PREPU Chapter 33 ACTIVITY NR410
The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response? A. "If you recently fell, you might have a fractured hip." B. "Osteoarthritis is painful and very common as you age." C. "Because you lose muscle tone with age, it hurts to walk." D. "You have lost the padding in your joints and the friction causes pain."
"You have lost the padding in your joints and the friction causes pain." Osteoarthritis is a common disorder as people age. It is a noninflammatory, progressive disorder of movable joints (particularly weight-bearing joints) characterized by the deterioration of articular cartilage and pain with motion. Cartilage acts as a shock absorber and provides a smooth surface that reduces friction between the moving parts of the joint. If the client experienced a fall and subsequent hip fracture, mobility would be more impaired. The client would have difficulty walking. Also, this does not address the client's question of why pain accompanies osteoarthritis. Although it is true that osteoarthritis is painful and common as people age, this response does not answer the client's question of why there is pain. Furthermore, while it is also true that loss of muscle tone is common as people age, it may cause weakness, but does not necessarily cause pain with walking. Chapter 33: Activity - Page 1133
A nurse is conducting a home assessment of a 90-year-old male client with a history of several minor strokes that have left him 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. A. removal of clutter on the floor B. placing a nightlight in the bathroom and the hallways C. moving the bedroom to the ground floor D. installing hardwood floors
A, B, C Each of these activities will reduce the risk of falling and encourage the client to increase his mobility. Chapter 33: Activity - Page 1152
A client works in a warehouse and has been having low back pain. Which statement would indicate the need for more education regarding safe lifting? A. "I hold the boxes away from my body so I don't drop them on my feet." B. "I stand with my feet apart so I have a better stance when I lift." C. "I bend with my knees when I pick up boxes." D. "I try to rest between periods of lifting."
A. "I hold the boxes away from my body so I don't drop them on my feet." Heavy objects should be held close to the body to distribute the weight evenly and prevent muscle strain. Other options are correct lifting techniques. Chapter 33: Activity - Page 1136
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? a. Pull the shoulder blade forward and out from under the client. b. Place the call bell within reach. c. Cover the client with the bed linens. d. Assess for pain.
A. Pull the shoulder blade forward and out from under the client. Positioning the shoulder blade in this manner removes pressure from the bony prominence and thus helps decrease the risk of impaired skin integrity. The other actions should also be performed but do not decrease the risk of impaired skin integrity. Chapter 33: Activity - Page 1183
When assessing for proper body alignment of a standing client, which finding is normal? A. The weight of the body is distributed on the soles and heels B. The chest is downward and displaced slightly backward C. The abdominal muscles are held downward and the buttocks upward E. The line of gravity is deviated slightly to the left.
A. The weight of the body is distributed on the soles and heels A client's body is in correct body alignment while standing when the weight of the body is distributed on the soles and heels. The chest is held upward and forward. The abdominal muscles are held upward and the buttocks downward. The line of gravity goes midline through the center of the knees and in front of the ankle joints. Chapter 33: Activity - Page 1149
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. A. Use a chair alarm when the client is out of the bed B. Keep all bed rails up at night C. Use a bed alarm to signal when the client gets up D. Hold diuretic medications E. Keep the client's slippers at the bedside for easy reach.
A. Use a chair alarm when the client is out of the bed. C. Use a bed alarm to signal when the client gets up 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. Chapter 33: Activity - Page 1169
Which type of mobility aid would be most appropriate for a client who has poor balance? A. a cane with four prongs on the end (quad cane) B. a single-ended cane with a half-circle handle C. a single-ended cane with a straight handle D. axillary crutches
A. a cane with four prongs on the end (quad cane) 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. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. 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. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation. Chapter 33: Activity - Page 1169
The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep? A. supine B. lateral C. prone D. Sims'
A. supine Supine position is recommended as a way to reduce the incidence of sudden infant death syndrome (SIDS) among newborns. Other positions are inappropriate for placing the infant to sleep. Chapter 33: Activity - Page 1137
The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? A. the 24-month-old child who is unable to walk unassisted B. the 3-month-old child who is unable to raise the head when prone C. the 6-month-old child who is unable to roll over D. the 18-month-old child who is unable to stack blocks
A. the 24-month-old child who is unable to walk unassisted At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raise the head, but this is not expected at this age. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month-old infants. Stacking blocks is accomplished by most 3-year-olds, but doing so at 18 months is considered early. Chapter 33: Activity - Page 1137
The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize? A. thrombus formation B. skeletal contractures C. pooling of secretions D. oliguria
A. thrombus formation 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). Chapter 33: Activity - Page 1144
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? A. trochanter rolls B. foot boards C. foot splints D. roller sheets
A. trochanter rolls 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. Chapter 33: Activity - Page 1158
A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? a. "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly." b. "Your elbows will be slightly bent when you are using your crutches." c. "When your crutches fit right, most of your body weight will be supported by your armpits." d. "We'll have the nursing assistant watch you while you walk around the unit the first time."
