Chapter 33 Flashcards
A staff development nurse is discussing techniques to prevent back injury with a group of nursing assistants. The nurse informs the group that back stress and injury can be prevented by doing which of the following?
A) Spreading feet shoulder-width apart to broaden the base of support
B) Using the strength of the back muscles during strenuous activities
C) Holding the object that you are lifting or moving away from the body
D) Pulling equipment, rather than pushing it, when possible
A) Spreading feet shoulder-width apart to broaden the base of support
Techniques that prevent back stress and injury include spreading the feet shoulder-width apart to broaden the base of
support; pushing equipment, rather than pulling, whenever possible; holding the object you are lifting or moving close to
the body; and using the longest and strongest muscles of the arms and legs to provide power, since the muscles of the
back are less strong and more easily injured
While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon
the understanding that the client has which of the following?
A) Paralysis of the legs
B) Weakness affecting one-half of the body
C) Paralysis affecting one-half of the body
D) Paralysis of the legs and arms
A) Paralysis of the legs
Paraplegia is paralysis of the legs, and quadriplegia is paralysis of the arms and legs. Hemiparesis refers to weakness of
one half of the body, and hemiplegia is paralysis of one half of the body.
The physician’s admitting orders indicate that the client is to be placed in a Fowler’s position. Upon positioning this
client, how much will the nurse elevate the head of the bed?
A) 45 to 60 degrees
B) 15 to 20 degrees
C) 30 degrees
D) 90 degrees
A) 45 to 60 degrees
In the Fowler’s position, the head of the bed is elevated 45 to 60 degrees. Low-Fowler’s or semi-Fowler’s is positioning of the head of the bed to only 30 degrees. In the high-Fowler’s position, the head of the bed is elevated 90 degrees
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?
A) Fowler’s
B) Low-Fowler’s
C) Protective supine
D) Semi-Fowler’s
A) Fowler’s
Fowler’s position optimizes cardiac function and respiratory function in addition to being the best position for eating.
The client’s risk of aspiration would be extreme in a supine position. Low-Fowler’s and semi-Fowler’s are synonymous, and this position does not aid swallowing as much as a high-Fowler’s position.
An obstetrical nurse is preparing to help a client up from her bed and to the bathroom three hours after the woman
delivered her baby. Which of the following actions should the nurse perform first?
A) Explain to the client how the nurse will assist her.
B) Position a walker in front of the client to provide stability.
C) Enlist the assistance of another nurse or the physiotherapist.
D) Have the client stand for 30 seconds prior to walking.
A) Explain to the client how the nurse will assist her.
Any effort to assist a client with mobilization should be preceded by thoroughly explaining the procedure; this optimizes
the client’s participation and lessens the potential for falls and injuries. The client is unlikely to require a walker or the assistance of multiple care providers, but even if she did, an explanation should still be provided first. It is not necessary to have the client stand for an extended period before ambulating
A client 86 years of age with a diagnosis of late-stage Alzheimer’s disease requires full assistance with transfers to and
from his bed. Which of the following nursing actions is most likely to promote safe handling of this client?
A) Provide to the client brief, clear instructions that are phrased positively.
B) Post written instructions at the client’s bedside to supplement spoken instructions.
C) Ask for the client’s input on the timing and technique for transfers.
D) Ask for the client’s feedback frequently during transfers.
A) Provide to the client brief, clear instructions that are phrased positively.
When handling clients who have dementia, clear, short instructions are most effective. These instructions should be
phrased positively (“stand up” rather than “don’t sit down”). For a client with an advanced state of dementia, asking for
feedback during transfers, and input on planning transfers is likely to be ineffective and may be frustrating for both the
client and the nurse.
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? A) The client’s ability to assist B) The client’s body weight C) The client’s cognitive status D) The client’s age
A) The client’s ability to assist
The nurse assesses several parameters when choosing whether to use a mechanized assistive device for a client transfer.
The most important consideration, however, is the client’s ability to safely assist with his or her transfer
What function of the skeletal system is essential to proper function of all other cells and tissues? A) Supporting soft tissues of the body B) Protecting delicate body structures C) Providing storage area for fats D) Producing blood cells
D) Producing blood cells
The production of blood cells (hematopoiesis) is the function of the skeletal system that is essential to all other cells and
tissues of the body working properly.
