mobility exam 5, chapters 25 (G), 38 and 39 (P/P)

The nurse has delegated the task of ambulating a client who is experiencing activity intolerance. Which of the following statements made by the nurse best reflects an understanding of the nurses role to properly instruct the ancillary personnel regarding this task? 1 Stop the walking if the client complains of pain or weakness. 2 Please be sure she has proper footwear on before starting out. 3 Be sure to document the time spent and the distance she walked. 4 Take her blood pressure and pulse both before and after walking.

1

The nurse understands that using metabolic functioning, measures of height, weight,and skinfold thickness, to evaluate muscle atrophy in an immobilized client is known as: 1 Anthropometric measurements 2 Anhydrous measurements 3 Balke test 4 Calorimetry

1

Nurses need to implement appropriate body mechanics in order to prevent injury to themselves and their clients. Which principle of body mechanics should the nurse incorporate into client care? 1 Flex the knees and keep the feet wide apart. 2 Assume a position far enough away from the client. 3 Twist the body in the direction of movement. 4 Use the strong back muscles for lifting or moving.

1

The nurse caring for a 78-year-old male client recovering from hip replacement surgery is assessing for signs of improvement of the clients activity tolerance. The nurse determined a baseline for ongoing assessments by: 1 Determining how much time it takes the client to recover from an activity 2 Assessing how much the client can do at one time 3 Determining the level of pain experienced by the client during the activity 4 Asking the client how much the client feels like doing

1

During a musculoskeletal assessment of a 20-month-old toddler, the nurse expects to observe: 1 A swayback and outwardly turned feet 2 A spine that is flexed and lacking anteroposterior curves 3 Widened hips and fat deposits on the thighs and buttocks 4 A stance with moderately spaced foot placement and a slightly rounded abdomen

1

The nurse has determined that a client reporting general fatigue is experiencing activity intolerance. Which of the following assessment findings, observed after the client ambulates to the bathroom, best confirms this nursing diagnosis? 1 Dyspnea 2 Diaphoresis 3 Hypotension 4 Mental confusion

1

The nurse chooses to use a mechanical lift to move an obese immobile client. Thenurse recognizes that the positive outcomes for both the client and the staff resulting fromthis intervention will be: (Select all that apply.) 1 Less of the clients body will be dragged along the sheets during the transfer 2 There will be less chance of injuring the skin on the clients elbows and buttocks 3 The staff involved in the transfer will have less likelihood of self-injury 4 The staff will have a greater degree of control over the move 5 The client will feel physically safer during the transfer 6 The move will be accomplished more quickly

1, 2, 3, 4

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.) 1 Popliteal pulse equal in both legs 2 Slight footdrop noted on affected leg 3 Swelling noted at ankle on affected leg 4 Weight bearing less stable on affected leg 5 Calf circumference greater in unaffected leg 6 Greater range of motion of knee of unaffected leg

1, 4, 5, 6

A client who experienced a myocardial infarction has been placed on bed rest. The nurse caring for the client recognizes that the inactivity will result in certain assessment findings that include: (Select all that apply.) 1 Lethargy 2 Confusion 3 Depression 4 Poor appetite 5 Hypoactive bowel sounds 6 Decrease in baseline respiratory rate

1, 4, 5, 6

The nurse caring for a 73-year-old female client who has been hospitalized with a stroke instructs the clients 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: 1 8 hours 2 24 hours 3 1 week 4 1 month

1, 8 hours

A client is getting up for the first time after a period of bed rest. The nurse should first: 1 Assess respiratory function 2 Obtain a baseline blood pressure 3 Assist the client with sitting at the edge of the bed 4 Ask the client if he or she feels light-headed

2

Prevention of plantar flexion (footdrop) through the application of high-topped shoes is a primary intervention for which of the following mobility-impaired clients? 1 A 54-year-old diagnosed with osteoarthritis in all lower extremity joints 2 A 25-year-old with a fractured pelvis as a result of a motorcycle accident 3 A 78-year-old who has experienced left-sided paralysis resulting from a cerebral vascular accident (CVA) 4 A 15-year-old who has been comatose for 2 years as a result of a head injury sustained from a fall off a roof

