Chapter 8: Body Mechanics and Patient Mobility

21. To maintain a wide base of support, the nurse should stand with the feet separated by the distance of times the length of the nurse's shoe.

ANS: 1.5 one and one half A wide base of support of 1.5 times the length of the nurse's shoe is recommended. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 161 OBJ: 1 TOP: Base of support KEY: Nursing Process Step: Implementation

23. machines flex and extend joints to mobilize them passively without the strain of active exercises.

ANS: Continuous passive motion (CPM) Continuous passive motion CPM Continuous passive motion (CPM) machines flex and extend joints to mobilize them passively without the strain of active exercises. It is imperative that the CPM machine be set according to the health care provider's orders for the degree and the speed of flexion and extension for each individual patient to prevent damage to the joint or surgical site. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 172 OBJ: 12 TOP: Continuous passive motion machines KEY: Nursing Process Step: Implementation

12. What implementation might the nurse use to improve safety during a transfer? a. Weighing the patient first b. Using a transfer belt c. Putting shoes on the patient d. Supporting a flaccid arm

ANS: B As a general rule, the nurse should use a transfer belt. PTS: 1 DIF: Cognitive Level: Application REF: Page 182 OBJ: 5 TOP: Body mechanics KEY: Nursing Process Step: Implementation

17. The LPN/LVN assists a patient into the semi-Fowler position per physician order. What would indicate that this patient is in the correct position? a. Patient is leaning over the bedside table b. Head of bed is at a 30-degree angle c. Knee is drawn toward the chest d. Arms are flexed toward the head

ANS: B The semi-Fowler position is when the head of the bed is raised approximately 30 degrees. Orthopneic position is when the patient is leaning over the bedside table. Sims position is when the knee is drawn toward the chest. Arms are not flexed toward the head in the semi-Fowler position. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 164 Skill 8-1 OBJ: 7 TOP: Positioning patients KEY: Nursing Process Step: Implementation

11. What is the site of the most common strain injury acquired by the nurse when working? a. Trapezius muscle group b. Thoracic muscle group c. Lumbar muscle group d. Thigh muscle group

ANS: C The most common back injury is strain of the lumbar muscle group. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 159 OBJ: 2 TOP: Body mechanics KEY: Nursing Process Step: N/A

6. The nurse counsels the immobilized patient in regard to prevention of muscle atrophy and contractures. What will the nurse be sure to include when counseling this patient? a. The need for additional calcium b. The need for additional protein c. The need for some type of exercise d. The need for a special protective bed

ANS: C The immobilized patient must receive some type of exercise to prevent atrophy and contractures. PTS: 1 DIF: Cognitive Level: Application REF: Page 169 OBJ: 6 TOP: Immobility KEY: Nursing Process Step: Implementation

4. Where should the nurse place the load when carrying heavy objects? a. In a low position b. To the side of the body c. Close to the body midline d. With another's assistance

ANS: C The nurse should carry objects close to the midline of the body. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 162 OBJ: 11 TOP: Body mechanics KEY: Nursing Process Step: Implementation

3. What should the nurse do to protect his or her back when lifting or moving a patient? a. Lowering the height of the bed b. Holding the back straight with locked knees c. Bending knees and hips d. Getting the patient to the side of the bed

ANS: C The nurse's back can be well protected when he or she bends knees and hips. PTS: 1 DIF: Cognitive Level: Application REF: Page 161 OBJ: 11 TOP: Body mechanics KEY: Nursing Process Step: Implementation

1. The nurse instructs a nursing assistant to use large muscle groups when lifting. What is the rationale for this instruction? a. Workers' compensation claims will be prevented b. Big muscles work more effectively c. It guarantees no muscle strain d. It distributes workload more evenly

ANS: D Proper body mechanics provide for even distribution of workload. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 161 OBJ: 1 | 2 TOP: Body mechanics KEY: Nursing Process Step: Implementation

15. What profession has the highest workers' compensation claim rates of any occupation or industry? a. Firefighters b. Truck drivers c. Law enforcement d. Nursing personnel

ANS: D Studies of workers' compensation claims show that nursing personnel have the highest claim rates of any occupation or industry. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 159 OBJ: 2 TOP: Workers' compensation KEY: Nursing Process Step: N/A

5. The nurse is educating a patient on ways to regain the ability to perform ADLs and maintain normal physiological activities. What will the nurse relay as a requirement? a. Strength b. Wellness c. Alertness d. Mobility

ANS: D The purpose of mobility is completing ADLs and maintaining physiological activities. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 166 OBJ: 4 TOP: Mobility KEY: Nursing Process Step: Assessment

24. The nurse points to the X in the illustration below and describes this point as the of .

ANS: center, gravity The center of gravity is the centermost point from the base of support. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 161 OBJ: 2 TOP: Center of gravity KEY: Nursing Process Step: Implementation

22. When a fall occurs, the nurse should document the incident and initiate a(n) report.

ANS: incident The nurse must initiate an incident report describing the events of a patient's fall. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 167 Box 8-2 OBJ: 6 TOP: Incident report KEY: Nursing Process Step: Implementation

20. The most common cause of musculoskeletal disorders in nurses involves a movement that requires the nurse to and at the same time.