B. "Your elbows will be slightly bent when you are using your crutches." When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down, if fatigued.
The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason? A. Acts as a safeguard against legal action by the client B. Acts to prevent injury to the client and/or nurse C. Primarily protects the client from injury D. Primarily protects the nurse from injury
B. Acts to prevent injury to the client and/or nurse When nurses use their bodies to perform therapies, to assist clients with movement, or to move equipment, they benefit from the effective use of body mechanics to prevent injury to themselves and clients. The actions do not safeguard against legal action by the client but rather are in place to prevent injury. Chapter 33: Activity - Page 1136
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? A. The brain is sending impulses to the muscles to avoid the table. B. The client is aware of spatial relationships to avoid the table. C. The client's muscles are being stretched to walk around the table. D. The cerebellum is responding to impulses from the inner ear.
B. The client is aware of spatial relationships to avoid 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 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 (e.g., 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. Chapter 33: Activity - Page 1135
A nurse is assisting in the transfer of a client with a diagnosis of Alzheimer's disease to a stretcher. The client experiences frequent periods of agitation and is unable to follow cues or directions. Which device would be the best choice for transferring this client? A. Powered stand-assist B. Transfer chair C. Repositioning lift D. Gait belt
B. Transfer chair Chairs that can convert into stretchers are available. These are useful with clients who have no weight-bearing capacity, cannot follow directions, and/or cannot cooperate. The back of the chair bends back and the leg supports elevate to form a stretcher configuration, eliminating the need for lifting the client. Powered stand-assist and repositioning devices require the client to have weight-bearing capacity in one leg. Gait belts are used to assist clients to ambulate safely. Chapter 33: Activity - Page 1156
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed? A. near the client's hip, with legs together B. near the client's hip, with legs shoulder-width apart and one foot near the head of the bed C. to the dominant side of the client, with legs together and one foot near the head of the bed E. to the nondominant side of the client, with legs together and one foot near the head of the bed.
B. near the client's hip, with legs shoulder-width apart and one foot near the head of the bed When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder-width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight, to assist the client to a sitting position safely. The dominant or nondominant side is not relevant when moving a client with equal strength, but would be helpful with a client who had a stroke. Chapter 33: Activity - Page 1159
The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client? A. "Put on your shirt." B. "Don't put on your shoes yet." C. "Put your arm in this sleeve." D. "Put your pants on and zip the zipper."
C. "Put your arm in this sleeve." When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions. "Put your arm in this sleeve" gives one step in the process of getting dressed. "Put on your shirt" involves many steps and should be broken down into the steps of putting on a shirt. "Put your pants on and zip the zipper" should be broken down into steps and given in clear, short sentences. Furthermore, putting on pants and zipping a zipper involves many steps and may be too complicated for the client with dementia to follow. Instructions should be phrased positively as the client may not register the "Don't"; the client may put the shoes on if the nurse states "Don't put on your shoes yet." Chapter 33: Activity - Page 1153
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? A. "Your armpits will grow accustomed to the weight in a few days." B. "I hear that a lot from clients." C. "Try to bear your weight on your hands, not your armpits." D. "Thankfully you will only need to be on crutches for one week or two."
