Immobility EAQ's
While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning?
"I will ask the client to move his or her arm towards the body."
A client is admitted to a rehabilitation unit after a brain attack (cerebrovascular accident, CVA) with residual hemiparesis. To help achieve the goal of safe walking with a cane, what should the nurse teach the client to do?
Advance the cane and the affected extremity simultaneously
The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?
Inactivity
A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, what should the nurse instruct the client to do?
Increase oral fluid intake to 2 to 3 L/day
After a prostatectomy, a client's plan of care will include the prevention of postoperative deep vein thrombosis. Which nursing goal will best achieve prevention?
Increase velocity of the venous return
A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation?
Length of time this problem has existed
A client with hemiparesis is reluctant to use a cane. How does the nurse explain the cane's purpose to the client?
Maintain balance to improve stability
A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what?
Moves the walker no more than 12 inches (30.5 cm) during use
The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it where?
On the right side
While assessing a client's joint for mobility, the primary healthcare provider moved the client's first and fifth metacarpals anteriorly from the flattened palm. Which type of synovial joint movement is this termed?
Opposition
The nurse is reviewing the plan of care to prevent contractures of the joints of the lower extremities in a client with paraplegia. The nurse should question which item that is listed on the plan?
Provide the client with active lower-extremity exercise instructions
A stationary (nonrolling) walker has been prescribed for a client to aid in ambulation. Which instruction is the best description the nurse can provide when teaching a client how to use a walker?
Put the front walker leg tips about an arm's length ahead of the feet, shift the body weight to the walker, and step forward
A client with a fractured tibia and fibula is to be discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, the nurse should teach the client to do what?
Remove loose rugs from the environment
Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait?
The client must be able to bear weight on both legs
The practitioner prescribes no weight bearing on a leg that has been casted because of a fracture of the femur. How should the nurse determine the appropriate length of the crutches for this child? Select all that apply.
The crutches should reach 2 inches (5 centimeters) below the axillae; The tips of the crutches should rest 6 inches (15.2 centimeters) outside the feet
Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left leg, and she is admitted to the hospital for bed rest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer?
Heparin
A client who had a brain attack (stroke) is admitted to the hospital with right-sided hemiplegia. For what reason does the nurse recognize the importance of identifying restrictions of mobility or neuromuscular abnormalities?
Shortening and eventual atrophy of the muscles will occur