Chapter 25 Mobility

Question 1

Best position for client with impaired swallowing and wants to eat

Answer 1

Fowlers

Fowler’s position optimizes cardiac function and respiratory function in addition to being the best position for eating.

Question 2

Using proper body mechanics, which motions would the nurse make to move an object?

Answer 2

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.

Question 3

What other factors contribute to increased risk for falls in clients?

Answer 3

Gait disturbances, history of falls, certain medications, and weakness are highly predictive of a fall.

Question 4

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?

Answer 4

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.

Question 5

A client that is being ambulated in the hallway by the nurse reports dizziness and proceeds to begin falling. Which nursing action is appropriate?

Answer 5

The nurse will create a wide base of support by placing his or her foot to the side, and sliding an arm under the client’s axilla. If necessary, the nurse can balance the client on his or her hip until her arrives, or slide the client gently down the length of the nurse’s leg to the floor. All other actions are inappropriate

Question 6

The nurse performs passive range of motion for a client by turning each palm upward, and then downward. How will the nurse document this motion?

Answer 6

Supination involves turning upward; pronation involves turning downward. Other answers are incorrect.

Question 7

While performing passive range-of-motion exercises on the lower extremities of a client with a spinal cord injury, the nurse assesses permanent flexion of the muscles. What term will the nurse use to document this finding related to the muscles?

Answer 7

Contractures are permanent contraction of a muscle.

Question 8

Tonus

Answer 8

is the term used to describe the state of slight contraction, the usual state of skeletal muscles.

Question 9

Atrophy

Answer 9

the decrease in muscle size from immobility

Question 10

Ankylosis

Answer 10

a consolidation and immobilization of a join

Question 11

A nurse is caring for a comatose client. What can happen to the feet if they are unsupported in the dorsiflexed position?

Answer 11

plantar flexion and footdrop

The greatest danger to the feet occurs when they are unsupported in the dorsiflexed position. The toes drop downward and the feet are in plantar flexion. If maintained for an extended position, the client may develop footdrop.

Question 12

Platform crutches

Answer 12

used by clients who cannot bear weight with their hands and wrist

Question 13

Walker

Answer 13

Clients who require considerable support and assistance with balance

A walker is often used for clients beginning to ambulate after prolonged bedrest or after hip surgery. Other devices do not offer the same level of support.

Question 14

Cane

Answer 14

used for clients who have weakness on one side of the body

Question 15

Axillary crutches

Answer 15

have a bar that fits beneath the axilla. Clients who need brief, temporary assistance with ambulation

Question 16

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?

Answer 16

decreased or unsteady mobility

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.

Question 17

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

Answer 17

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.

Question 18

The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care?

Answer 18

Trapeze bar

Promoting client independence with movement and activity is an important intervention for clients with musculoskeletal problems. overhead trapeze is used by the client.

Question 19

The nurse performs passive range of motion for a client by turning the sole of the foot toward midline, and then away from the midline. How will the nurse document this motion?

Answer 19

Inversion involves turning the sole of the foot towards the midline; eversion involves turning the sole of the foot away from the midline. Other answers are incorrect.

Question 20

Single-ended cane with straight handles

Answer 20

recommended for clients with hand weakness because the handgrip is easier to h

Question 21

Single-ended canes with half-circle

Answer 21

are recommended for clients requiring minimal support and those who will be using stairs frequentl

Question 22

Canes with three (tripod) or four prongs (quad cane) or legs

Answer 22

provide a wide base of support are recommended for clients with poor balanc

Question 23

When assisting a client with ambulation using an assistive device such as parallel bars or a walking belt, what should the nurse observe the client for?

Answer 23

When assisting a client with ambulation using an assistive device such as parallel bars or a walking belt, the nurse should observe the client for pallor, weakness, or dizziness. Observing the client’s walking gait would not be an appropriate action in this case. The nurse should preferably observe the walking gait of clients who ambulate with crutches, walkers, or canes.

Question 24

The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client?

Answer 24

Placing a client in slight Trendelenburg position may help keep the client from sliding down toward the foot of the bed.

Question 25

A client with paralysis has been prescribed swing-through crutch-walking. Which teaching regarding gait pattern will the nurse provide?

Answer 25

The nurse will teach the client to walk by moving both crutches forward, and then advancing both legs beyond the crutches.

both crutches are moved forward, one or both legs are advanced beyond crutches