25: Mobility

A nurse is demonstrating the proper use of body mechanics to a group of nursing students. What would be most appropriate for the nurse to do?

stand with legs wide apart Proper body mechanics include having a wide base of support; facing the direction of the work or the direction of motion; keeping objects close to the body when lifting; and bending the knees and hips to change positions while keeping the knees relaxed and the trunk erect.

The nurse is teaching a client on the proper use of the knee immobilizer. Which statement by the client will indicate to the nurse the teaching has been effective?

"I can take the immobilizer off to shower and dress each morning." An immobilizer is a commercial splint which limits the motion of an area of a painful but healing injury. An immobilizer is removed for brief periods during hygiene and dressing. It should remain on during sleep to decrease the risk of reinjuring the joint during sleep. Exercise will be limited and most likely not include walking or jogging. The client should wait until the health care provider determines it is safe to remove the immobilizer.

A nurse is caring for an older client with osteoarthritis who is recovering from the West Nile virus. Isometric exercises have been prescribed. What will the nurse teach the client about isometric exercises?

Isometric exercises will improve muscle tone and strength. Isometric exercises are recommended to improve the muscle strength when preparing a client for ambulation, recovering from a debilitating illness, or living with a chronic condition. In this scenario, the client would benefit from isometric exercises because of the client has osteoarthrosis and is recovering from the West Nile virus. Aerobic exercise promotes cardiac conditioning. Isometric exercises are not a tool used to measure muscle performance. Likewise, isometric exercises are not prescribed to promote tissue perfusion. Isometric: weight training

The nurse is performing range-of-motion exercises on a client's arm. The nurse starts by lifting the arm forward to above the head of the client. Which action would the nurse perform next?

Return the arm to the starting position at the side of the body The nurse would return the joint to a neutral position (i.e., its normal position of alignment) when finishing each exercise.

Which postural deformity might be assessed in a teenager?

Scoliosis Scoliosis, a lateral curvature of the spine, would most likely be assessed in a teenager. Kyphosis and osteoporosis are seen in older adults. Rickets is seen in children.

The client is an active, healthy 2-year-old child. His mother asks a nurse what she can expect developmentally from the boy over the next few years. What is the nurse's best response?

The client will continue to grow rapidly and will refine both gross and fine motor skills The toddler years are a time of rapid longitudinal growth and rapid skill acquisition and refinement. Any regression in skill acquisition is indicative of a larger problem and must be evaluated.

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?

Transfer Belt A transfer belt is designed for clients who can bear weight and help with the transfer but are unsteady. The other options are inappropriate for this client.

The nurse is caring for an older adult client who is recovering from hip surgery. Which assistive device will the nurse use to facilitate client ambulation?

Walker A walker is often used for clients beginning to ambulate after prolonged bedrest or after hip surgery. Other devices do not offer the same level of support.

A nurse is performing range-of-motion exercises for a client and moves the client's fingers apart and then back together. The nurse is performing which range of motion?

adduction/abduction Spreading the fingers apart and then bringing them back together reflects adduction and abduction. Making a fist and then opening it back up reflects flexion and extension. Turning the ankle inward and then outward reflects inversion and eversion. Moving the foot toward the floor and then back up reflects plantar flexion and dorsiflexion.

When explaining the benefits of isotonic exercises to promote cardiorespiratory conditioning and increase lean muscle mass, which exercise should the nurse tell the client to perform?

aerobic exercise The nurse should ask the client to perform aerobic exercise, which involves rhythmically moving all parts of the body at a moderate-to-slow speed without hindering the ability to breathe. Bodybuilding, weight lifting, and push-ups are isometric exercises, which improve blood circulation but do not promote cardiorespiratory function. In fact, strenuous isometric exercises temporarily elevate blood pressure.