ANS: twist, lift lift, twist The motion of twisting and lifting at the same time frequently strains the muscles of the lower back. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 162 OBJ: 1 | 2 TOP: Muscle strain KEY: Nursing Process Step: N/A

13. What is considered to be the minimum number of hours of daily activity necessary to prevent the negative consequences of immobility? a. 2 hours b. 4 hours c. 6 hours d. 8 hours

ANS: A The amount of exercise required to prevent physical disuse syndrome is 2 hours in 24 hours. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 167 Box 8-2 OBJ: 6 TOP: Immobility KEY: Nursing Process Step: Implementation

9. How should the nurse assist the patient with moving when pain is anticipated? a. Be supportive b. Apply heat before moving them c. Administer medication before ambulation d. Obtain assistance if the patient is heavy

ANS: C The nurse may want to administer medication before an activity that may be painful. PTS: 1 DIF: Cognitive Level: Application REF: Page 174 Skill 8-3 OBJ: 6 TOP: Body mechanics KEY: Nursing Process Step: Implementation

18. A newly hired group of graduate practical/vocational nurses are attending orientation at a long-term care facility. What information will be included regarding considerations of mobility and the older adult? (Select all that apply.) a. The skin of older adults is more fragile and susceptible to injury. b. Always support older adults under the soft tissue when moving them in bed. c. Weakness and hypertension are common signs and symptoms noted in an older adult on bed rest. d. Aging tends to result in loss of flexibility and joint mobility. e. Older adults sometimes become fearful when hydraulic lifts are used for transfers.

ANS: A, D, E The skin of older adults is more fragile and susceptible to injury. Aging tends to result in the loss of flexibility and joint mobility and older adults sometimes do become fearful with use of hydraulic lifts. Older adults should be supported under the joints when moving in bed. Weakness and hypotension are common signs and symptoms noted in an older adult on bed rest. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 160 OBJ: 3 TOP: Older adult KEY: Nursing Process Step: N/A

10. The 125-pound nurse assesses the weight of a patient. What weight is the heaviest the nurse may safely lift by herself? a. 158.75 lb b. 168.75 lb c. 178.75 lb d. 188.75 lb

ANS: B Nurses should never attempt to lift more than 35% above their own body weight. 125 0.35 = 43.75 125 + 43.75 = 168.75 PTS: 1 DIF: Cognitive Level: Analysis REF: Page 182 OBJ: 11 TOP: Body mechanics KEY: Nursing Process Step: Implementation

19. The nurse receives a patient from the recovery room following total hip replacement surgery. What will the nurse include when assessing neurovascular status on this patient? (Select all that apply.) a. Pupils b. Pain c. Sensation d. Color e. Skin temperature

ANS: B, C, D, E One of the responsibilities of the nurse is to frequently monitor the patient's neurovascular function, or circulation, movement, and sensation (CMS) assessment. The LPN/LVN checks for skin color, temperature, movement, sensation, pulses, capillary refill, and pain. Pupil assessment is part of a neurologic assessment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 166 OBJ: 8 | 13 TOP: Neurovascular function KEY: Nursing Process Step: Assessment

14. The nurse is performing passive range-of-motion exercises on a patient following a traumatic injury. What is the number of times the nurse should move each joint when performing passive range-of-motion (ROM) exercises? a. Three b. Four c. Five d. Six

ANS: C Each movement should be repeated five times. PTS: 1 DIF: Cognitive Level: Application REF: Page 173 Skill 8-2 OBJ: 6 TOP: Range of motion (ROM) KEY: Nursing Process Step: Implementation

16. A nurse instructs a nursing assistant about moving older adult patients in bed. When should the nurse intervene when observing the nursing assistant perform a return demonstration? a. The nursing assistant is using simple language. b. The nursing assistant is avoiding jerky movements. c. The nursing assistant is avoiding sudden movements. d. The nursing assistant is pulling the patient across bed linens.

ANS: D The skin of older adults is more fragile and susceptible to injury. When moving or transferring older adults, it is essential to avoid pulling them across bed linens because this may cause shearing or tearing of the skin. The nurse should explain each step in simple language and avoid jerky, sudden movements. PTS: 1 DIF: Cognitive Level: Application REF: Page 174 Skill 8-3 OBJ: 10 | 11 TOP: Moving patients KEY: Nursing Process Step: Implementation

25. Place the nursing activities in priority order for the preparation of a patient to ambulate. Put a comma and space between each answer choice (A, B, C, D, etc.). a. Dangle the patient at the side of the bed b. Apply a gait belt c. Assist the patient to stand d. Inform the patient of activity e. Roll up the head of the bed

ANS: D, E, A, B, C The order that is most organized is inform, roll up head of bed, dangle, apply belt, and assist to stand. PTS: 1 DIF: Cognitive Level: Application REF: Page 167 box 8-2 OBJ: 6 TOP: Preparation to ambulate KEY: Nursing Process Step: Implementation

7. What is the term for range of motion (ROM) when it is performed by the patient? a. Assisted b. Passive c. Active d. Coordinated

ANS: C ROM performed actively by the patient is designated as active ROM. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 169 OBJ: 9 TOP: Range of motion (ROM) KEY: Nursing Process Step: Implementation

2. What should the nurse do to reduce the effort of moving a heavy object? a. Bring the feet close together and flex the knees b. Keep the back straight and bend at the waist c. Widen the base of support in the direction of movement d. Broaden the base of support and twist toward the direction of movement

ANS: C The base of support should be broadened in the direction of movement. PTS: 1 DIF: Cognitive Level: Application REF: Page 161 OBJ: 1 | 2 TOP: Body mechanics KEY: Nursing Process Step: Implementation

8. The nurse is performing passive range of motion (ROM) for the patient. How will the nurse move the joint through ROM? a. The fullest extent b. Place the joint in normal position c. The point of pain d. Relax the patient

ANS: C The joints are moved to the point of resistance or pain. PTS: 1 DIF: Cognitive Level: Application REF: Pages 173 OBJ: 9 TOP: Range of motion (ROM) KEY: Nursing Process Step: Implementation