Chapter 26: Prep U

A client is beginning to ambulate with crutches after surgery on his right leg. He is allowed to bear weight only on his left leg. The nurse would work with the client to use which gait?

3 point

The nurse is caring for a client who sustained a foot fracture while playing football. Which crutch-walking gait will the nurse teach?

3 point non weight bearing

The nurse is assessing a client's ability to walk with a new cane. What degree of the client's elbow flexion does the nurse assess as appropriate?

30

The client's strength and type of disability are guides to the best possible crutch-walking gait or style of walking. The client is using each crutch and each leg separately. What would be the bestdescription of this type of crutch-walking gait to include in the documentation in the electronic medical record?

4 point gate

A client is practicing the use of a cane. While evaluating the client's technique, the nurse makes sure that the client's cane is at what distance from the side of the toes?

4 to 6 inches

The client's strength and type of disability are guides to the best possible crutch-walking gait or style of walking. The client is using each crutch and each leg separately. What would be the bestdescription of this type of crutch-walking gait to include in the documentation in the electronic medical record?

4-point gait

The nurse is providing client education on crutch-walking. Into which shape should the client place the feet and crutches to provide balance and support?

triangle

Which type of mobility aid would be most appropriate for a client who has poor balance?

a cane w/ 4 prongs on the end (quad cane)

The nurse is visiting a client at home to assess the progress of the client's exercise program. Which is the best response if the client reports that the mattress is too soft to perform the upper arm strengthening exercises?

"Do you have a sturdy armchair available?"

The nurse is teaching a client who had a below-the-knee amputation about a temporary prosthetic limb. Which client statement requires further nursing teaching?

"I will tighten the belt when I go to sleep."

The nurse is caring for an older adult client who has difficulty walking. The client states, "I hate that I can barely walk. I'm such a burden to my family." What is the appropriate nursing response?

"Let's talk about how mobility can increase your independence."

A client's plan of care specifies the goal that the client perform quadriceps setting four times daily. The nurse has explained the rationale for this exercise to the client and is now teaching the client to perform the exercises safely and effectively. What instructions should the nurse provide to the client?

"Slowly alternate between tightening the muscles in your thighs & then relaxing them."

A client is preparing to mobilize for the first time following the surgical removal of a bunion on her left foot. How should the nurse instruct the client to ambulate with her crutches?

"Try to avoid putting too much pressure on your armpits w/ the top of the crutches."

The nurse is providing education to a client who has recently had an amputation below the knee. When educating the client regarding care of the stump and prosthetic limb, what will the nurse include?

- cleanse the skin on the stump each evening, not morning - lie on your back or front periodically throughout each day - gradually increase wearing time of the prosthesis each day - inform the HCP immediately if you have gained more than 10 lb

The nurse is providing care to a client with right-sided weakness due to a recent cerebrovascular accident. The nurse is preparing the client to use a cane as an assistive mobility device. Which action(s) will the nurse take to ensure the client can use the cane effectively?

- ensure all measurements are taken on the right side of the client's body - take an accurate measurement from the client's wrist to the floor - instruct the client to avoid leaning forward or elevating the shoulders during measurement

A client who will be using a walker needs to perform upper arm exercises. What upper arm exercise(s) is appropriate?

- flexion & extension of the arms & wrists - raising & lowering weights w/ the hands - squeezing a ball or spring grip - performing modified hand push ups in bed

The nurse is preparing a client who has been on bed rest to ambulate for the first time in 1 week. Which action(s) will the nurse take to prevent a fall due to orthostatic hypotension?