A nurse is caring for a client whose fractured leg is in a cast. Which ambulatory device could the nurse suggest for the client to use at the health care facility?

axillary crutch The nurse should suggest the use an axillary crutch for the client who has her fractured leg in a cast. This will aid the client to ambulate at the health care facility. Axillary crutches have a bar that fits beneath the axilla. Clients who need brief, temporary assistance with ambulation are likely to use axillary crutches. A cane is used for clients who have weakness on one side of the body. Clients who require considerable support and assistance with balance use a walker. Platform crutches are used by clients who cannot bear weight with their hands and wrists. Many clients with arthritis use them. armpit crutches: allow pt to lift injured leg

The nurse is teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when the graduate states that back injuries:

can occur when uncooperative clients are being repositioned. Many nurses believe that back pain is a routine consequence of the job, but it need not be. Employing principles of body mechanics, use of algorithms, and guidelines for transferring or lifting clients contributes to the prevention of back injuries and pain. Back injuries can occur when uncooperative clients are being repositioned. Back injuries cannot be prevented with the use of a gait belt. Inappropriate use of the gait belt and other factors can contribute to back injuries. Standing, not sitting, for long periods can contribute to back injuries.

The nurse has applied a sling to a client who has an arm injury. Which assessment finding requires the nurse to further intervene?

capillary refill time is 4 seconds Capillary refill should be 2 seconds or less. If it is greater than 2 seconds, circulation may be impaired, which requires nursing intervention. All other findings are normal.

A nurse at a health care facility is caring for clients who are using crutches to ambulate. In which client would the nurse observe a four-point walking gait?

clients with disabilities such as arthritis or cerebral palsy The nurse would observe a four-point gait in clients with disabilities such as arthritis or cerebral palsy who are using crutches to ambulate. Clients who have more coordination and balance are more likely to have a two-point gait. A three-point non-weightbearing gait can be observed in clients with one amputated, injured, or disabled extremity. A client with an amputated limb learning to use a prosthesis would have a three-point partial weight-bearing gait.

What is a benefit of regular exercise over time?

decreased heart rate Regular physical activity over time results in cardiovascular conditioning and therefore decreased heart rate. Regular exercise increases circulating fibrinolysin that serves to break up small clots, thus decreasing the risk for blood clots. Over time, regular exercise leads to improved pulmonary function, including decreased work of breathing. Venous return is improved when contracting muscles compress superficial veins and push blood back to the heart against gravity.

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair 3 times per day. Which action will be most effective to transfer the client safely into the chair?

having the client sit on the side of the bed for several minutes before moving to the chair Having the client sit at the side of the bed minimizes the risk for blood pressure changes (orthostatic hypotension) that can occur with position change.

A client with a right lower limb prosthesis uses a cane for additional stability. Which behavior demonstrates to the nurse that the client is ambulating appropriately?

holds cane in left hand A client with a right lower limb prosthesis who uses a cane should hold the cane in the hand opposite the prosthetic limb. The client should walk with eyes ahead, avoid hiking the hip, and place the unaffected leg onto steps first.

A client has begun exercising four times each week. Which of the following is a cardiovascular response to regular exercise?

increased efficiency of the heart Regular exercise produces cardiovascular responses such as an increased efficiency of the heart, decreased heart rate and blood pressure, increased blood flow to all body parts, and increased circulation of fibrinolysin.

As a part of his workout regimen, a 21-year-old college football player often engages in squats and lateral arm holds. These are examples of what type of exercise?

isometric Isometric exercise isolates a specific muscle or muscle group and exercises it by holding the muscle steady and maintaining tension. Key word: holds - strength training

The client recently had abdominal surgery and has now developed pneumonia. The client requires frequent turning by the nurse. In what position will the nurse avoid placing the client?

prone The nurse avoids placing the client in the prone position. The prone position would be uncomfortable for this client due to the recent abdominal surgery. The client can be placed in the other positions: side-lying, lateral oblique, and Fowler position using support devices. These positions can be used for clients who had abdominal surgery and clients who have pneumonia.

