Chapter25 PrepU 251

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse? positioning a friction-reducing sheet under the client to facilitate movement using back muscles to gently and gradually pull the client to the side placing the bed in its lowest position to reduce the client's risk for falls standing at the top of the bed and having a colleague stand at the bottom of the bed

positioning a friction-reducing sheet under the client to facilitate movement Explanation: After placing the bed in a comfortable working position (usually elbow height of the caregiver), position a nurse on either side of the bed, place a friction-reducing sheet under the client, and use the leg muscles to pull the client to the side.

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.

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. placing nightlights in the bathroom and hallways moving the bedroom to the ground floor installing hardwood floors removing clutter from the floor

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 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 the walker when walking. leans over the walker when walking. places the walker far in front when walking. uses the sides of the walker to rise from a chair.

steps into the walker when walking. Explanation: 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.

A nurse is working with a female client with osteoporosis on an exercise program. The nurse instructs the client to increase her tolerance gradually. The nurse determines that the education was effective when the client states: "I need to avoid weight-bearing exercises." "Strength training will be of little benefit to me." "My initial goal is to exercise every day of the week." "If I experience pain when I'm exercising, I should stop."

"If I experience pain when I'm exercising, I should stop." Explanation: The client's statement about stopping if pain occurs is correct. Initially, clients should plan on a realistic goal, such as beginning with 3 days a week and working up to an average of 3 to 5 days a week. Weight-bearing exercises are beneficial for those with osteoporosis. Strength training is helpful in increasing range of motion, strength, and balance, especially in older adults.

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? "Put that thought out of your mind, and let's focus on using a walker." "Who told you that you are burden?" "I'm sure no one feels that way about you." "Let's talk about how mobility can increase your independence."

"Let's talk about how mobility can increase your independence." Explanation: The older adult client's self-perception may be related to functional ability. The nurse should explore ways to motivate the client to find ways of increasing the client's independence as much as possible. The other responses do not address the client's concern therapeutically.

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response? "To help client to turn independently." "To prevent foot drop." "To preserve the client's functional ability to grasp and pick up objects." "To prevent the legs from rotating outward."

"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 home health nurse is visiting a client who was taught to crutch-walk in the hospital following a knee surgery. The client says, "My armpits are so sore." Which information does the nurse provide? "Try to bear your weight on your hands, not your armpits." "I hear that a lot from clients." "Fortunately you will only need to be on crutches for a week or two." "Your armpits will grow accustomed to the weight in a few days."

"Try to bear your weight on your hands, not your armpits." Explanation: When crutch-walking, the client should bear weight on the hands, not the axillae. The length of time the client is to use the crutches and the fact that many clients have had the same report are not relevant.

The nurse has applied a sling to a client who has an arm injury. Which assessment finding requires the nurse to further intervene? Client reports arm pain of "3" on scale of 1-10. Skin temperature is warm to touch. No edema noted. Capillary refill time is 4 seconds.

Capillary refill time is 4 seconds. Explanation: 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 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? protective supine Fowler's low Fowler's semi-Fowler's

Fowler's Explanation: Fowler's position optimizes cardiac function and respiratory function in addition to being the best position for eating. The client's risk of aspiration would be extreme in a supine position. Low Fowler's and semi-Fowler's are synonymous, and this position does not aid swallowing as much as a high Fowler's position.

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? Fowler's Sims' prone supine

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.

The nurse is assisting with client transfer. Which guideline(s) will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply. Provide the client with nonskid slippers to put on prior to standing up. Provide step-by-step instructions to the client before the transfer begins. Lower the bed to the lowest position allowing the client's soles to contact the floor. Ensure that the client's bedrails are up prior to transfer. Make sure the client's weaker leg is nearest to the chair.

Lower the bed to the lowest position allowing the client's soles to contact the floor. Provide the client with nonskid slippers to put on prior to standing up. Provide step-by-step instructions to the client before the transfer begins. Explanation:Lowering the bed to the point where the client is able to touch the ground allows the client to be as stable as possible prior to standing up. Having the client wear nonskid slippers prevents the client from slipping and falling during the transfer. Providing step-by-step instructions to the client allows the nurse to solicit the client's help as much as possible. This action informs the client, encourages self-help, and reduces the workload/burden on the nurse. The nurse should ensure the bedrails are down prior to starting the transfer. Having these up will obstruct movement and make the transfer more difficult. Since the client is not lying in bed, the bedrails do not need to be up for client safety. The client's strongest leg should be positioned closest to the chair to provide stability and prevent a fall as the client moves to lower oneself into the chair.