A nurse is assessing the activity level of an infant age 5 months. What normal findings would be assessed? A) Ability to sit and head control B) Ability to pick up small objects C) Progress toward running and jumping D) Progress toward unassisted walking
A) Ability to sit and head control
At 5 months of age, the infant usually has achieved head control and is able to sit alone. Individual variations in activity
patterns and neuromuscular development should be expected.
Which postural deformity might be assessed in a teenager? A) Kyphosis B) Rickets C) Osteoporosis D) Scoliosis
D) Scoliosis
Scoliosis, a lateral curvature of the spine, would most likely be assessed in a teenager. Kyphosis and osteoporosis are seen in older adults. Rickets is seen in children.
A nurse is teaching an older woman how to move and lift her disabled husband. The woman has osteoarthritis of the hips
and knees. What is the goal of the nurse’s education plan?
A) Minimize stress on the wife’s joints
B) Povide exercise for the husband
C) Increase socialization with neighbors
D) Maintain self-esteem of the wife
A) Minimize stress on the wife’s joints
Older adults often have osteoarthritis, a noninflammatory progressive disorder of the moveable joints, particularly
weight-bearing joints. Teaching clients to minimize stress on the joints to prevent possible injury and reduce pain is
important.
Why is it important for the nurse to teach and role model proper body mechanics?
A) To ensure knowledgeable client care
B) To promote health and prevent illness
C) To prevent unnecessary insurance claims
D) To demonstrate knowledge and skills
B) To promote health and prevent illness
The correct use of body mechanics is a part of health promotion and illness prevention. The nurse has a major
responsibility to teach good body mechanics, both directly and indirectly, by example.
A nurse is placing a client in Fowler’s position. What should she teach the family about this position?
A) “Use at least two big pillows to support the head.”
B) “Cross the arms over the client’s abdomen.”
C) “Do not raise the knees with the knee gatch.”
D) “Keep the hands lower than the rest of the body.”
C) “Do not raise the knees with the knee gatch.”
When positioning the client in Fowler’s position, allow the head to rest against the mattress or use only a small pillow. Support the forearms on pillows, with the hand slightly elevated above the forearm. Do not use the knee gatch to raise
the knees
While performing a physical examination on a client, the nurse observes that the client has scoliosis based on which of
the following?
A) Lateral deviation of the thoracic spine
B) Concave curvature of the cervical spine
C) Convex curvature of the thoracic spine
D) Concave curvature of the lumbar spine
A) Lateral deviation of the thoracic spine
Scoliosis is the lateral deviation of the thoracic spine. Concave curvature of the cervical spine, convex curvature of the
thoracic spine, and concave curvature of the lumbar spine are the characteristics of a normal spinal alignment
A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease. The client always remains in a
sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client?
A) Back of the skull
B) Elbows
C) Sacrum
D) Heels
C) Sacrum
The sacrum bears the greatest pressure during a sitting position. The back of the skull, elbows, and heels bear pressure in a supine position.
A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes
weakness, dizziness, and feeling faint. The nurse correctly recognizes that which of the following conditions is likely
affecting the client?
A) Thrombophlebitis
B) Anemia
C) Orthostatic hypotension
D) Bradycardia
C) Orthostatic hypotension
Orthostatic hypotension refers to a reduction in blood pressure with position changes from lying to sitting or standing.
Blood pooling in the legs increases, thus increasing the postural hypotension. Thrombophlebiits refers to an inflammation of a the veins; it manifests with redness and swelling. Anemia refers to
Which of the following activities is normally acquired in the toddler years? Select all that apply. A) Rolling over B) Pulling to a standing position C) Walking D) Running E) Jumping
C) Walking
D) Running
E) Jumping
In the toddler, gross and fine motor development continue rapidly; by 15 months, most can walk unassisted, run, and
jump. Rolling over and pulling to a standing position are accomplished by the infant.
The nurse cares for a newly admitted client who will soon need to be taken to the radiology department for a CT scan.
The client has a Body Mass Index (BMI) of 52. Which of the following strategies to transport the client is most
appropriate?
