Chapter 33: Activity
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.
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 on your shirt." -"Don't put on your shoes yet." -"Put your arm in this sleeve." -"Put your pants on and zip the zipper."
"Put your arm in this sleeve." Explanation: 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 UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response?
"To preserve the client's functional ability to grasp and pick up objects." Explanation: Trochanter rolls prevent the legs from rotating outward. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop. Side rails help a weak client turn independently and protect the client from falling out of bed.
A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response? -"To preserve your functional ability to grasp and pick up objects." -"To prevent foot drop." -"To avoid contractures." -"To prevent your legs from rotating outward."
"To prevent your legs from rotating outward." Explanation: Trochanter rolls prevent the client's legs from rotating outward. The other statements do not describe trochanter rolls. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop.
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." -"I can only allow you to transfer without assistance with a physician's order, so I will help you now." -"You may not transfer without my help, because you need a friction-reducing device to prevent harm to your skin." -"That is fine if you want to transfer without my help; ring your call bell after you have transferred and are ready to go."
"You are free to move onto the stretcher without assistance, but I will supervise for your safety." Explanation: If the client is fully able to assist in the transfer, the nurse should allow the client to complete the movement independently, with supervision for safety. A physician order is not necessary for a transfer from a stretcher to a bed. The client can move independently and therefore does not need a friction-reducing device. A nurse should remain at the bedside to monitor the transfer.
A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? -"If you feel tired while walking with your crutches, rest your -weight on your armpits for a moment and then continue slowly." -"Your elbows will be slightly bent when you are using your crutches." -"When your crutches fit right, most of your body weight will be supported by your armpits." -"We'll have the nursing assistant watch you while you walk around the unit the first time."
"Your elbows will be slightly bent when you are using your crutches." Explanation: When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down, if fatigued.
The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply. -Fowler -Semi-Fowler -Upright =Supine =Modified supin
-Fowler =Semi-Fowler -Upright Explanation: The Fowler position is a sitting position, also known as upright, that raises the client's head 80 to 90 degrees and benefits the client by preventing aspiration, promoting ventilation, facilitating eating, and improving cardiac output. The semi-Fowler position is a 45-degree angle, which also allows for ventilation without aspiration. The supine and modified supine (pillow under knees) would not be appropriate for facilitation ventilation and preventing aspiration.
The nurse is orienting a new unlicensed assistive personnel (UAP) to hospital policies. While a client is participating in physical therapy the UAP decides to make the bed. What are appropriate action(s) by the nurse after entering a hospital room and observing the UAP in the image? Select all that apply.
-Inform the UAP the linens should not be placed on the floor for any reason -Communicate the importance of using proper body mechanics to avoid straining the back Explanation: The UAP is at risk for back injury or straining due to lifting the linens using the back muscles and the shift in gravity beyond the base of support. The UAP should move close to and work as closely as possible to an object that is to be lifted or moved to avoid injury. The linens should not be placed on the floor for any length of time due to the increase risk for transmission of microorganisms from the hospital room to other areas of the hospital. It is important to educate all health care personnel when a potential risk to safety or possible harm is occurring. This will help minimize possible injury. Avoiding the conversation with the UAP until there is a more appropriate time is not an appropriate action.
The nurse directs the unlicensed assistive personnel (UAP) to help a partially blind older adult client with meals. Which information is appropriate for the nurse to provide the UAP to facilitate the client's comfort and safety during mealtime? Select all that apply.
-Place client in upright position at a 45- to 90-degree angle in the bed or chair -Provide verbal cues regarding location of food on plate -Cut food into small pieces -Ensure that the temperature of food is safe Explanation: Appropriate information for the nurse to provide the UAP includes placing the client in an upright position in the bed or chair, providing verbal cues regarding location of food on plate, cutting food into small pieces, and ensuring that the temperature of the food is safe. It is not appropriate to place a pillow behind the neck as this could cause difficulty swallowing. The bed should be at least a 45-degree, preferably at a 90-degree, angle to prevent aspiration while eating.