2

To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse should implement the use of a: 1 Footboard 2 Trochanter roll 3 Trapeze bar 4 Bed board

2

Which of the following assessment questions is most likely to result in pertinent information regarding the clients expectations of the outcomes of a regular exercise program? 1 What is your greatest barrier to regular exercise? 2 What is your idea of a workable exercise program? 3 What do you want to happen from exercising regularly? 4 How much time can you comfortably dedicate to exercise daily?

2

Which of the following nursing assessment questions will best determine the nature of an exercise-related injury? 1 Do you experience the pain during or after your workout? 2 Tell me what is included in your typical workout routine. 3 How long does it hurt after you have stopped exercising? 4 On a scale of 1 to 10, please rate your postexercise pain for me.

2

An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as: 1 Harsh crackles 2 Wheezing on inspiration 3 Diminished breath sounds 4 Bronchovesicular whooshing

3

The nurse is presenting a teaching session on exercise for a group of corporate executives. An appropriate recommendation is that: 1 Continuous activity is required in order for the exercise to be worthwhile 2 3000 to 4000 calories may be easily expended each week 3 Lower-intensity activities need to be done more often for value 4 Only formal exercise activities are counted in a regular plan

3

The general goal of exercise and activity for all clients is to: (Select all that apply.) 1 Encourage weight loss 2 Improve joint flexibility 3 Minimize social isolation 4 Improve motor function 5 Foster personal independence 6 Maintain the optimal level of function

3, 5

An average-size male client has right-sided hemiparesis. The nurse helps this client to walk by: 1 Standing at his left side and holding his arm 2 Standing at his left side and holding one arm around his waist 3 Standing at his right side and holding his arm 4 Standing at his right side and holding one arm around his waist

4

The lack of weight bearing leads to what effects on the skeletal system? Demineralization, calcium loss Thickened bones Increased range of motion Increased calcium deposition in the bones

a

The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement? "Patients with impaired bed mobility have an increased risk for pressure ulcers." "Patients with impaired bed mobility like to have extra visitors." "Patients with impaired bed mobility need to have a mechanical soft diet." "Patients with impaired bed mobility are prone to constipation."

a

A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. What is the nurse's best response? "Your iron level is low. This is known as anemia." "Your immobility in the hospital is known as deconditioning." "Your poor appetite is known as malnutrition." "Your medications have caused drug induced weakness."

b

What percentage of hip fractures is the result of falls? a. 50% b. 80% c. 90% d. 100%

c

A client is admitted to the medical unit following a CVA (stroke). There is evidence of left- sided hemiparesis and the nurse will be following up on range-of-motion and other exercises performed in physical therapy. The nurse correctly teaches the client and family members which one of the following principles of range-of-motion exercises? 1 Flex the joint to the point of discomfort. 2 Work from proximal to distal joints. 3 Move the joints quickly. 4 Provide support for distal joints.

1

A client is discussing an exercise program that includes running 1.5 miles 3 times a week. Which of the following suggestions made by the nurse is most likely to result in minimizing the clients risk for injury? 1 Stretching before and after running 2 Alternating running paths every week 3 Hydrating well with sports drinks during and after running 4 Wearing running shoes that have been professionally fitted

1

A client who is confined to a wheelchair is encouraged to engage in resistive isometric exercises to increase muscle strength and decrease the development of pressure ulcers. Which of the following is the most appropriate example of such an exercise for this client? 1 Hip lifting 2 Gluteal contraction 3 Foot pressure off-loading 4 Bicep-tricep compression

1

A client with a fractured left femur has been using crutches for the past 4 weeks. The physician tells the client to begin putting a little weight on the left foot when walking. Which of the following gaits should the client be taught to use? 1 Two-point 2 Three-point 3 Four-point 4 Swing-through

