mobility question

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?

A transfer belt is designed for clients who can bear weight and help with the transfer, but are unsteady. Other options are inappropriate for this client.

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?

Trochanter rolls prevent the legs from turning outward. The trochanters are the bony protrusions at the head of the femur near the hip. Placing a positioning device at the trochanters helps to prevent the leg from rotating outward. Other devices are inappropriate for this client.

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

1. 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. 2. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. 3. 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. 4. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.

What is a benefit of regular exercise over time?

1. Regular physical activity over time results in cardiovascular conditioning, thus decreasing heart rate. 2. Regular exercise increases circulating fibrinolysin that serves to breakup small clots, thus decreasing the risk for blood clots. 3. Over time, regular exercise leads to improved pulmonary function, including decreased work of breathing. 4. Venous return is improved when contracting muscles compress superficial veins and push blood back to the heart against gravity.

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern?

Activity Intolerance may result from any condition that interferes with the transport of oxygenated blood to tissue. The altered response to activity includes exertional dyspnea, shortness of breath. Shortness of breath after walking up five stairs would be included in this nursing diagnosis. Another altered response would be excessive increase in pulse rate. After walking up 20 stairs, a change in pulse of 4 points is not excessive. Joint stiffness is a defining characteristic of the nursing diagnosis Impaired Physical Mobility. Walking with a slow and uncoordinated movement is another defining characteristic of Impaired Physical Mobility.

Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. In which position should the nurse place the client?

Lethargy puts the posttonsillectomy client at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he's fully awake is best. The semi-Fowler's, supine, and high-Fowler's positions don't allow for adequate oral drainage of a lethargic posttonsillectomy client and increase the risk of blood aspiration.

A client is discharged to his daughter's home. He weighs 250 lb (113.4 kg) and is immobile. The nurse should instruct the daughter on the use of a:

A hydraulic lift is a mechanical device that permits a client to be transferred from the bed to a chair.

An 80-year-old client with osteoarthritis and osteoporosis has difficulty ambulating and is seeking a prescription for a walker. The nurse assesses the client's type of disability as

Age-associated disabilities in the elderly population result from the aging process. Acquired disabilities may be progression of a chronic disorder, such as multiple sclerosis. Developmental disabilities are those disabilities that occur any time from birth to 22 years and may result in impairment of physical or mental health, cognition, speech, language, or self-care. Sensory disabilities affect hearing or vision.

The client has been diagnosed with schizophrenia and is showing the following symptoms: immobility, rigidity, and stupor. These symptoms can be further classified as which characteristic symptoms of schizophrenia?

Catatonic clients show motoric immobility or stupor, rigidity, excessive motor activity, extreme negativism, stupor, and peculiarities of movement, such as posturing, echolalia and echopraxia, mutism, and waxy flexibility.

The nurse is observing an unlicensed assistive personnel (UAP) transferring a client with left-sided weakness from the bed to the chair. What observation made by the nurse requires immediate intervention to prevent injury to the client? Select all that apply.

Correct response: 1. instructs the client to hold on to the side rail when standing to move into the chair 2. stands next to the client when the client is sitting on the side of the bed 3. stands near the client's head and shoulders before sitting the client up in bed The nurse keeps the client in good body alignment and protects the client from injury while being moved. Safety and comfort are key concerns when assisting a client out of bed. 1. The side rails should be down when transferring a client out of bed. 2. The client should be instructed to use an arm to steady himself on the arm of the chair when getting out of bed for support and stability. 3. The nurse should stand in front of, not next to, the client when the client is sitting on the side of the bed; this will prevent falls or injuries from orthostatic hypotension. 4. When assisting the client to sit up on the side of the bed, the nurse should stand near the client's hips. The nurse's center of gravity is placed near the client's greatest weight to assist the client to a sitting position safely. 5. The head of the bed should be elevated to place the client in a sitting position, or as high as the client can tolerate. The amount of energy needed to move from a sitting position or elevated position to a sitting position is decreased. 6. Bracing the knees against a weak extremity prevents a weak knee from buckling and the client from falling.

A client has been taking haloperidol for 5 years when the client is admitted to the inpatient unit for relapse of symptoms of schizophrenia. Upon assessment, the client demonstrates akathisia, dystonia, a stiff gait, and rigid posture. The nurse correctly identifies these symptoms are indicative of what?

Extrapyramidal side effects include severe restlessness, muscle spasms, or contractions; chronic motor problems such as tardive dyskinesia; and the pseudoparkinsonian symptoms of rigidity, masklike faces, and stiff gait.