A) Obtain a mechanical lateral transfer device to move the client onto a stretcher.
B) Enlist the aid of two other staff members and pull the client across the bed and onto a stretcher.
C) Position a friction-reducing sheet under the client before attempting the transfer.
D) Transport the client to the radiology department in the hospital bed
A) Obtain a mechanical lateral transfer device to move the client onto a stretcher.
The combined weight of the bed and client will be difficult to move safely. Additionally, this strategy does not address
the need to transfer the client onto, and off of, equipment in the radiology department.
The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the
client to sit in the chair three times a day. Which of the following actions will be most effective to transfer the client
safely into the chair?
A) Have the client sit on the side of the bed for several minutes before moving to the chair.
B) Infuse an intravenous fluid bolus 15 minutes before transferring the client into the chair.
C) Position a friction-reducing sheet under the client.
D) Obtain a quad cane for the client to use as a transfer aid.
A) Have the client sit on the side of the bed for several minutes before moving to the chair.
Having the client sit at the side of the bed minimizes the risk for blood pressure changes (orthostatic hypotension) that
can occur with position change.
The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, “I feel so
weak. I think I am going to pass out.” Which of the following initial actions by the nurse is appropriate?
A) Firmly grasp the client’s gait belt.
B) Support the client’s body against yours and gently slide the client onto the floor.
C) Ask the client to lean against the wall while you obtain a wheelchair.
D) Apply oxygen and wait several minutes for the weakness to pass.
E) Ask the patient, “When was the last time you ate?”
B) Support the client’s body against yours and gently slide the client onto the floor.
Once applied, antiembolism stockings should not be removed until the primary care provider writes an order to
discontinue them.
A) True
B) False
B) False
Antiembolism stockings may be removed (for example, during morning care to inspect the legs) without the primary
care provider writing an order to discontinue them
A nurse uses proper body mechanics to move a client up in bed. Which of the following is a guideline for using these
techniques properly?
A) Face the direction of movement.
B) Twist body at the waist when lifting.
C) Keep body weight higher than center of gravity.
D) Keep feet together to provide a base of support
A) Face the direction of movement.
When using body mechanics, the nurse should face the direction of movement and avoid twisting the body. Maintaining
balance involves keeping the spine in vertical alignment, body weight close to the center of gravity, and feet spread for a broad base of support.
Which of the following clients would be an appropriate candidate to move by using a powered stand-assist device?
A) A comatose client who is being taken for x-rays
B) An alert client after knee replacement surgery who is being assisted to ambulate
C) An obese client who has Alzheimer’s disease and is being escorted to the shower room
D) A car accident victim with fractures in both legs who is being moved to another room
B) An alert client after knee replacement surgery who is being assisted to ambulate
Powered stand-assist devices can be used with clients with weight-bearing ability on at least one leg, who can follow
directions, and who are cooperative. Clients who are unable to bear partial weight, full weight or who are uncooperative
should be transferred using a full body sling lift.
A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an
accurate step to 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 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 sliding the client down his or her body to the floor, protecting the client’s head.
The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client data would the nurse check
to see if the assistance of another nurse is needed?
A) Client restrictions
B) Client age
C) Client food preferences
D) Client restraints
A) Client restrictions
When attempting to move a client, the nurse would first check the client’s chart to see if the client has any physical limitations or restrictions. The nurse would also evaluate the client’s condition and determine whether or not the client can help with positioning or understand directions. Lastly, the nurse would evaluate the client’s body weight and his or
her own strength. Age and food preferences would not affect movement. Clients with restraints still need to be moved
and repositioned.
A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed? A) Every hour B) Every two hours C) Every four hours D) Every shift
B) Every two hours
The nurse would turn the client in bed every two hours to avoid complications due to inactivity. The nurse would also include this activity in the client plan of care.
The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure? A) Sitting up B) Lying prone C) Lying flat D) Lying flat with feet raised slightly
C) Lying flat
The nurse would position the bed so that the client is lying flat on his/her back and then raise the bed to a comfortable working height. This facilitates moving the client to the side in order to perform the turn in bed.