Which strategy(ies) does the nurse use to maintain proper body mechanics and prevent self-injury? Select all that apply. -Place feet shoulder width apart when lifting an object -Plant feet firmly on the floor when supporting the client during dangling -Bend at the waist when lifting an object -Lock elbows when grasping onto objects -Hold objects an arm's length away when lifting and carrying them
-Place feet shoulder width apart when lifting an object -Plant feet firmly on the floor when supporting the client during dangling Explanation: When lifting an object, the nurse will place the feet shoulder width apart with feet planted firmly to provide a stable base of support. When supporting the client during dangling, the nurse will tighten the gluteal and abdominal muscles to avoid back strain or injury. When lifting an object, the nurse will bend at the knees instead of the waist because the thigh muscles are larger in mass than either the buttocks or back muscles. The nurse will get close to the object to be lifted to prevent excess stress on arm and back muscles. The nurse does not hold heavy object away from the body nor lock the elbows during lifting and carrying objects. These actions put extra stress on the muscles of the back and this strain could lead to injury.
The nurse is considering the use of a power stand-assist machine with a client who has difficulty getting out of bed. The nurse will choose a different assistive device if which assessments are present? Select all that apply.
-The client makes no attempt to help with transfers. -The client is oriented to self, but not time or place Explanation: In order to safely use a power stand-assist machine, the client must be able to bear weight on at least one leg, follow directions, and be cooperative. A client who is not oriented to time or place and a client who does not attempt to help with transfers do not meet these criteria.
A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. -removing clutter from the floor -placing nightlights in the bathroom and hallways -moving the bedroom to the ground floor -installing hardwood floors
-removing clutter from the floor -placing nightlights in the bathroom and hallways -moving the bedroom to the ground floor Explanation: Removing clutter from the floor, placing nightlights in the bathroom and hallways, and moving the bedroom to the ground floor will reduce the risk of falling and encourage the client to increase his mobility. Installing hardwood floors may induce falls due to the smooth surface; wall-to-wall carpeting would provide traction.
A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. -removing clutter from the floor -placing nightlights in the bathroom and hallways -moving the bedroom to the ground floor -installing hardwood floors
-removing clutter from the floor -placing nightlights in the bathroom and hallways -moving the bedroom to the ground floor Explanation: Removing clutter from the floor, placing nightlights in the bathroom and hallways, and moving the bedroom to the ground floor will reduce the risk of falling and encourage the client to increase his mobility. Installing hardwood floors may induce falls due to the smooth surface; wall-to-wall carpeting would provide traction.
The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device? -A client who has leg strength and can cooperate with the movement -A client who has an abdominal incision -A client with a thoracic incision -A client who is confined to bed rest
A client who has leg strength and can cooperate with the movement. Explanation: The gait belt is used to help the client stand and provides stabilization during pivoting. Gait belts also allow the nurse to assist in ambulating clients who have leg strength, can cooperate, and require minimal assistance. A gait belt is not used on clients who have either an abdominal or thoracic incision. A gait belt would not be used on a client who is confined to bed rest.
The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason? -Acts as a safeguard against legal action by the client -Acts to prevent injury to the client and/or nurse -Primarily protects the client from injury -Primarily protects the nurse from injury
Acts to prevent injury to the client and/or nurse Explanation: When nurses use their bodies to perform therapies, to assist clients with movement, or to move equipment, they benefit from the effective use of body mechanics to prevent injury to themselves and clients. The actions do not safeguard against legal action by the client but rather are in place to prevent injury.
A nurse is promoting exercise and activities for an older adult client. Which teaching point would be appropriate for this client? -Encourage the client to quickly increase the repetitions for arm and leg exercises. -Encourage the client to warm up before beginning exercises and to cool down after exercising. -Instruct the client to continue exercise even if feeling weak, to build up stamina. -Teach the client to force joints to meet their natural limit and beyond prior to modifying exercises.
Encourage the client to warm up before beginning exercises and to cool down after exercising. Explanation: The client should be encouraged to develop an exercise program that specifies warm-up and cool-down activities (walking, stretching). The client should not be encouraged to quickly increase the repetitions for arm and leg exercises. The client should not continue to exercise when feeling weak; this could lead to injury. The client should not be taught to force joints to meet their natural limit and beyond prior to modifying exercises. This could lead to injury.
The nurse is transferring the client from the bed to a wheelchair when the client reports dizziness. What is the next step for the nurse? -Have the client stand without moving to see if the dizziness will pass. -Firmly grasp the gait belt and gently lower the client into bed. -Quickly pivot the client into the wheelchair to prevent client fall. -Apply oxygen 2L via nasal cannula to the client.
Firmly grasp the gait belt and gently lower the client into bed. Explanation: The nurse should ease the client back on the bed to prevent fall and injury. Having the client stand may increase risk of fall and injury if dizziness persists. The client should not be quickly pivoted into the chair, because this could cause injury to the client and/or the nurse. Applying oxygen would not be priority over ensuring the client is safe in bed.