1

The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to: 1 Measure the calf and thigh circumferences 2 Attempt to elicit Homans sign 3 Palpate the temperature of the feet 4 Observe for a loss of hair and skin turgor in the lower legs

1

Which of the following clients is most at risk for losing his or her balance? 1 A woman who is 9 months pregnant walking down a flight of stairs 2 A 16-year-old skate boarding down a 15-degree slope 3 A 45-year-old taking hypertensive medication 4 A 4-year-old riding a tricycle

1

he nurse recognizes that the older adults tendency to take smaller steps with feet kept closer together will most likely: 1 Increase the clients risk of injury resulting from falls 2 Result in less stress on the clients knees, hips, and ankles 3 Decrease the amount of energy the client expends on movement 4 Allow for mobility in spite of the effects of aging on the clients joints

1

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.) 1 The clients age 2 Prior overall health 3 Length of immobility 4 The degree of immobility 5 Situation requiring the inactivity 6 Clients mental attitude about the limitations

1, 2, 3, 4

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.) 1 A comfortable nights sleep 2 Minimized activity intolerance 3 Muscle tone that promotes ambulation 4 Reduction of falls caused by general weakness 5 Minimal strain placed on the spinal column 6 Increased socialization, resulting in peace of mind

1, 2, 3, 4, 5

The first rule of safety when managing client transfers is: 1 Flex your knees and plant your feet far apart 2 Keep your back aligned with your neck, pelvis, and feet 3 Use lift teams or mechanical lifts when the transfer requires it 4 Always use the large muscles of the arms and legs, not the small muscles of the back

3

One of the most debilitating health hazards among nurses is musculoskeletal injuries. In order to eliminate these injuries, the American Nurses Association is advocating which of the following? 1 Mandate that physical therapists do all patient transfers. 2 Require minimum staffing levels in health care organizations. 3 Request the use of assistive equipment and devices. 4 Require a minimum number of staff to be involved in all patient transfers.

3

Passive range-of-motion exercises are most important for which of the following clients? 1 Pediatric client with a broken femur 2 Diabetic client with a total knee replacement 3 Unconscious client in ICU 4 Elderly client with a bowel obstruction

3

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 granddaughters wedding. Which of the following nursing interventions will have the greatest impact on achieving that goal? 1 Informing physical therapists that the client has expressed that goal 2 Reminding the ancillary staff to offer to walk with the client after her bath 3 Regularly praising the client for the efforts she is making to reach her goal 4 Walking with the client to and from the dining room where she eats her meals

4

The client needs to use crutches at home, and will have to manage going up and down a short flight of stairs. The nurse evaluates the use of an appropriate technique if the client: 1 Uses a banister or wall for support when descending 2 Uses one crutch for support while going up and down 3 Advances the crutches first to ascend the stairs 4 Advances the affected leg after moving the crutches to descend the stairs

4

The nurse is assessing the body alignment of an alert and mobile client. The first action that the nurse should take is to: 1 Observe gait 2 Put the client at ease 3 Determine activity tolerance 4 Determine range of joint motion

2

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: 1 Decrease metabolic rate 2 Catabolic tissue breakdown 3 Inactivity-induced depression 4 Anorexia caused by decreased peristalsis

2

Which of the following statements made by a nurse caring for a client who experienced a myocardial infarction 8 hours ago shows the greatest insight as to the purpose for keeping the client on bed rest? 1 This has been exhausting; she needs a period of uninterrupted rest. 2 The pain she experienced is exhausting; its imperative that she rest. 3 Keeping her on bed rest decreases the need her body has for oxygen 4 She needs complete rest; she is really very ill, especially her heart.

3

When moving a client who is unable to assist, what is the most important principle for the nurse to remember to avoid injury? 1 Face opposite of the direction of movement. 2 Keep your feet close together. 3 The higher the center of gravity, the greater the stability of the nurse. 4 Try to avoid lifting the patient if possible.

