mobility PrepU
The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include? "Picture yourself with good posture standing; that is how good lying posture works." "Keep knees and legs very straight." "Your feet should be at 45-degree angles from the legs." "Sleep with your head tilted to one side to take pressure off your neck."
"Picture yourself with good posture standing; that is how good lying posture works." Explanation: The best posture lying down will be the same as standing posture, except the client is horizontal. Knees should be slightly flexed; feet should be at a right angle from the legs; the head and neck muscles should be in a neutral position, centered between the shoulders. It is not correct to say to keep the knees and legs very straight, to position feet at a 45-degree angle from the legs, or to sleep with the head tilted to one side.
A nurse is educating a client on how to walk with crutches. Which teaching points are recommended guidelines for this activity? Select all that apply. -Keep elbows close to sides. -Prevent crutches from getting closer than 3 inches to the feet. -Support body weight with hands and arms. -Place pressure on the axillae when walking. -When descending stairs, move crutches and the unaffected leg first, followed by the affected leg. -When climbing stairs, advance the unaffected leg past the crutches, place weight on the crutches, and then advance the affected leg followed by the crutches.
Keep elbows close to sides. Support body weight with hands and arms. When climbing stairs, advance the unaffected leg past the crutches, place weight on the crutches, and then advance the affected leg followed by the crutches. Explanation: The client should keep the elbows close to sides. The crutches should not be any closer than 12 inches from the feet to help prevent the client from falling. The client should support body weight with hands and arms and should not put pressure on the axillae when walking. Pressure on the axillae can cause damage to nerves and circulation. When climbing stairs, the client should advance the unaffected leg past the crutches, then place weight on the unaffected leg. Then the client should advance the affected leg and the crutches to the step. When descending stairs, the client should move crutches and the affected leg first, followed by the unaffected leg.
Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight? Shift their weight back and forth from the legs to the back muscles. Rock the client back and forth to raise the client up in bed. Turn the client from side to side while pushing upward. Shift their weight back and forth, from back leg to front leg.
Shift their weight back and forth, from back leg to front leg. Explanation: The nurses would use a rocking motion to counteract the client's weight. The nurses would shift their weight back and forth, from back leg to front leg, count to three, and then move the client up toward the head of the bed. Rocking the client or turning the client from side to side is not used to move a client.
Using proper body mechanics, which motions would the nurse make to move an object? -The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. -The nurse uses the muscles of the back to help provide the power needed in strenuous activities. -The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. -The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity.
The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. Explanation: Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The internal girdle is made by contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward. It is helped further by making a long midriff by stretching the muscles in the waist. The nurse would not relax the stomach muscles or use the muscles of the back when moving an object. The nurse would not lift an object when it can be safely slid, rolled, pushed, or pulled.
The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher? alongside the bed 2 in (5 cm) lower alongside the bed 1 in (2.5 cm) either lower or higher alongside the bed at the same height alongside the bed 2 in (5 cm) higher
alongside the bed at the same height Explanation: By placing the bed and the stretcher at the exact same height, it makes for easier transfer and decreases risk of potential injury. If the stretcher were lower or higher, it would not make for a smoother transfer and the client could be injured during transfer.
The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse correctly documents the presence of: ataxia. tremors. chorea. athetosis.
ataxia. Explanation: Ataxia refers to a lack of muscle coordination. Tremors are rhythmic, repetitive movements. Chorea is spontaneous, brief, involuntary muscle twitching of the limbs or facial muscles. Athetosis refers to movement characterized by slow, irregular, twisting motions.
When moving a client up in bed with the assistance of another caregiver, the nurse should: ask another nurse about the plan of care. elevate the head of the bed. maintain a pillow under the client's head. have the client fold the arms across the chest.
have the client fold the arms across the chest. Explanation: Positioning the arms across the chest improves assistance, reduces friction, and prevents hyperextension of the neck. Before attempting to move a client up in bed, the nurse should review the medical record and the nursing plan of care. This validates the correct client and correct procedure, identification of limitation, and ability. Reviewing the medical record and plan of care also identifies use of an algorithm to prevent injury and assists in determining the best plan for client movement. The head of the bed should be flat or as low as the client can tolerate; this will help to decrease the gravitational pull of the upper body. If tolerated, a slight Trendelenburg position aids in movement. Pillows should be removed from under the client's head; this facilitates movement.
The nurse observes an older adult client walks walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating? should have an orthopedic consultation. is demonstrating a common gait for the older adult. requires a better walking shoe. requires crutches for mobility.
is demonstrating a common gait for the older adult. Explanation: Many older people have more difficulty overcoming inertia and using gravity efficiently. One contributing factor is the shift in the center of gravity. To compensate for this shift, the knees flex slightly for support.
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed? -near the client's hip, with legs together -near the client's hip, with legs shoulder width apart and one foot near the head of the bed -to the dominant side of the client, with legs together and one foot near the head of the bed -to the nondominant side of the client, with legs together and one foot near the head of the bed.
near the client's hip, with legs shoulder width apart and one foot near the head of the bed Explanation: When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight to assist the client to a sitting position safely. The dominant or nondominant side is not relevant when moving a client with equal strength but would be helpful with a client who has had a stroke.
A nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program? obtain a pre-exercise medical examination for clearance pick an activity the client enjoys to promote adherence choose a specific single-exercise activity understand that the activity will have positive benefits.
obtain a pre-exercise medical examination for clearance Explanation: The client has underlying medical conditions and should obtain a pre-exercise medical examination before beginning any exercise program. Picking an enjoyable activity and understanding that the activity will have positive benefits will help promote success. Variety is preferable to a single-exercise activity to promote success.
The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include? helping the client change positions every 4 hours placing the client in good alignment with joints slightly flexed providing skin care before repositioning using a sheet to drag and lift the client
placing the client in good alignment with joints slightly flexed Explanation: The inactive client should be repositioned every 2 hours with the use of a low-friction fabric or gel-filled plastic sheet and then placed in good alignment with joints slightly flexed. Skin care should be provided after repositioning.
The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? increase in the movement of secretions in the respiratory tract increase in circulating fibrinolysin predisposition to renal calculi increased metabolic rate
predisposition to renal calculi Explanation: In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.
The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? -the 24-month-old child who is unable to walk unassisted -the 3-month-old child who is unable to raise the head when prone -the 6-month-old child who is unable to roll over -the 18-month-old child who is unable to stack blocks
the 24-month-old child who is unable to walk unassisted Explanation: At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raise the head, but this is not expected at this age. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month-old infants. Stacking blocks is accomplished by most 3-year-olds, but doing so at 18 months is considered early.