A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client? -supine -prone -Sims' -Fowler's
Fowler's Explanation: Fowler's position, a semi-sitting position, will assist the client with dyspnea because this position allows the abdominal organs to drop away from the diaphragm. The other position choices do not promote oxygenation.
A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?
If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Explanation: Be prepared to apply the stockings in the morning before the client is out of bed. Assist the client to a supine position. If the client has been sitting or walking, have him or her lie down with legs and feet well elevated for at least 15 minutes before applying the stockings. Powder the leg lightly unless client has a breathing problem, dry skin, or sensitivity to the powder. If the skin is dry, a lotion may be used. Powders and lotions are not recommended by some manufacturers; check the package material for manufacturer specifications.
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? -Make sure the bed brakes are unlocked. -Put the chair at the foot of the bed. -Place the bed in the highest position. -Raise the head of the bed to a sitting position.
Raise the head of the bed to a sitting position. Explanation: When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair.
When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body? -The wrist is classified as an irregular bone. -Short bones contribute to movement. -Long bones are relatively thin and contribute to shape. -Flat bones are found in the spinal column.
Short bones contribute to movement. Explanation: Short bones contribute to movement and are located in the wrist and ankle. The wrist is classified as a short bone. Long bones, such as the femur and humerus, are located in the upper and lower extremities and contribute to height and length. The flat bones are relatively thin and contribute to shape. The flat bones are found in the ribs and several of the skull bones and contribute to shape (structural contour).
The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? -supine -prone -Sims' -Fowler's
Sims' Explanation: Sims' position, a semi-prone position, can be used for certain examinations of the rectum and vagina. The other positions do not allow adequate examination of this area.
The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination? -supine -prone -Sims' -Fowler's
Sims' Explanation: Sims' position, a semi-prone position, can be used for certain examinations of the rectum and vagina. The other positions do not allow adequate examination of this area.
The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table? -The brain is sending impulses to the muscles to avoid the table. -The client is aware of spatial relationships to avoid the table. -The client's muscles are being stretched to walk around the table. -The cerebellum is responding to impulses from the inner ear.
The client is aware of spatial relationships to avoid the table. Explanation: The client has awareness of spatial relationships (where objects are located in space). This ability comes from the visual or optic reflexes. The labyrinthine sense relates to the sensory organs in the inner ear and provides a sense of position, orientation, and movement. It does not contribute to where objects are in space. When the extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture (e.g., when the knee buckles under, the reflex contraction aids the person to straighten the knee). This does not contribute to perception of where objects are in space.
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 refine both gross and fine motor skills but longitudinal growth will slow. -The client will continue to grow rapidly but gross and fine motor skill acquisition will slow. -The client will regress in fine and gross motor skill development. -The client will continue to grow rapidly and will refine both gross and fine motor skills.
The client will continue to grow rapidly and will refine both gross and fine motor skills. Explanation: 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.
A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall? -The nurse should place his or her feet close together with one foot in front of the other. -The nurse should rock his or her pelvis out on the opposite side of the client. -The nurse should grasp the gait belt and pull the client's body backward away from his or her body. -The nurse should gently slide the client down his or her body to the floor.
The nurse should gently slide the client down his or her body to the floor. Explanation: The nurse should place feet wide apart, with one foot in front, and rock the pelvis out on the side nearest the client. The nurse should grasp the gait belt and support the client by pulling his or her weight backward against his or her body and then gently slide the client down his or her body to the floor, protecting the client's head.
A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate? -The nurse discourages the client from helping with the transfer. -The nurse administers pain medication following the transfer. -The nurse grabs and holds the client by his arms. -The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight.
The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight. Explanation: During any client-transferring task, if the lift is more than 35 lb (16 kg) of a client's weight, consider the client to be fully dependent and use assistive devices for the transfer. The nurse would encourage the client to help with the transfer if the client is able and can safely assist. Pain medication would not be indicated after the transfer unless a pain assessment indicated this action. The nurse would not grab and hold the client by the arms. This action could cause injury to the 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.
In an assessment 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 chest is downward and displaced slightly backward. -The abdominal muscles are held downward and the buttocks upward. -The line of gravity is deviated slightly to the left.
The weight of the body is distributed on the soles and heels. explanation: A client's body is in correct body alignment while standing when the weight of the body is distributed on the soles and heels. The chest is held upward and forward. The abdominal muscles are held upward and the buttocks downward. The line of gravity goes midline through the center of the knees and in front of the ankle joints.