The nurse is preparing to move a patient up in bed with the assistance of another nurse. In what position would the nurse place the patient, if tolerated? A) Reverse Trendelenburg B) Supine C) Sitting D) Semi-Fowler’s
B) Supine
The nurse would adjust the head of the bed to a flat position or slight Trendelenburg, as low as the patient can tolerate.
Flat positioning helps to decrease the gravitational pull of the upper body
When moving a client up in bed, the nurse asks the client to fold the arms across the chest and lift the head with the chin
on the chest. What is the rationale for placing the client in this position?
A) To prevent hyperextension of the neck
B) To prevent pressure on the arms
C) To lower the client’s center of gravity
D) To decrease the effort needed to move the client
The nurse would ask the client to fold the arms across the chest and lift the head with the chin on the chest. Positioning
in this manner provides assistance, reduces friction, and prevents hyperextension of the neck.
When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board
partially underneath the patient. What is the rationale for using a transfer board in this procedure?
A) To lift the client off the bed.
B) To slide the board with the client onto the stretcher.
C) To reduce friction as the client is pulled laterally onto the stretcher.
D) To protect the client’s head from hitting the headboard
C) To reduce friction as the client is pulled laterally onto the stretcher.
The transfer board or other lateral-assist device reduces friction, easing work load to move the client. It is positioned
partially under the client, across the space between the bed and stretcher
When assisting a client from the bed into a wheelchair, the nurse assesses the client standing up and notices the client is
weak and unsteady. What would be the recommended nursing intervention in this situation?
A) Allow the client to keep standing for several minutes until balance returns.
B) Use the call bell to summon the assistance of another nurse.
C) Return the client to the bed.
D) Place the client into the wheelchair.
C) Return the client to the bed.
Once the client is standing, the nurse would assess the patient’s balance and leg strength. If the client is weak or
unsteady, the nurse would return the client to the bed.
Student nurses are turning a client in bed. In order to move the client to the edge of the bed, which positioning
instruction is best to give the client when using the friction-reducing sheet?
A) Cross the arms across the chest and keep the legs straight.
B) Cross the arms across the chest and cross the legs.
C) Keep the arms at the sides and the legs crossed.
D) Keep the arms folded loosely at the abdomen and the legs straight.
B) Cross the arms across the chest and cross the legs.
The nurse would ask the client to cross the arms across the chest, and cross the legs. This facilitates the turning motion and protects the client’s arms during the move. Or, if the client is able, the nurse may ask the client to assist by grasping the bed rail on the side toward which the client is turning.
A nurse is assisting in the transfer of a client to a stretcher. The client has casts on both legs. What is the nurse’s best
choice of transfer equipment for this client who cannot bear weight on either leg?
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 devices and repositioning devices require the client to have weight-bearing capacity in one leg. Gait belts are used to assist clients to ambulate
safely
While being measured for anti-embolism stockings, the client asks the nurse why they are necessary. What would be the
nurses’s best response?
A) They promote venous blood return to the heart.
B) They eliminate peripheral edema.
C) They provide a nonslip foot surface to help prevent falls.
D) They reduce the risk for impaired skin integrity
A) They promote venous blood return to the heart
Anti-embolism stockings are used to promote venous blood return to the heart and help in preventing blood clots. They often do help with edema in the legs, but they do not eliminate edema (nor is this their main goal). They do not provide a
nonslip foot surface. If applied incorrectly they can increase the risk for impaired skin integrity.
The nurse and an assistant are preparing to move a client up in bed. Arrange the following steps in the correct order.
1. Adjust the head of the bed to a flat position.
2. Place a friction-reducing sheet under the client.
3. Ask the client to bend legs and place the chin on the chest.
4. Position the assistant on the side opposite you.
5. Remove all pillows from under the client.
6. Grasp the sheet and move the client on the count of 3
A) 3, 1, 2, 4, 5, 6
B) 1, 2, 4, 3, 5, 6
C) 1, 5, 4, 2, 3, 6
D) 3, 2, 1, 4, 6, 5
E) 1, 3, 2, 4, 5, 6
C) 1, 5, 4, 2, 3, 6
This is the correct order for a nurse and an assistant who are preparing to move a client up in bed