4

A client with coronary heart disease has been meeting with a cardiac rehabilitation nurse for the past 5 weeks. The nurse has provided the client with interventions to increase the clients activity level. The client states that they dont know if the exercise program is helping. The nurse can assess the effectiveness of the interventions by: 1 Comparing baseline vital signs with current vital signs 2 Weighing the client 3 Asking the client if he feels that he has met his goals 4 Telling the client that the exercise will only help if the client has a positive attitude

1

An obese quadriplegic client has requested being transferred to a chair so he can be fed lunch sitting upright. Which of the following statements made by the ancillary personnel assigned the task reflects the best understanding of the implementation of this transfer? 1 Ill reserve the mechanical lift for right before lunch. 2 Ill certainly need someone to help me with this transfer. 3 Eating in an upright position will certainly make lunch more enjoyable for him. 4 Maybe he would enjoy being transferred into the dayroom to eat with the others.

1

When discussing the benefits of physical activity and exercise with a client, the nurse identifies which of the following as a positive outcome to the client? (Select all that apply.) 1 Stress management 2 Enhanced cardiac output 3 Improved bone integrity 4 Facilitation of weight control 5 Increased cognitive function 6 Increased musculoskeletal flexibility

1, 2, 3, 4, 6

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? 1 Encourage an even gait when walking in place. 2 Assess the extremities for unilateral swelling and muscle atrophy. 3 Encourage holding the breath frequently to hyperinflate the clients lungs. 4 Teach the use of a two-point crutch technique for ambulation.

2

A client has sequential compression stockings in place. The nurse evaluates that they are implemented appropriately by the new staff nurse when the: 1 Initial measurement is made around the clients calves 2 Intermittent pressure is set at 40 mm Hg 3 Stockings are wrapped directly over the leg from ankle to knee 4 Stockings are removed every hour during application

2

A client who is immobilized in bed due to skeletal traction tells the nurse that they miss their exercise regimen that they had started prior to the accident that resulted in their hospitalization. The nurse knows that which of the following is a good form of exercise that this client can still perform while immobilized? 1 Isotonic exercise 2 Isometric contraction 3 Resistive isometric exercise 4 Aerobic exercise

2

A client with cancer expresses interest in increasing his activity level. The nurse begins by assessing baseline data regarding the clients current activity patterns. The nurse uses professional standards to develop a plan of care for this client. Professional standards are important because they: 1 Are developed by government agencies 2 Establish scientifically proven guidelines 3 Shift responsibility for the plan of care from the nurse 4 Are required by all healthcare organizations

2

A newly diagnosed client with type 2 diabetes expresses concern that he will not be able to maintain his active lifestyle, which includes bicycling. The nurse instructs the client about risks and precautions regarding exercise including which of the following? 1 To avoid leisurely bicycling day trips 2 To avoid strenuous bicycling for long periods of time 3 It is better for them to exercise for 1 to 2 hours once a week than for 20 minutes 3 days per week 4 As long as he is not participating in strenuous exercise, there is no need to include warm-up or cool-down exercises

2

A postmenopausal client is experiencing mild osteopenia and has been encouraged to walk 1 mile daily . Which of the following statements made by the client shows the best understanding of the positive effects of exercise on her condition? 1 It makes me stronger and healthier. 2 It helps make all my bones stronger. 3 Walking increases the muscle mass in my legs. 4 Regular walking improves my stamina and endurance.