A nurse is teaching a client who has unilateral weakness how to walk with a cane. Which guideline promotes safe use of this device? -The client should hold the cane in the hand on the same side as the leg with the most severe deficit. -The client should stand with as much weight as possible placed on the feet, using the cane for balance. -When taking a step, the client should advance the stronger leg forward ahead of the cane and follow with the weaker leg. -When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane.
When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane. Explanation: When stepping forward, the heel should be slightly beyond the tip of the cane. The client should hold the cane on the opposite side of the foot with the deficit and evenly distribute weight between the feet and the cane. The client should step first with the weaker leg.
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) -a single-ended cane with a half-circle handle -a single-ended cane with a straight handle -axillary crutches
a cane with four prongs on the end (quad cane) Explanation: Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold but are not recommended for clients with poor balance. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.
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.
The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change? -reports of pain in the lower back -decrease in flexibility -stumbling gait -unequal pupil size
decrease in flexibility Explanation: A decrease in the flexibility of joints is a normal age-related finding. Pain in the lower back, stumbling gait, and unequal pupil can be indicators of pathology and are not normal age-related findings.
The nurse observes an older adult client 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.
A nurse is interviewing a client about the client's usual activity level. The client states, "I swim laps 2 to 3 times a week and walk 1 to 2 miles twice a week. The nurse interprets this activity as which type of exercise? -isometric -isokinetic -isotonic -range-of-motion
isotonic' Explanation: Isotonic exercise involves muscle shortening and active movement. Examples include carrying out ADLs, independently performing range-of-motion exercises, and swimming, walking, jogging, and bicycling. Isometric exercise involves muscle contraction without shortening (i.e., there is no movement or only a minimal shortening of muscle fibers). Examples include contractions of the quadriceps and gluteal muscles, such as that which occurs when someone holds a yoga pose. Isokinetic exercise involves muscle contractions with resistance. The resistance is provided at a constant rate by an external device that has a capacity for variable resistance. Examples include rehabilitative exercises for knee and elbow injuries and lifting weights. Range-of-motion exercise refers to the maximum degree of movement of which a joint is normally capable.
When turning a client in bed, what muscle groups would the nurse use to pull the client to the opposite side of the bed? -back -arm -chest -leg
leg Explanation: The nurse would tighten gluteal and abdominal muscles, flex the knees, and use the leg muscles to do the pulling. This saves strain on the nurse's lower back. The arms and chest are part of the accessory muscle groups used in pulling a client.
The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene? -lowering the height of the bed prior to moving the client -turning the client as a complete unit to avoid twisting the -spine -placing the client in good alignment with joints slightly flexed -replacing pillows and positioning devices
lowering the height of the bed prior to moving the client Explanation: Lowering the height of the bed is an incorrect action that would require the nurse to intervene. The bed should be raised to the height of the caregiver's elbow, or to a comfortable working height before the client is positioned. All other options are appropriate positioning techniques.
The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure? -sitting up -lying prone -lying flat -lying flat with feet raised slightly
lying flat Explanation: The nurse would position the bed so that the client is lying flat on the back and then raise the bed to a comfortable working height. This facilitates moving the client to the side in order to perform the turn in bed. If the client was prone, the client will need to be moved to the client's back. Sitting up is another position a client can be moved into.
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. -allow the client's leg to rest on the bed. -maximize the client's participation. -prevent the blood stasis that can lead to skin breakdown.
maintain the natural alignment of the client's body. Explanation: Logrolling is a technique used for turning clients who have had surgery or an injury involving the back or spine. It maintains spinal alignment, thus preventing injury. It is not performed for the purpose of maximizing the client's participation or preventing blood stasis.
One of the most common injuries/risks associated with exercise in a healthy person is: -increased work of breathing. -chest pain. -decreased joint mobility. -muscle injury.
muscle injury. Explanation: Orthopedic problems caused by irritation of bones, tendons, ligaments, and sometimes muscles are the most common injuries associated with exercise. With exercise, healthy individuals benefit from improved respiratory functioning, including improved alveolar ventilation, decreased work of breathing, and improved diaphragmatic excursion. Major cardiac events in a healthy person are minimal, although the risk is much higher for those with known or suspected cardiovascular disease. The rhythmic contraction and relaxation of muscle groups during exercise results in increased muscle mass, tone, strength, and increased joint mobility.