C. "Try to bear your weight on your hands, not your armpits." When crutch walking, the client's weight should be borne on the hands, not the axilla. 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. Chapter 33: Activity - Page 1169
A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings? a. Apply the stockings at night when the client is going to bed b. Apply the stockings after the client has been sitting up for an hour c. If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings d. Avoid the use of powders on the legs before applying stockings.
C. If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Be prepared to apply the stockings in the morning before the client is out of bed. Assist the client to a supine position. If the client has been sitting or walking, have him or her lie down with legs and feet well elevated for at least 15 minutes before applying the stockings. Powder the leg lightly unless client has a breathing problem, dry skin, or sensitivity to the powder. If the skin is dry, a lotion may be used. Powders and lotions are not recommended by some manufacturers; check the package material for manufacturer specifications. Chapter 33: Activity - Page 1178-1180
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? A. Stand at the top of the bed and have a colleague stand at the bottom of the bed B. Place the bed in its lowest position to reduce the client's risk for falls C. Position a friction-reducing sheet under the client to facilitate movement D. Use back muscles to gently and gradually pull the client to the side.
C. Position a friction-reducing sheet under the client to facilitate movement. 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. Chapter 33: Activity - Page 1181-1182
The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination? A. supine B. prone C. Sims' D. Fowler's
C. Sims' Sims' position, a semi-prone position, can be used for certain examinations of the rectum and vagina. Other positions do not allow for adequate examination of this area. Chapter 33: Activity - Page 1159
The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? A. supine B. prone C. Sims' D. Fowlers'
C. Sims' Sims' position, a semiprone position, can be used for certain examinations of the rectum and vagina. Other positions do not allow for adequate examination of this area. Chapter 33: Activity - Page 1159
Using proper body mechanics, which motions would the nurse make to move an object? A. The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. B. The nurse uses the muscles of the back to help provide the power needed in strenuous activities. C. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. D. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity.
C. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The internal girdle is made by contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward. It is helped further by making a long midriff by stretching the muscles in the waist. The nurse would not relax the stomach muscles or use the muscles of the back when moving an object. The nurse would not lift an object when it can be safely slid, rolled, pushed, or pulled. Chapter 33: Activity - Page 1151
What is a benefit of regular exercise over time? A. increased risk for blood clots B. increased work of breathing C. decreased heart rate D. decreased venous return
C. decreased heart rate Regular physical activity over time results in cardiovascular conditioning, thus decreasing heart rate. Regular exercise increases circulating fibrinolysin that serves to breakup small clots, thus decreasing the risk for blood clots. Over time, regular exercise leads to improved pulmonary function, including decreased work of breathing. Venous return is improved when contracting muscles compress superficial veins and push blood back to the heart against gravity. Chapter 33: Activity - Page 1142 - 1143
A nurse applies padded boots to maintain the foot in dorsiflexion on a client who is comatose. The nurse is protecting the client from: A. decubitus ulcers B. blood pressure changes C. footdrop D. pooling of blood.
C. footdrop A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Footdrop is a contracture in which the foot is fixed in plantar flexion. Chapter 33: Activity - Page 1158
When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what adverse condition is the nurse assessing the client? A. deep vein thrombosis B. circulatory alterations C. orthostatic hypotension D. hypertension
C. orthostatic hypotension The nurse would stand in front of the client and assess for any balance problems or reports of dizziness upon standing, due to orthostatic hypotension. Orthostatic hypotension occurs when the blood pressure drops when standing from the sitting or lying position. Standing in front of the client prevents falls or injuries. Hypertension or high blood pressure is a condition in which the force of the blood against the artery walls is too high. Hypertension needs to be treated with medications to lower the blood pressure. Deep vein thrombosis is a thrombosis or blood clot in a vein lying deep below the skin, especially in the legs. Treatment is by medications, compression stockings, and filters. There are other circulatory alterations like peripheral artery disease which is caused by narrowed blood vessels that reduce blood flow to the limbs. Chapter 33: Activity - Page 1140
The nurse has been educating the client about how to use a walker safely. The nurse knows the education has been effective when the client: A. uses the sides of the walker to rise up out of a chair B. places the walker far in front when walking C. steps into the walker when walking D. leans over the walker when walking.