2

A staff member experienced a shoulder injury while assisting with a client transfer. The nurse managers most therapeutic response to this situation is to: 1 Thoroughly review the accident report filed by the injured personnel to determine the factors that contributed to the injury 2 Have a nonpunitive meeting with all the involved staff to discuss correcting the factors that resulted in the injury 3 Require that mechanical lifts be used in the transfer of all clients incapable of assisting with the transfer 4 Implement new policies and procedures to correct the factors that resulted in the injury

2

An infant born via cesarean section because of a breech presentation is diagnosed with bilateral congenital hip dysplasia. The primary nursing intervention directed toward this diagnosis is: 1 Assessing the infant frequently to determine abduction of the thighs 2 Maintaining the infant in the position of continuous abduction of both hips 3 Educating the parents about the importance of positioning the infant so that the head of the femurs are in alignment with the hip sockets 4 Providing pain management so that the infant is comfortable in the therapeutic position required

2

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: 1 To avoid frightening the client 2 To avoid shearing the clients skin 3 To avoid getting written up for not following lift procedures 4 Because the nurse is tired

2

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: 1 Keep the PaO2 level at or above 94% 2 Instruct the client to deep breathe and cough every hour while awake 3 Turn the client every 2 hours 4 Keep the client on the ventilator as long as possible

2

The nurse is caring for a 48-year-old male client who was involved in a motor vehicle accident and had a fractured pelvis, a ruptured spleen, and multiple contusions. The client has been in the hospital for 5 days on bed rest. The nurse knows that this client is at risk for venous thrombus formation because of prolonged bed rest, potential damage to vessel walls during surgery, and the platelets he received in the trauma unit. These three factors are also known as: 1 Trigeminy 2 Virchows triad 3 Trigone 4 Hutchinsons triad

2

The nurse is providing ancillary personnel with instructions regarding the performance of passive range-of-motion (ROM) exercises for a client experiencing paralysis from the waist down (paraplegia) as a result of an automobile accident. Which of the following statements made by the ancillary personnel reflects the greatest insight regarding the frequency with which the intervention should be provided for this client? 1 I will do a whole body range of motion as I complete her daily bath. 2 Bath time, bedtime, after lunch, and at least once more; she can pick when. 3 It works well with her bath and when she is being prepared for bed at night. 4 Ill ask her when she wants me to exercise her joints in addition to bath time.

2

The nurse is working with a client who has left-sided weakness. After instruction, the nurse observes the client ambulate in order to evaluate the use of the cane. Which action indicates that the client knows how to use the cane properly? 1 The client keeps the cane on the left side. 2 Two points of support are kept on the floor at all times. 3 There is a slight lean to the right when the client is walking. 4 After advancing the cane, the client moves the right leg forward.

2

To promote respiratory function in the immobilized client, the nurse should: 1 Change the clients position every 4 to 8 hours 2 Encourage deep breathing and coughing every hour 3 Use oxygen and nebulizer treatments regularly 4 Suction the clients secretions every hour

2

To reduce the chance of plantar flexion (footdrop) in a client on prolonged bed rest, the nurse should implement the use of: 1 Trapeze bars 2 High-top sneakers 3 Trochanter rolls 4 Thirty-degree lateral positioning

2

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 clients body as they prepare for the move? 1 Even with the thorax 2 Even with the shoulders 3 Even with the hips 4 Even with the knees

2

Which of the following statements made by a woman recently diagnosed with osteoporosis indicates the greatest degree of readiness to begin a daily walking routine? 1 The tests showed that I have osteoporosis and need to walk. 2 Ive walked around the local park three times, and that measures 1.75 miles. 3 My sister has this problem, and she walks one mile a day around her neighborhood. 4 I can join the spa and use the treadmill when the weather gets too cold to walk outside.

2

Which of the following statements made by an older adult reflects the best understanding of the need to exercise no matter ones age? 1 You are never too old to start exercising. 2 My grandson and I walk together around the park 3 times a week. 3 I got my granddaughter a subscription to a runners magazine for her birthday. 4 Kids today just dont seem to get the exercise we did when I was growing up.

2

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? 1 Im hoping to be back at soccer practice in 3 weeks. 2 Walking and riding my bike will help regain the muscle. 3 Ill practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring. 4 There was a good bit of muscle and strength loss, but Ill work at getting it back like it was before the break.