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.
When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what adverse condition is the nurse assessing the client? -deep vein thrombosis -circulatory alterations -orthostatic hypotension -hypertension
orthostatic hypotension. Explanation: The nurse would stand in front of the client and assess for any balance problems or reports of dizziness upon standing due to orthostatic hypotension. Orthostatic hypotension occurs when the blood pressure drops when standing from the sitting or lying position. Standing in front of the client prevents falls or injuries. Hypertension or high blood pressure is a condition in which the force of the blood against the artery walls is too high. Hypertension needs to be treated with medications to lower the blood pressure. Deep vein thrombosis is a thrombosis or blood clot in a vein lying deep below the skin, especially in the legs. Treatment is by medications, compression stockings, and filters. There are other circulatory alterations, like peripheral artery disease, which is caused by narrowed blood vessels that reduce blood flow to the limbs.
The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement? -instruct the client to place arms on the side rails -place a small pillow under each arm -elevate the head of the bed -place a trochanter roll under the arms
place a small pillow under each arm. Explanation: A small pillow may be used to elevate the extremities, shoulders, or incisional wounds. Instructing the client to place the arms on the side rails will place pressure on the arms and affect circulation to the extremity. Elevating the head of the bed (Fowler) will not elevate the arms. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward.
A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate? -contacting the primary care physician -placing a small towel under the neck -administering a muscle relaxer -positioning the client on the stomach
placing a small towel under the neck Explanation: Kyphotic changes can cause pressure on cervical vertebrae when someone is in a supine position. Effects of this can be minimized by placing a small towel or cervical pillow under the neck. Placing the client on the stomach is incorrect, and a muscle relaxer will not help reduce the pressure caused by the kyphosis. Contacting the physician is unnecessary.
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 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 -place the call bell within reach -cover the client with the bed linens -assess for pain
pull the shoulder blade forward and out from under the client. Positioning the shoulder blade in this manner removes pressure from the bony prominence and thus helps decrease the risk of impaired skin integrity. The other actions should also be performed but do not decrease the risk of impaired skin integrity.
The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select? -risk for disuse syndrome -impaired transfer ability -impaired physical mobility -risk for impaired skin integrity
risk for impaired skin integrity. Explanation: Although the client may have or be at risk for any of these nursing diagnoses, risk for impaired skin integrity is the priority, as the client has incontinence and has been left in a supine position, which could facilitate skin breakdown. Therefore the other nursing diagnoses are not the priority.
The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group? -kyphosis -shifted center of gravity -increased need for calcium and vitamin D -scoliosis
scoliosis Explanation: Numerous factors, including growth and development, influence a person's posture, movement, and daily activity level. The adolescent should be assessed for scoliosis (curvature of the spine). Kyphosis is increased convexity in the thoracic spine from disk shrinkage and decreased height, common in older adults. A shifted center of gravity occurs during pregnancy (in the adult) because of the developing fetus. Older adults have an increased need for calcium and vitamin D related to the risk for osteoporosis.
The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client? -supine -slight Trendelenburg -Sims' -prone
slight Trendelenburg Explanation: Placing a client in slight Trendelenburg position may help keep the client from sliding down toward the foot of the bed. Placement into the other position choices does not accomplish the same purpose.
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? -under the client's head -supporting the client's back -in front of the client's abdomen -under the client's feet
supporting the client's back Explanation: The nurse would place the pillow under the client's back to provide support and help maintain the proper position. A pillow can also be placed between the knees. More than one pillow under the client's head is not necessary. Placing a pillow in front of the client's abdomen would be helpful for a client who has undergone abdominal surgery. Placing a pillow under the client's feet is not helpful for the side lying position.
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.
When assessing the physical activity of clients, the nurse would be most concerned about which client? -the young mother of a 2-year-old and 4-year-old -the older adult client who goes to the mall 3 times a week -the Native American who hunts -the middle-aged computer programmer
the middle-aged computer programmer. Explanation: 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.
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 -skeletal contractures -pooling of secretions -oliguria
thrombus formation Explanation: Prolonged sitting can increase a client's risk for thrombus formation. The nurse will emphasize this and teach stretching exercises. Skeletal contractures, pooling of secretions, and oliguria are not risk factors associated with flying (prolonged sitting).
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 -transfer boards -mechanical lift -roller sheet
transfer belt. Explanation: 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 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 -log rolling -pull sheets -trochanter rolls
trapeze bar Explanation: 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.