The occupational nurse is assessing a worker's vital signs at rest. Which finding requires nursing intervention?

pulse rate 120 beats per minute Elevated blood pressure, pulse rate, and/or respiratory rate while resting may indicate a life-threatening cardiovascular concern. The nurse should intervene when the client's resting pulse rate is high. All other vital signs are normal. (should be btwn 60-100 BPM)

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:

steps into walker when walking A walker is mechanical aid that enhances the client's balance and ability to bear weight. Education is usually done by physical medicine or physical therapy, but the nurse should continue to assess the client's ability to use the walker properly. The client should step into the walker when walking rather than walking behind it. When the client is rising from a seated position, the arms of the chair, not the walker, should be used for support. The client should be cautioned to avoid pushing the walker out too far in front. Also, the client should avoid leaning over the walker but should instead stay upright while moving.

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 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.

The nurse is teaching a client about moving joints into positions of pronation and supination. Which client action does the nurse identify that appropriately reflects these movements?_

turns the arms downward and then upward Pronation and supination involve turning downward and then upward. Moving the legs away from the midline and then toward the midline is reflective of abduction and adduction. Tilting the chin downward and then stretching the head backward comfortably reflects flexion and extension. Turning the sole of the foot toward and then away from the midline is reflective of inversion and eversion.

The nurse is planning discharge care for an older adult client who had been on prolonged bed rest. Which assistive device will the nurse plan to use to facilitate client ambulation?

walker A walker is often used for clients beginning to ambulate after prolonged bed rest. Other devices do not offer the same level of support.

The nurse is observing an unlicensed assistive personnel (UAP) ambulate a client. Which UAP behavior requires nursing intervention?

walks slightly ahead of the client to clear pathways The nurse will intervene if the UAP walks ahead, instead of slightly behind, the client. All other actions are appropriate.

At what juncture would a nurse assess the gait of an ambulatory client?

when the client walks into the room Begin the physical assessment of an ambulatory client the moment the client walks into the room, observing gait, posture, and voluntary or involuntary movements.

The nurse is working to increase functional ability of a client who is bedbound. Which assistive technique should the nurse prioritize in the plan of care?

trapeze bar Promoting client independence with movement and activity is an important intervention for clients who are bedbound, especially ones with musculoskeletal problems. Unlike log rolling, trochanter rolls, and pull sheets, which are nurse-initiated methods, the overhead trapeze is used by the client.

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client?

the client's ability to assist The nurse assesses several parameters when choosing whether to use a mechanized assistive device for a client transfer. The most important consideration, however, is the client's ability to safely assist with the transfer.

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?

"Put your arm in this sleeve." When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions. "Put your arm in this sleeve" gives one step in the process of getting dressed. "Put on your shirt" involves many steps and should be broken down into the steps of putting on a shirt. "Put your pants on and zip the zipper" should be broken down into steps and given in clear, short sentences. Furthermore, putting on pants and zipping a zipper involves many steps and may be too complicated for the client with dementia to follow. Instructions should be phrased positively as the client may not register the "Don't"; the client may put the shoes on if the nurse states "Don't put on your shoes yet."

The occupational nurse is teaching an administrative assistant about proper posture when sitting. Which teaching will the nurse include?

"Both of your feet should rest on the floor." Proper sitting posture includes using the buttocks and upper thighs as the base of support, keeping both feet resting on the floor and the knees bent, with the backs of the knees away from the chair to avoid distal circulation concerns. The other choices are unsafe practices.

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?

bed trapeze A trapeze bar is a handgrip suspended from a frame near the head of the bed. A client can grasp the bar with one or both hands and raise the trunk from the bed. The trapeze makes moving and turning considerably easier for many clients and facilitates transfers into and out of bed. A foot board helps reduce the risk of foot drop. A bed cradle is usually a metal frame that supports the bed linens away from the client while providing privacy and warmth. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward.

What body system benefits the most from aerobic exercises?

cardiovascular Aerobic exercises are sustained muscle movements that increase blood flow, heart rate, and metabolic demand for oxygen over time, promoting cardiovascular conditioning.