3

A 78-year-old inactive client diagnosed with acute renal failure is at risk for which of the following skeletal maladies? 1 Rickets 2 Osteomyelitis 3 Pathological fractures of long bones 4 Compression fractures of the spinal column

3

A client who will be going home will need to use crutches for ambulation. Following teaching, the nurse notes that the client complains of pain under his arms. How much room should be between the crutch pad and clients axilla? 1 Axilla should lightly touch the crutch pad 2 1 to 2 finger widths from the axilla 3 3 to 4 finger widths from the axilla 4 4 to 5 finger widths from the axilla

3

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: 1 Keep the skin warm and dry 2 Prevent abnormal joint flexion 3 Apply external pressure 4 Prevent bleeding

3

Following an assessment of the client, the nurse identifies the nursing diagnosis activity intolerance related to increased weight gain and inactivity. An outcome identified by the nurse should be: 1 Resting heart rate will be 90 to 100 beats/minute 2 Blood pressure will be maintained between 140/80 and 160/90 mm Hg 3 Exercise will be performed 3 to 4 times over the next 2 weeks 4 Achievement of a rating of 3 for activity endurance

3

In teaching a newly diagnosed 17-year-old client with type 1 diabetes, the nurse knows that the exercise is an important component in care. Which of the following activities would be most appropriate for the previously sedentary client? 1 Kick-boxing class 2 Football 3 Bicycling 4 Soccer

3

It has been determined that all of the following clients are at risk for falling. Which one requires the nurses priority for ambulation? 1 A 16-year-old with a sprained ankle being discharged from the emergency department 2 A 54-year-old who has taken the initial dose of an antihypertensive medication 3 A 45-year-old postoperative client up for the first time since knee surgery 4 An 81-year-old who is asthmatic and had a hip replaced 18 months ago

3

The nurse is caring for a client diagnosed with bilateral middle ear infections. Which of the following statements made by the nurse best reflects an understanding of the effects of this condition on the clients ability to move appropriately? 1 He hasnt reported any nausea or vomiting. 2 His ability to hear doesnt seem to be affected. 3 Ill identify the client as a high falls risk by noting it on his Kardex. 4 I believe he is capable of using his call bell when he needs assistance.

3

The nurse is working with a nursing assistive personnel to provide care for a group of clients. The nurse can delegate which of the following activities to the nursing assistive personnel? 1 Assess for medical limitations before beginning the exercise activity. 2 Teach the clients breathing skills to help reduce their anxiety. 3 Obtain preexercise and postexercise vital signs. 4 Document the clients progress.

3

To provide for the psychosocial needs of an immobilized client, an appropriate statement by the nurse is which of the following? 1 The staff will limit your visitors so that you will not be bothered. 2 A roommate can be a real bother. Youd probably rather have a private room. 3 Lets discuss the routine to see if there are any changes we can make. 4 I think you should have your hair done and put on some makeup.

3

When planning care for a client with newly diagnosed hypertension, the nurse knows that which form of exercise would be most beneficial in lowering both systolic and diastolic blood pressure? 1 Lifting weights 2 Running 3 Bicycling 4 Competitive swimming

3

Which of the following nursing interventions is likely to have the most impact on reducing friction when positioning an immobile client? 1 Involving at least two personnel in the actual transfer 2 Lubricating all body parts that are in contact with the bed 3 Dressing the bed with a lift sheet to be use during the transfer 4 Thoroughly explaining the process to the client before the move

3

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? 1 I know I need to walk more if I want to get stronger. 2 I dont like walking, but I do it because I know it will make me stronger. 3 I try to walk a little farther each afternoon so I can dance at my grandsons wedding. 4 I walk with my son three evenings a week because its good for his weight and for my bones.

