PrepU Chapter 23 - Body Mechanics
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? semi-Fowler's Fowler's protective supine low Fowler's
Fowler's
A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from: blood pressure changes. decubitus ulcers. pooling of blood. foot drop.
foot drop
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.
The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? supine Sims' prone Fowler's
Sim's
The nurse is preparing to turn a client from the supine position into the lateral position. Which instruction will the nurse provide the client when performing this action? "I am going to help you flex your knee over the other knee and cross your arms over your chest." "It will only be me and you doing this together so I need you to help where you are able." "I will leave the side rail down to prevent you from hitting your head on it as you move." "I will be using both of my hands on your upper back to push you onto your side."
"I am going to help you flex your knee over the other knee and cross your arms over your chest."
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 preserve the client's functional ability to grasp and pick up objects." "To prevent foot drop." "To prevent the legs from rotating outward."
"To preserve the client's functional ability to grasp and pick up objects."
The nurse is assisting a client from the bed to a chair that is positioned next to the bed. The client requires partial assistance in the transfer. What action will the nurse perform to prevent injury to self? Keep the knees bent while assisting the client from the bed. Lean over at the waist to assist when guiding the client into the chair. Maintain distance by standing at least 1 ft (0.3 m) away from the client. Twist the frame of the body while assisting the client to the chair.
Keep the knees bent while assisting the client from the bed.
A nurse is providing care for a frail older adult client with chronic obstructive pulmonary disease (COPD). The client always remains in a sitting position, leaning forward to improve oxygenation. Which assessment(s) provide data of possible impaired tissue integrity? Select all that apply. Assess for edema. Monitor skin integrity of heels. Evaluate nutritional status. Evaluate the client's awareness of pressure sensation. Monitor ischial tuberosities for pressure injury.
Monitor skin integrity of heels. Monitor ischial tuberosities for pressure injury. Evaluate the client's awareness of pressure sensation. Assess for edema.
The meal tray has been delivered to the client's room. The client needs to be repositioned higher in the bed with the head raised. The client is unable to assist with moving in the bed. What action is best for the nurse to perform to prevent injury to the nurse and/or the client? Place the bed in Trendelenburg position with side rails raised. Position self at the head of the bed and pull the client up. Obtain assistance from another nursing staff member. Position a roller sheet under the client.
Obtain assistance from another nursing staff member.
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 Place a pillow behind the neck for support Ensure that the temperature of food is safe Provide verbal cues regarding location of food on plate Cut food into small pieces
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
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? Place the bed in the highest position. Put the chair at the foot of the bed. Raise the head of the bed to a sitting position. Make sure the bed brakes are unlocked.
Raise the head of the bed to a sitting position.
The nurse is helping the unlicensed assistive personnel (UAP) to complete several tasks. What action(s) by the UAP requires the nurse to intervene? Select all that apply. The UAP carries the load of linens in a trash bag close to the body. The UAP asks for assistance when transferring a client from the bed to the chair. The UAP twists to reach behind oneself for a washcloth. The UAP turns the client as a complete unit. The UAP has the bed at knee-level when making an occupied bed.
The UAP twists to reach behind oneself for a washcloth. The UAP turns the client as a complete unit. The UAP has the bed at knee-level when making an occupied bed.
In an assessment for proper body alignment of a standing client, which finding is normal? The line of gravity is deviated slightly to the left. The weight of the body is distributed on the soles and heels. The abdominal muscles are held downward and the buttocks upward. The chest is downward and displaced slightly backward.
The weight of the body is distributed on the soles and heels.
The client is immobile and on bed rest. When the client lays supine in the bed, the client exhibits external rotation of both hips. What action will the nurse perform to maintain the client's hips and legs in proper alignment? Place a foot board in the bed. Use trochanter rolls bilaterally. Position a roller sheet under the client. Have the client wear ankle-high tennis shoes in bed.
Use trochanter rolls bilaterally.
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 lifting an object, I will keep my feet shoulder width apart. 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 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.
The proper use of the principles of body mechanics: acts to prevent injury to the client and/or nurse. primarily protects the nurse from injury. acts as a safeguard against legal action by the client. primarily protects the client from injury.
acts to prevent injury to the client and/or nurse.
When a client is lifted or held by a nurse, the additional weight becomes a part of the nurse's weight and should be: supported with a narrow base. counterbalanced by a horizontal adjustment. balanced over the center of gravity. controlled with the upper arm muscles.
balanced over the center of gravity.
While performing a head-to-toe assessment of a hospitalized older adult client, the nurse notes redness around the client's coccyx region. The client's health history indicates the presence of a foot drop. Which bed position will the nurse use most frequently when repositioning this client? prone supine semi-Fowler lateral
lateral
The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action? move the client to edge of the bed opposite the side that client will be turning push the client to the opposite side of the bed pull the client to the edge of the bed to which the patient will be turning push the client to the edge of the bed to which the client will be turning
move the client to edge of the bed opposite the side that client will be turning
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 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 together
near the client's hip, with legs shoulder width apart and one foot near the head of the bed
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? elevate the head of the bed place a small pillow under each arm instruct the client to place arms on the side rails place a trochanter roll under the arms
place a small pillow under each arm
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? placing the bed in its lowest position to reduce the client's risk for falls positioning a friction-reducing sheet under the client to facilitate movement standing at the top of the bed and having a colleague stand at the bottom of the bed using back muscles to gently and gradually pull the client to the side
positioning a friction-reducing sheet under the client to facilitate movement
The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? roller sheet mechanical lift transfer belt transfer boards
transfer belt
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? cover the client with the bed linens assess for pain pull the shoulder blade forward and out from under the client place the call bell within reach
pull the shoulder blade forward and out from under the client
A nurse is demonstrating the proper use of body mechanics to a group of nursing students. What would be most appropriate for the nurse to do? stand with legs wide apart approach the work from the side hold objects away from the body keep knees locked in position
stand with legs wide apart
The pediatric nurse is caring for a 3-week-old infant. In which position will the nurse place the infant to sleep? supine lateral Sims' prone
supine
The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep? supine Sims' prone lateral
supine
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 under the client's feet supporting the client's back in front of the client's abdomen
supporting the client's back
A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client?
the client's ability to assist
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
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.