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? Change the pattern of exercises each time. Move each joint until there is resistance but no pain. Use pillows and other positioning devices. Perform different movements with each extremity.

Move each joint until there is resistance but no pain. Explanation: 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 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? Move the opposite arm forward to above the head of the client. Move the arm across the body as far as possible. Return the arm to the starting position at the side of the body. Rotate the lower arm and hand so the palm is up.

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

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial action by the nurse is appropriate? Firmly grasp the client's gait belt. Ask the client, "When was the last time you ate?" Ask the client to lean against the wall while you obtain a wheelchair. Apply oxygen and wait several minutes for the weakness to pass. Support the client's body against yours and gently slide the client onto the floor.

Support the client's body against yours and gently slide the client onto the floor. Explanation: Assessing for the potential causes of the weakness should occur after the client's safety is assured.

A nurse is recommending aerobic exercise for a client who is overweight. Which exercise might the nurse suggest? Stretching exercises Yoga Swimming Lifting weights

Swimming Explanation: Swimming is an aerobic exercise, also known as a cardio exercise. The other options listed are anaerobic exercises.

The nurse is performing an admission for a client determined to be a high fall risk. What interventions should be a priority for the nurse to employ to provide a safe environment for the client? Select all that apply. Keep all bed rails up at night. Hold diuretic medications. Use a chair alarm when the client is out of the bed. Use a bed alarm to signal when the client gets up Keep the client's slippers at the bedside for easy reach.

Use a chair alarm when the client is out of the bed. Use a bed alarm to signal when the client gets up Explanation: Interventions for decreasing fall rates and decreasing the severity of injury if a fall occurs have become a focus to ensure safe client care. By identifying clients at greatest risk, the nurse can increase and individualize surveillance and preventive interventions. Some fall prevention strategies for all clients include orientating the client to the environment and keeping a call light and personal belongings within reach. If the assessment determines that the client is at high risk for falling, the nurse should individualize the plan based on the specific risk factors. One thing to consider is using a bed or chair alarm for confused clients.

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? Logrolling can be performed by one experienced nurse. It is acceptable to twist the client's head, but not the hips, while logrolling. Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Logrolling will maintain straight alignment when the client is sitting in a chair.

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Explanation: 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 nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education? When I lift and carry a heavy box of supplies I will keep it at arm's length from my body. When I lift an object, I will get close to the object being lifted. When lifting an object, I will keep my feet shoulder width apart. When lifting an object, I will bend at the knees instead of the waist.

When I lift and carry a heavy box of supplies I will keep it at arm's length from my body Explanation: The nurse teaching a group of UAPs about proper body mechanics recognizes the need for additional education when a class participant states that, when lifting and carrying a heavy box of supplies, the UAP will keep it at an arm's length from body. This motion will result in injury and the UAP should be instructed to keep items close to the body. The UAPs should lift an object with feet shoulder width apart by bending at the knees instead of the waist and getting close to the object being lifted. These actions reflect the correct understanding of proper body mechanics.

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 plantar flexion/dorsiflexion inversion/eversion flexion/extension

adduction/abduction

The nurse is caring for a client with postural hypotension. Which nursing intervention is appropriate? applying antiembolism stockings before rising using a gait belt to quickly get the client out of bed using a tilt table to move from supine to standing asking the client to dangle before moving from a reclining position

asking the client to dangle before moving from a reclining position Explanation: Having the client dangle before moving from a reclining position can help normalize blood pressure. Other interventions listed will not effectively decrease the risk for postural hypotension

Which ambulatory aid could a nurse suggest to assist a client who has weakness in one side of his body? cane forearm crutch walker axillary crutch

cane Explanation: The nurse could suggest the use of a cane to a client who has weakness in one side of his body in order to aid ambulation. Canes are hand-held ambulatory devices made of wood or aluminum. A walker is used by clients who require considerable assistance with balance. Clients who need brief, temporary assistance with ambulation are likely to use axillary crutches. Forearm crutches generally are used by experienced clients who need permanent assistance with walking.