3

While ambulating in the hallway of a hospital, the client complains of extreme dizziness. The nurse, alert to a syncopal episode, should first: 1 Support the client and walk quickly back to the room 2 Lean the client against the wall until the episode passes 3 Lower the client gently to the floor 4 Go for help

3

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): 1 Increased blood pressure 2 Decreased heart rate 3 Increased urinary output 4 Decreased peristalsis

4

A client has been prescribed bed rest for a prolonged time. To specifically promote the use of resistive isometric exercise for the client, the nurse will initiate: 1 Quadriceps setting 2 Gluteal muscle contraction 3 Moving the arms and legs in circles 4 Pushing against a footboard

4

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? 1 Elevate the head of the bed. 2 Explain the procedure to the client. 3 Place the client in the prone position. 4 Assess the situation for any potentially unsafe complications.

4

A client with a nursing diagnosis of activity intolerance has developed reddened areas on both heels and his coccyx. Which of the following nursing interventions will most likely have the greatest impact on this diagnosis? 1 Ambulating him to the bathroom before returning to bed 2 Encouraging him to change position every 2 hours while in bed 3 Including active range-of-motion exercises in both AM and PM care 4 Planning a rest period after AM care but before walking to the dining room for lunch

4

The nurse assesses that the client has torticollis and that this may adversely influence the clients mobility. This individual has a(n): 1 Exaggeration of the lumbar spine curvature 2 Increased convexity of the thoracic spine 3 Abnormal anteroposterior and lateral curvature of the spine 4 Contracture of the sternocleidomastoid muscle with a head incline

4

The nurse encourages a noninsulin-dependent diabetic client to engage in a regular exercise program primarily because to do so will most likely improve the clients: 1 Gastric motility, thus affecting glucose digestion 2 Respiratory recovery time, thus decreasing breath load 3 Average cardiac output, thus decreasing resting heart rate 4 Use of glucose and fatty acids, thus decreasing blood glucose level

4

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? 1 My wife knows how to do those exercises for the joints on my left side. 2 Physical therapy really exercises my left side when I go there every afternoon. 3 Ill remind the staff to exercise my left side when they come to help me with my bath and getting dressed. 4 I will do those passive range of motion exercises you taught me to my left side at least 3 times a day.

4

The nurse is discussing the benefits of regular walking with a group of senior citizens. Which of the following statements shows the best understanding of the positive impact of exercise on the older adult? 1 Remember to warm up and cool down with stretching exercises. 2 Find a walking partner that will accompany you on a regular basis. 3 Be sure to hydrate yourself well before, during, and after your walk. 4 Talk with your health care provider before starting a regular walking program.

4

The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in an immobile client is to: 1 Keep the skin dry 2 Provide range of motion every shift 3 Use lift equipment when transferring a client 4 Turn the client a minimum of every 2 hours

4

The primary purpose for placing an immobile clients arms across his or her chest when preparing to transfer the client up in the bed is to: 1 Increase the stability of the clients body 2 Protect the clients arms from being hurt during the transfer 3 Produce a more compact form that facilitates the transfer 4 Reduce the amount of body surface area that is in contact with the bed.

4

Which of the following is the most important to consider when assisting the client in passive range-of-motion exercises? 1 Flex the joint to the point of discomfort. 2 Work from the proximal joints to the distal joints. 3 Quickly work through the range of motion. 4 Support the distal joints while performing range-of-motion exercises.

4

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 clients activity tolerance? 1 The more he does for himself, the more he will be able to do for himself. 2 He doesnt like washing and dressing himself, but it makes him stronger. 3 Doing for himself makes him tired, but in the long run he has more energy and strength when he does. 4 By washing and dressing himself he is building muscle strength that lets him actually walk a little better.

4

An older patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. What is the nurse's best response? "Walk at least 5 miles every day for exercise." "Wear proper fitting shoes to prevent tripping." "Talk with your physician about a calcium supplement." "Stand up slowly so you don't feel faint."

c

Mobility for the patient changes throughout the lifespan. What is the term that best describes this process? Aging and illness Illness and disease Health and wellness Growth and development

d

The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement? "Patients must have a trapeze over the bed to move properly." "Patients should move themselves in bed to prevent immobility." "Patients should always have a two-person assist to move in bed." "Patients must be moved correctly in bed to prevent shearing."

d