Ch. 23 - Body Mechanics, Positioning, and Moving
A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?
Fowler's
A nurse applies padded boots to maintain the foot in dorsiflexion on a client who is comatose. The nurse is protecting the client from:
footdrop
When moving a client up in bed with the assistance of another caregiver, the nurse should:
have the client fold the arms across the chest.
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?
have the client sit on the side of the bed for several minutes before moving to the chair
The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?
Sims
The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination?
Sims
A client works in a warehouse and has been having low back pain. Which statement would indicate the need for more education regarding safe lifting?
"I hold the boxes away from my body so I don't drop them on my feet."
The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response?
"You are free to move onto the stretcher without assistance, but I will supervise for your safety."
A nurse is to place the client in the low Fowler position. To what level should the nurse elevate the client's head and torso?
30 degrees
The proper use of the principles of body mechanics:
Acts to prevent injury to the client and/or nurse
A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client?
Client is in supine position with arms in functional position and pillow support under the knees.
The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action?
Move the client to edge of the bed opposite the side that client will be turning.
The middle-aged client asked the nurse about developing an exercise program to help lose weight and improve health. What instructions would the nurse include? (3)
Obtain a medical evaluation by the primary care provider first. Include warm-up and cool-down activities. Participate in activities that you consider fun.
A nurse is preparing to turn a hospitalized client age 65 years. Which action is a recommended guideline for performing this skill?
Position a friction-reducing sheet under the client.
The nurse would like to assist a client out of bed and into a chair. The client is uncooperative, has a leg cast, and can bear weight on the unaffected leg. Which equipment or assistive device should the nurse use?
Powered full-body lift
The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity?
Pull the shoulder blade forward and out from under the client.
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?
Raise the head of the bed to a sitting position.
The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?
Supporting the client's back.
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
Which type of mobility aid would be most appropriate for a client who has poor balance?
a cane with four prongs on the end (quad cane)
When a client is lifted or held by a nurse, the additional weight becomes a part of the nurse's weight and should be:
balanced over the center of gravity
A nurse is caring for a client with extensive burns. Which would the nurse have to attach to the client's bed to prevent the bedclothes from touching the client's body?
bed cradle
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 she states that back injuries:
can occur when repositioning uncooperative clients.
The nurse is moving a client from bed to a wheelchair using a powered full-body sling lift. Where would the nurse position the frame of the lift?
centered over the client
A 45-year-old man is interested in starting an exercise program. The nurse informs him that exercise does not:
decrease appetite
What is a benefit of regular exercise over time?
decreased heart rate
A client with a diagnosis of chronic obstructive pulmonary disease has been experiencing debilitating periods of dyspnea since being admitted to the health care facility. What position is most likely to alleviate this client's shortness of breath?
high fowler position
An infant develops one extremity that is shorter than the other. This occurs with:
hip dislocation
The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure?
lying flat
When logrolling a client, the nurse should use supportive devices in turning the client in order to:
maintain the natural alignment of the client's body.
A nurse is helping a client to stand up from a lying position. What can the nurse do to improve the base of support?
move nurse's feet wider apart
A nurse knows that use of a trapeze would be contraindicated for a client:
on lifting restrictions
A nurse is caring for an older adult client who is very ill. The nurse uses a lifting sheet to transfer the client from the bed to the stretcher. How does transfer by lifting sheet help the client?
prevents shearing of tissue
The nurse is caring for a client who has a lower body injury and who is able to partially assist with transfers. The nurse should:
provide the client with an overhead trapeze
A nurse is conducting a home assessment of a 90-year-old male client with a history of several minor strokes that have left him with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? (3)
removal of clutter on the floor placing a nightlight in the bathroom and the hallways moving the bedroom to the ground floor
A nurse is performing a general physical assessment for a client. What is the most important thing the client can do to promote work endurance?
rest between periods of exeriton
A nurse is caring for a client with dyspnea in a health care facility. What intervention should the nurse follow to control the speed when repositioning the client?
shift hands from the posterior of the shoulder and hip to the anterior as the client rolls toward the client's abdomen
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
The nurse has been educating the client about how to use a walker safely. The nurse knows the education has been effective when the client:
steps into the walker when walking.
The pediatric nurse is caring for a 3-week-old infant. In which position will the nurse place the infant to sleep?
supine
The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?
supine
The nurse is assessing an older adult client and observe the client attempting To compensate for the shift in the center of gravity, What assessment does the nurse document?
the client flexes the knee for support
When assessing the physical activity of clients, the nurse would be most concerned about which client?
the middle-age computer programmer
When assessing for proper body alignment of a standing client, which finding is normal?
the weight of the body is distributed on the soles and heels
The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?
thrombus formation
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 nurse places a client in the position shown in the accompanying photo. What position is the client assuming?
trendelenburg
A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?
trochanter rolls