Using proper body mechanics, which motions would the nurse make to move an object?

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. 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.

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct?

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight alignment when the client is being turned. The nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement. The nurse should avoid twisting the client's head, spine, shoulders, knees, or hips while logrolling. A chair is not used with logrolling.

The occupational nurse is assessing an employee's vital signs at rest. Which finding requires nursing intervention?

blood pressure 140/90 mmHg Elevated blood pressure, pulse rate, and/or respiratory rate while resting may indicate a life-threatening cardiovascular concern. The nurse should intervene when the client's resting blood pressure is high. All other vital signs are normal.

A physician has directed a nurse to assist a client to perform exercises in order to prevent ankylosis. What type of exercise should the nurse assist the client with in this case?

range-of-motion exercises The nurse should assist the client to perform range-of-motion exercises in order to prevent ankylosis. Range-of-motion (ROM) exercises are therapeutic activities that move the joints. They are performed to assess joint flexibility before initiating an exercise program, maintain joint mobility and flexibility in inactive clients, prevent ankylosis (permanent loss of joint movement), stretch joints before performing more strenuous activities, and evaluate the client's response to a therapeutic exercise program. A continuous passive motion (CPM) machine is an electrical device that is used as a supplement or substitute for manual ROM exercise. Active exercises are therapeutic activities that the client performs independently after proper instruction. Aerobic exercises are isotonic exercises that promote cardiorespiratory conditioning and increase lean muscle mass. Ankylosis - fussing of bones. If don't lubricate joints with ROM exercises, bones will fuse together

A young client, 3 months after a right below-the-knee amputation (BKA), is brought to the clinic by the caregiver over concerns that the stump is turning red. Which question should the nurse prioritize?

"How long are you wearing the prosthesis during the day?" he reddened skin could be an early sign of impaired skin integrity. This could be related to the client wearing the prosthetic device for too long a period during this early phase of recovery. The client should wear the prosthesis for short periods of time and gradually increase the wearing time to prevent overexertion and impaired skin integrity. The other options would then be assessed to ensure they are also not increasing the risk for problems. Lying down periodically will help promote venous circulation, reduce stump edema and avoid joint contractures. It is important that the stump be washed in the evening to give the skin time to be moisture free. Proper cleaning of stump socks will promote cleanliness and comfort.

The nurse is preparing a 5-year-old child for application of a cast on the fractured right arm. The child is very upset and does not want a cast. Which is the best response from the nurse?

"The cast will hold your bones in place so they can heal." The nurse should explain to the client why the cast is needed and what it will do. In this situation, explaining that the cast will hold the bones in place is the best choice. The nurse should avoid talking down to the client or fail to provide proper teaching.

The nurse is encouraging the client to use hand rolls to prevent contractures. Which statement by the client indicates that further teaching is necessary?

"The hand rolls help me develop strength in my grip." Hand rolls prevent contractures (permanently shortened muscles that resist stretching) of the fingers. They keep the thumb positioned slightly away from the hand and at a moderate angle to the fingers. The fingers are kept in a slightly neutral position rather than a tight fist. A rolled-up washcloth or a ball can be used as an alternative to commercial hand rolls. Hand rolls are removed regularly to facilitate movement and exercise. Hand rolls are not used to strengthen the grip.

An unlicensed assistive personnel (UAP) has alerted the nurse that a client who is 36 hrs postoperative for a fracture of the tibia/fibula is having difficulties. Which action should the nurse prioritize after reviewing the UAP's report?

Contact Health care provider immediately The increased pain, condition of the toes, and cast being too tight are indications the client has developed compartment syndrome and the health care provider needs to be notified immediately, as this is a medical emergency and requires immediate care to prevent permanent damage to the leg. The vital signs and drainage on the cast could also be related to compartment syndrome and would be evaluated with care given after the health care provider is notified.