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

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(요산염결석), 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(피브린 용해 효소).

During range-of-motion exercises, the nurse turns the sole of a client's foot toward the midline and then turns the sole of the foot outward. Which type of movement is this nurse promoting by these actions?

Inversion and eversion are movements of the ankle. Inversion is the movement of the sole of the foot inward. Eversion is the movement of the sole of the foot outward. Internal rotation is the turning of a body part on its axis toward the midline of the body. External rotation is the turning of a body part on its axis away from the midline of the body. Dorsiflexion is the backward bending of the hand or foot. Plantar flexion is flexion of the foot. Flexion is the state of being bent. Extension is the state of being in a straight line.

A nurse obtains an order for a bed alarm for a confused client. This is an example of which ethical principle?

Making a decision for a client who is confused to prevent an injury is an example of paternalism. Deception occurs when the true nature or reason is concealed and the client is deprived of basic human rights. Confidentiality requires a health care provider to keep a client's personal health information private unless consent to release the information is provided by the client. Conflict is a disagreement or argument and does not represent the example in this question.

The nurse is teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when she states that back injuries:

Many nurses believe that back pain is a routine consequence of the job, but it need not be. Employing principles of body mechanics, use of algorithms, and guidelines for transferring or lifting clients contributes to the prevention of back injuries and pain. Back injuries can occur when repositioning uncooperative clients. Back injuries cannot be prevented by use of a gait belt. Inappropriate use of the gait belt and other factors can contribute to back injuries. Standing, not sitting, for long periods of times can contribute to back injuries.

The nurse observes an older adult client walks walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating?

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 comprehensive nursing assessment for neuroleptic malignant syndrome (NMS) should include checking for which in a client taking an antipsychotic medication?

NMS is characterized by muscular rigidity, tremors, difficulty swallowing, fever, hypertension, and diaphoresis.

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group?

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 is discussing nutritional needs for a postmenopausal patient. What dietary increase should the nurse recommend to the patient?

Postmenopausal women should be encouraged to observe recommended calcium and vitamin D intake, including calcium supplements, if indicated, to slow the process of osteoporosis. Iron and vitamin K need not be increased unless there are signs of deficiency. Salt should be eaten in moderation, not increased, to prevent hypertension.

A client is being seen in the health clinic. The nurse observes a shuffling gait, drooling, and slowness of movement. The client is currently taking an antipsychotic for treatment of schizophrenia. The nurse knows that which side effect is occurring?

Pseudoparkinsonism is exhibited by a shuffling gait, drooling, and slowness of movement. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness. Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis.

The nurse is caring for an adult with a grade III compound fracture of the right femur; the client has been placed in skeletal traction. The intended outcome of the traction is to:

Skeletal traction is often used to regain normal length of the bone, but in this situation the main purpose of the traction is to reduce and immobilize the fracture. This type of traction allows the client to move in bed without dislocating the fracture. This client has an open fracture, but skeletal traction will not prevent further skin breakdown.

What part of the brain would be responsible for activities such as walking and dancing?

The cerebellum, which is located behind and below the cerebrum, controls and coordinates muscle movement integral to physical activities such as walking and dancing. Cerebrum, midbrain, and brain stem are incorrect.

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 client has awareness of spatial relationships (where objects are located in space). This ability comes from the visual or optic reflexes. The labyrinthine(복잡한) 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, such as 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 nurse uses gait belts when assisting patients to ambulate. Which patient would be a likely candidate for this assistive device?

The gait belt is used to help the patient stand and provides stabilization during pivoting. 1. Gait belts also allow the nurse to assist in ambulating patients who have leg strength, can cooperate, and require minimal assistance. 2. A gait belt is not used on clients who have either an abdominal or thoracic incision. 3. A gait belt would not be used on a client who is confined to bedrest.

The nurse is caring for a client who is postoperative from a hip fracture repair. The nurse must be careful to avoid:

To prevent injury, it is important to avoid hip adduction on clients who have had hip replacement surgery.

A client has been taking neuroleptic medications for many years as a treatment for schizophrenia. The client is exhibiting tongue protrusion, facial grimacing, and excessive blinking. These manifestations are characteristic of which extrapyramidal side effects (EPS)?

Unusual movements of the tongue, neck, and arms suggest tardive dyskinesia, an adverse reaction to neuroleptic medication. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis. Akathisia causes restlessness, anxiety, and jitteriness.

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?

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.

The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action?

When turning a client in bed, the nurse would use a friction-reducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Pushing the client to the opposite side of the bed is not good for back safety. Consult a Safe Patient Handling Algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client.