What body system benefits the most from aerobic exercises? respiratory musculoskeletal cardiovascular neurologic

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

Which client would benefit the most from the use of a forearm crutch to assist in ambulation? client who needs permanent assistance when walking client who cannot bear weight with the hands and wrists client who has weakness on one side of the body client who requires considerable assistance with balance

client who needs permanent assistance when walking Explanation: A nurse should suggest the use of forearm crutches for clients who need permanent assistance when walking. Crutches are generally used in pairs and require a great deal of upper arm strength and balance; therefore, older adults or weak clients do not commonly use them. Clients who have weakness on one side of the body use a cane to ambulate. A walker is used by clients who require considerable assistance with balance, whereas platform crutches are used by clients who cannot bear weight with their hands and wrists.

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: scoliosis. crepitus. chorea. swelling.

crepitus. Explanation: 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 45-year-old man is interested in starting an exercise program. The nurse informs him that exercise does not: prevent constipation. enhance mood. improve sleep quality. decrease appetite.

decrease appetite.

A nurse is caring for an older adult client at a health care facility. What should the nurse consider to be a normal, age-related change? decreased or unsteady mobility occasional falls appearance of corns or calluses decreased sensory perception

decreased or unsteady mobility Explanation: Limited or unsteady mobility may be a problem for some older adults as a result of age-related postural changes. Limited or unsteady mobility may lead to the development of a swaying or shuffling gait. As a person ages, he may develop flexion of the spine, which can alter the center of gravity and may result in an increase in falls. If a client appears to have an unusual gait, assess the feet for corns, calluses, bunions, and ingrown or very long toenails. If any of these conditions are found, a podiatry referral may be indicated. Vascular changes may lead to numbness and a decreased sensory ability to perceive contact with the ground, which can also change a person's gait. Falls are more common in older adults, but these are not considered to be a normal event.

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? sit-ups gluteal setting exercises flexion and extension of the arms and the wrists quadriceps setting exercises

flexion and extension of the arms and the wrists Explanation: When educating a client about preparing for the use of crutches, the nurse should include exercises for strengthening the upper arms, an example of which is flexion and extension of the arms and wrists. Other exercises for upper-arm strengthening include raising and lowering weights with the hands, squeezing a ball or spring grip, and performing modified hand push-ups in bed. Quadriceps and gluteal setting exercises are beneficial for lower body strengthening exercises and sit-ups for abdominal strengthening.

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. maintain a pillow under the client's head. ask another nurse about the plan of care. elevate the head of the bed.

have the client fold the arms across the chest. Explanation: Positioning the arms across the chest improves assistance, reduces friction, and prevents hyperextension of the neck. Before attempting to move a client up in bed, the nurse should review the medical record and the nursing plan of care. This validates the correct client and correct procedure, identification of limitation, and ability. Reviewing the medical record and plan of care also identifies use of an algorithm to prevent injury and assists in determining the best plan for client movement. The head of the bed should be flat or as low as the client can tolerate; this will help to decrease the gravitational pull of the upper body. If tolerated, a slight Trendelenburg position aids in movement. Pillows should be removed from under the client's head; this facilitates movement.

A physician has ordered an obese client to join an aerobic exercise class to promote cardiorespiratory conditioning. Which of the following fitness exercises is most suitable for the client? therapeutic exercise isometric exercise isotonic exercise active exercise

isotonic exercise Explanation: Isotonic exercise is most suitable for an obese client, as it involves movement and work. The prime example is aerobic exercise, which involves moving all body parts at a moderate-to-slow speed without hindering the ability to breathe. To promote cardiorespiratory conditioning, a person should perform isotonic exercise at his target heart rate. Isometric exercise does not promote cardiorespiratory conditioning; in fact, strenuous isometric exercise elevates blood pressure temporarily. Therapeutic exercise is performed by people with health risks or those who are being treated for an existing health problem. In contrast, active exercise is therapeutic activity that the client performs independently, after proper instruction.

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize? oliguria pooling of secretions skeletal contractures thrombus formation

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 working to increase functional ability with a client. Which assistive technique should be included in the plan of care? trochanter rolls trapeze bar pull sheets log rolling

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

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 forearm crutch cane axillary crutch

walker Explanation: The nurse could suggest the use of a walker for the client who is recovering from hip surgery and has been recommended complete bed rest. Clients who require considerable support and assistance with balance use a walker, the most stable form of ambulatory aid. A cane is used by clients who have weakness on one side of the body. Clients who need brief, temporary assistance with ambulation are likely to use axillary crutches. Forearm crutches generally are used by experienced clients who need permanent assistance with walking.