A nurse is assessing the musculoskeletal system of a client during an initial visit to the clinic. The assessment reveals insufficient joint lubrication in the knees. The nurse documents this finding as:

Crepitus Crepitus indicates insufficient joint lubrication in the client. The nurse should listen for a crunching or grating sound, which can occur when bones rub against one another during movement because of inadequate protection or insufficient joint lubrication. Chorea refers to spontaneous, brief, involuntary muscle twitching of the limbs or facial muscles. Scoliosis refers to a lateral deviation of the thoracic spine. Swelling refers to an enlargement of the area, such as with fluid in the subcutaneous tissues.

A nurse provides home care for an older woman with severe osteoporosis. Which strategy(ies) does the nurse include in the client's care plan to help prevent fractures? Select all that apply.

Encourage client to take prescribed calcium and vitamin D Instruct client to take magnesium and eat foods high in iron Check area rugs have a slip-resistant foundation Recommend installation of handrails in bathrooms Instruct client to engage in weight-bearing exercise at least once per day The nurse working with the client with severe osteoporosis about the prevention of fractures will encourage the client to take prescribed calcium and vitamin D, not magnesium or iron, and engage in weight-bearing exercises every day. Installing handrails in bathrooms is a safety precaution that should be taken to prevent falls in and out of the tub/shower. Area rugs should not be used in living areas of clients at risk for falling or fractures.

A nurse is caring for a client with a leg fracture. The client is placed on an adjustable bed in the Trendelenburg position. How will this position help the client?

It prevents the client from sliding down toward the foot of the bed. The Trendelenburg position will prevent the client from sliding down toward the foot of the bed. Raising the head of the bed would help the client look around without twisting and bending. It also promotes drainage of the upper lobes of the lungs and prepares the client for standing and walking.

A nurse is caring for an inactive client and assisting the client in performing range-of-motion (ROM) exercises. What care should the nurse take when performing range-of-motion exercises?

Move each joint until there is resistance but no pain. The nurse assisting the inactive client with range-of-motion exercises should assist in moving each joint until there is resistance but no pain. This will ensure that each joint is exercised to its point of limitation. The nurse should not place any pillows and other positioning devices because they interfere with the exercises. The nurse should follow a systematic, repetitive pattern when performing the range-of-motion exercises to prevent overlooking any joint. The nurse must perform similar movements with each extremity to bilaterally exercise the joints.

The meal tray has been delivered to the client's room. The client needs to be repositioned higher in the bed with the head raised. The client is unable to assist with moving in the bed. What action is best for the nurse to perform to prevent injury to the nurse and/or the client?

Obtain assistance from another nursing staff member It would be best for the nurse to obtain another nurse for assistance. A general principle for positioning a client is to enlist the assistance of another staff member. This is to prevent injury to the nursing staff. The nurse will not pull the client up from the head of the bed. This action could cause injury to the nurse and/or client. The bed could be placed in the Trendelenburg position but with the side rails down, not up. The nurse would have to reach over the side rails to move the client. A roller sheet could be positioned and used for this client, but this still takes at least two nursing staff to use.

The nurse is teaching a 37-year-old client about factors that impair fitness and stamina. Which factors will the nurse identify? Select all that apply.

obesity health problems smoking age Obesity, health problems, smoking, and age (particularly advanced age) can impair a client's fitness and stamina. Optimal muscle and skeletal function do not impair fitness and stamina, yet compromised muscle and skeletal function does.

When assessing the physical activity of clients, the nurse would be most concerned about which client?

the middle-aged computer programmer Although further assessments should be done to avoid making assumptions and imposing stereotypes, there are many variables that may contribute to a sedentary lifestyle, such as occupations. A computer programmer has a job that is inactive. The nurse would be concerned about this client and would need to do further assessments to determine activity, frequency, and intensity that occur outside of work. The mother of small children would be involved in housecleaning and chasing after the children. Walking is a commonly prescribed exercise, and going to the mall provides a safe environment where walking would be possible. A Native American who hunts is engaging in culturally related physical activity.