- instruct the client to dangle on the side of the bed before getting up - apply anti embolism stockings on the client's legs before rising - assist w/ the use of a tilt table to support the client w/ being upright

The nurse is assessing a client for proper crutch size. The nurse would begin the measurement from which area?

anterior axillary fold

The nurse is preparing to help a client ambulate after hip surgery. Which nursing action promotes client autonomy?

allowing the client to select the time of day to ambulate

While walking behind a client using a walker, the nurse notes the client appears to be favoring the left foot. Which action should the nurse prioritize?

assess for abnormalities in the feet

The nurse is assisting a client into the sitting from the supine position in bed. As the client comes into the sitting position the client states, "I feel a little dizzy." In response to this, what action will the nurse take first?

assess the client's blood pressure in a seated position

A 91-year-old female client was admitted to the geriatric unit of the hospital with diagnoses of Hyponatremia, Dehydration, and Failure To Thrive. The care team is aware of the importance of early ambulation and has taken steps to facilitate this. How can the client be best prepared to begin ambulating?

assist the client w/ the performance of isometric exercises

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

A client with an above-the-knee amputation has been prescribed three-point non-weight bearing crutch-walking. Which teaching regarding gait pattern will the nurse provide?

both crutches move forward, followed by the weight-bearing leg

The nurse is evaluating a client's understanding of use of a leg prosthetic. Which client behavior indicates that nursing teaching has been effective?

cleans the valve on the prosthesis w/ a small brush

The nurse is reading documentation that indicates that a client has a Syme's amputation. Which client does the nurse associate with this condition?

client w/ amputation at the foot

An older adult client with generalized weakness who lives in a two-story home has a bathroom upstairs and a bedroom downstairs. Which nursing teaching is appropriate?

consider a bedside commode

A nurse checks that two fingers can be placed between the client's axilla and the axillary bar of crutches. This technique helps prevent which condition?

crutch palsy

To avoid postural hypotension, which teaching will the nurse provide to the client?

dangle feet before moving from a reclining position

The nurse is educating a client who will be using crutches for approximately 6 weeks. Which exercise would be beneficial to help with crutch use?

flexion & extension of the arms & the wrists

The nurse is caring for a client with impaired mobility who needs help to improve muscle tone and strength. What type of exercise will the nurse recommend for this client to begin the exercise regimen?

isometric

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 & strength

A client has been diagnosed with multiple sclerosis and will permanently require crutches. Which type of crutch would be most appropriate for this client?

lofstrand

The nurse is caring for a client after undergoing left hip surgery. What intervention should the nurse provide?

maintain hip abduction

A nurse is evaluating an older adult client's functional ability. What factor will the nurse include in this evaluation?

mobility & ability to compensate for age-related changes

A client requires crutches but cannot bear any weight with the hands or wrists. What type of crutches would the nurse prepare to assist this client with?

platform crutches

A male client with a history of type 1 diabetes has had a below-the-knee (BK) amputation. The client states that he is eager to be fitted for his prosthesis and to resume activities of daily living. When assisting the client with his adjustment to using his prosthesis, the nurse should prioritizewhat nursing diagnosis?

risk for impaired skin integrity

A client who had a hip replacement 2 days ago is reluctant to move for fear of experiencing pain. The client has received pain medication regularly and reports pain is a "3" on a 1 to 10 scale. Which nursing action encourages activity?

sit w/ the client to provide emotional support while the client uses the trapeze

A nurse is walking with a client, who stops walking and states, "I am suddenly feeling very lightheaded." What action would the nurse take next?

slide an arm under the client's axilla & place the nurse's foot to the side

An older adult client with weakness on one side of the body needs to use a cane for walking. How should the nurse determine the correct height of the cane to be used by the client?

the cane's handle should be parallel w/ the hip

After teaching a client how to perform a four-point crutch gait, the nurse determines that the teaching was successful when the client first moves the left crutch and then follows with:

the right foot

A college student fell and sprained his right ankle. The student health health care provider recommends the student use crutches to facilitate healing. What would the nurse teach the student?

the support of the body should be the hands & arms

The nurse is preparing to use a tilt table with a client who recently had the pins and traction removed from the right leg. Which action should the nurse take while operating the tilt table?

tilt slowly at 15 to 30 degrees until in vertical position

The nurse is caring for an older adult client who had a stroke and has regained ambulatory function. As the client is being discharged to home, which safety education will the nurse provide regarding use of stairs?

use a stair rail when going up or down

A nurse is caring for a client who is on complete bed rest while recovering from hip surgery 12 hours ago. When the client is able to start walking, which ambulation aid will most likely be recommended for use?

walker

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

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

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