C. steps into the walker when walking A walker is mechanical aide 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 it properly. The client should step into the walker when walking, rather than walking behind it. When rising from a seated position, the arms of the chair should be used for support, not the walker. 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 stay upright as he moves. Chapter 33: Activity - Page 1168
A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response? A. "To preserve the client's functional ability to grasp and pick up objects." B. "To prevent foot drop." C. "To avoid contractures." D. "To prevent the legs from rotating outward."
D. "To prevent the legs from rotating outward." Trochanter rolls prevent the legs from rotating outward. The other statements do not describe trochanter rolls. 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. Chapter 33: Activity - Page 1133
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? A. supine B. prone C. Sims' D. Fowler's
D. Fowler's 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. Other position choices do not promote oxygenation. Chapter 33: Activity - Page 1159
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? A. Push the client to the opposite side of the bed B. Push the client to the edge of the bed to which the client will be turning C. Pull the client to the edge of the bed to which the patient will be turning D. Move the client to edge of the bed opposite the side that client will be turning.
D. Move the client to edge of the bed opposite the side that client will be turning 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. Chapter 33: Activity - Page 1166
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? A. Make sure the bed brakes are unlocked. B. Put the chair at the foot of the bed. C. Place the bed in the highest position. D. Raise the head of the bed to a sitting position.
D. Raise the head of the bed to a sitting position. 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. Chapter 33: Activity - Page 1190
The client is an active, healthy 2-year-old child. His mother asks a nurse what she can expect developmentally from the boy over the next few years. What is the nurse's best response? a. The client will refine both gross and fine motor skills but longitudinal growth will slow b. The client will continue to grow rapidly but gross and fine motor skill acquisition will slow c. The client will regress in fine and gross motor skill development d. The client will continue to grow rapidly and will refine both gross and fine motor skills.
D. The client will continue to grow rapidly and will refine both gross and fine motor skills The toddler years are a time of rapid longitudinal growth and rapid skill acquisition and refinement. Any regression in skill acquisition is indicative of a larger problem and must be evaluated
A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall? A. The nurse should place his or her feet close together with one foot in front of the other. B. The nurse should rock his or her pelvis out on the opposite side of the client. C. The nurse should grasp the gait belt and pull the client's body backward away from his or her body. D. The nurse should gently slide the client down his or her body to the floor.
D. The nurse should gently slide the client down his or her body to the floor. The nurse should place feet wide apart, with one foot in front, and rock the pelvis out on the side nearest the client. The nurse should grasp the gait belt and support the client by pulling his or her weight backward against his or her body and then gently slide the client down his or her body to the floor, protecting the client's head. Chapter 33: Activity - Page 1166-1167
The nurse is transferring the client from the bed to a wheelchair when the client reports dizziness. What is the next step for the nurse? A. Have the client stand without moving to see if the dizziness will pass. B. Firmly grasp the gait belt and gently lower the client into bed. C. Quickly pivot the client into the wheelchair to prevent client fall. D. Apply oxygen 2L via nasal cannula to the client.
Firmly grasp the gait belt and gently lower the client into bed. The nurse should ease the client back on the bed to prevent fall and injury. Having the client stand may increase risk of fall and injury if dizziness persists. The client should not be quickly pivoted into the chair, because this could cause injury to the client and/or the nurse. Applying oxygen would not be priority over ensuring the client is safe in bed. Chapter 33: Activity - Page 1189-1192
A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take? A. Tell the client he can remove them for 20 or 30 minutes during this shift. B. Instruct the client to not remove them until the primary care provider writes a prescription to discontinue them. C. Explain that the stockings must be worn 48 hours straight before they may be removed temporarily. D. Permit the client to remove the stockings indefinitely and speak to the physician about the necessity of having the client wear them.
Tell the client he can remove them for 20 or 30 minutes during this shift. Antiembolism stockings should be removed once every shift for 20 to 30 minutes to allow for assessment of circulatory status and the condition of the skin on the lower extremity and for skin care. The nurse should not disregard the health care provider's prescription and allow the client to remove the stockings indefinitely, as this could endanger the client's health. Chapter 33: Activity - Page 1178-1181