neurovascular dysfunction?

Absence of feeling Capillary refill of 4 to 5 seconds Cool skin Pain Weakness in motion

A client is to have a total hip replacement. What nursing actions should the preoperative plan include? Select all that apply.

Administer antibiotics as prescribed to ensure therapeutic blood levels. Request a trapeze be added to the bed. Teach isometric exercises of quadriceps and gluteal muscles.

A client is scheduled to have an x-ray examination of his shoulder in which the synovial fluid will be aspirated and sent to the laboratory for analysis. This will be followed by administration of a contrast medium and x-rays. The nurse understands that the client will be undergoing which of the following?

Arthrogram

A client is preparing for discharge from the hospital after undergoing an above-the-knee amputation. Which instructions should the nurse include in the teaching plan for this client? Select all that apply.

Avoid exposing the skin around the stump to excessive perspiration. Be sure to perform the prescribed exercises. Rub the stump with a dry washcloth for 4 minutes three times per day if the stump is sensitive

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.

The nurse is caring for a client scheduled to have magnetic resonance imaging (MRI). The nurse contacts the health care provider to cancel the MRI when the nurse reads which element in the client's medical history?

Cochlear implant

A client is about to undergo total hip replacement surgery. Before the surgery, the nurse conducts a preoperative teaching session. The nurse can tell that teaching has been effective when the client verbalizes the importance of avoiding which actions? Select all that apply

Internally rotating the feet. Bending to pick items up from the floor.

A nurse practitioner provides health teaching to the family of a 75-year-old woman who has trouble walking independently. The nurse reviews age-related changes to the musculoskeletal system with the family. Which of the following statements would the nurse include in her teaching? Select all that apply.

Intervertebral discs become thin. Muscles atrophy. Muscle fibrosis increases. Collagen increases

Which nursing assessment finding is indicative of scoliosis?

Lateral curvature of the spine

To ensure safe postoperative care of a client after a total hip arthroplasty, which actions are most appropriate for the nurse to perform? Select all that apply.

Limit movements resulting in internal rotation and adduction of the affected hip. Teach the client not to cross their legs.

The nurse would expect which of the following age-related change of the musculoskeletal system?

Loss of bone mass

A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. This patient's prolonged immobility creates a risk for what complication?

Muscle atrophy

Which of the following are the major hormonal regulators of calcium homeostasis? Select all that apply.

Parathormone Calcitonin

A client had a posterolateral total hip replacement 2 days ago. What information should the nurse include in the client's plan of care? Select all that apply.

Position a pillow between the legs to maintain abduction. Allow the client to be in the supine position or lateral position on the unoperated side. Do not allow the client to bend down or to tie or slip on shoes. Place ice on the incision after physical therapy.

The nurse is teaching the client to administer enoxaparin following a total hip replacement. What should the nurse instruct the client to do? Select all that apply.

Report promptly any difficulty breathing, rash, or itching. Notify the health care provider (HCP) of unusual bruising. Avoid all aspirin-containing medications. Wear or carry medical identification.

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

A patient is receiving ongoing nursing care for the treatment of Parkinson's disease. When assessing this patient's gait, what finding is most closely associated with this health problem?

Shuffling gait

A patient is scheduled for a bone marrow biopsy. The nurse explains to the family that the bone marrow is located mainly in four areas. She tells the family that the site to be used would be the:

Sternum

A nurse is putting groceries in the car when an elderly client falls off of a curb. The nurse assesses the client and has a bystander call for an ambulance. Which assessment findings provide data of a suspected right hip fracture? Select all that apply.

The right leg is shorter than the left leg. The right leg is adducted. The right leg is externally rotated

The nurse is planning care for a client with multiple sclerosis. Which problems should the nurse expect the client to experience? Select all that apply.

Visual distrubances Balance problems Mood disorders

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

The nurse is instructing the unlicensed assistive personnel (UAP) about how to prevent plantar flexion (footdrop) for a client on complete bed rest. The UAP should:

encourage active range of motion to unaffected extremities.

The nurse is assessing a client's left leg for neurovascular changes following a total left knee replacement. Which are expected normal findings? Select all that apply.

reduced edema of the left knee skin warm to touch capillary refill response of less than 3 seconds moves toes

An older adult is being admitted to the hospital after falling from a 6- foot ladder. Which information is essential for the nurse to obtain at this time? Select all that apply.

symptoms at the time of the fall history of a previous fall location of the fall activity at the time of the fall time of the fall trauma after the fall

Upon reporting to work and receiving report, a nurse has been assigned to provide care for three clients. Each of the clients has called out to the nurses' station requesting assistance. Which client should the nurse see first?

A 32-year-old male, who had a plaster cast applied to his leg 2 hours ago, who complains that the cast feels as if it's getting tighter

A nurse is preparing discharge instructions for an above-the-knee amputation client. Which instructions would be a priority for home care? Select all that apply.

Avoid exposing the skin around the residual limb to excessive perspiration. Be sure to perform the prescribed exercises. Rub the residual limb with a dry washcloth for 4 minutes three times daily if the limb is sensitive to touch.