MOBILITY

Question 1

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take?

Answer 1

Remind the client to use incentive spirometer

Question 2

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture?

Answer 2

Muscles

Question 3

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include?

Answer 3

The top of the walker should be at the level of your wrist

Question 4

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage?

Answer 4

Prone

Question 5

A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL?

Answer 5

Toileting

Question 6

A nurse is assessing a client’s mobility and notes one of the client’s feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?

Answer 6

Foot drop

Question 7

A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics?

Answer 7

1. Stand as close to the object as possible
2. Keep abdominal muscles contracted and lower the back straight
3. Look straight ahead with shoulders raised up
4. Bend hips slightly and squat
5. Push up from the knees when lifting the object

Question 8

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?

Answer 8

Muscles assist with thermoregulation in the body

Question 9

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?

Answer 9

Fowler’s

Question 10

A nurse in a long term facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing?

Answer 10

Atrophy

Question 11

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client’s skin tone. The nurse should identify that the wound is in which of the following stages of damage?

Answer 11

Damage into the skin layer

Question 12

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include?

Answer 12

1. A stable center of gravity increases stability and balance
2. A wide base lowers the center of gravity
3. Proper body alignment involves tightening the abdomen

Question 13

A nurse is caring for a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client?

Answer 13

Mechanical lift

Question 14

A nurse is preparing to transfer a client from a bed to a wheel chair. Which of the following actions by the nurse demonstrates proper use of body mechanics?

Answer 14

Looking at the client face-to-face when transferring the client

Question 15

A nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at a Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks?

Answer 15

Sit on the edge of the bed for 1 min

Question 16

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include?

Answer 16

Kyphosis is a rounded upper back with the pelvis tilted forward

Question 17

A nurse is caring for a client who had stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions?

Answer 17

Deep vein thrombosis

Question 18

A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client?

Answer 18

Occupational Therapist

Question 19

A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include?

Answer 19

Tendons connect muscle to bone

Question 20

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?

Answer 20

The use of ergonomics increases job satisfactions

Question 21

A nurse is performing a focused assessment to an older adult client’s mobility. Which of the following findings should indicate to the nurse that the client is experiencing and age-related change to their musculoskeletal system?

Answer 21

Increased curvature of the thoracic spine

Question 22

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches?

Answer 22

The client has the crutches resting 5 cm (2 in) below their axilla

Question 23

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint?

Answer 23

The contraction of a muscle results in flexion of a joint

Question 24

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?

Answer 24

Slide board

Question 25

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following?

Answer 25

Diminished awareness of body position and balance

Question 26

A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include?

A. “Lean on the crutches to support your body weight when standing.”
B. “Fully extend your arms when holding onto the hand grips.”
C. “Hold the crutches on your unaffected side when preparing to sit in a chair.”
D. “Hold the crutches 9 inches in front of and to the side of each foot.”

Answer 26

C. “Hold the crutches on your unaffected side when preparing to sit in a chair.”

Rationale: The crutches should be held on the unaffected side when preparing to sit in a chair.

Incorrect rationale:

• crutches should be fitted so the client’s arms are flexed ~ 30° at elbows when holding onto hand grips.
• crutches should be held 6 inches in front of & to side of each foot to assist w/ balance

Question 27

A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?

A. Move their leg behind their body.
B. Move their leg forward and up.
C. Move their leg medially toward their other leg.
D. Turn their foot and leg away from their other leg.

Answer 27

A. Move their leg behind their body.

Rationale: This movement demonstrates hyperextension of the hip.

B. flexion
C. adduction
D. external rotation

Question 28

A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?

A. Place the stockings on the client after the client ambulates to the restroom.
B. Ensure the client’s toes are visible after placing the stockings on the client.
C. After applying the stockings, place two fingers between the client’s leg and stocking to check the fit.
D. Measure the client’s calf circumference and leg length from heel to knee.

Answer 28

D. Measure the client’s calf circumference and leg length from heel to knee.

Rationale: To ensure proper fit, the nurse should measure the widest part of the client’s calf as well as the length of client’s leg from heel to knee. Antiembolic stockings that are too large will not apply the pressure needed to prevent DVT. Antiembolic stockings that are too small could impair circulation in the client’s legs.

Question 29

A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take?

A. Wrap both arms around the client’s arms and shoulders.
B. Move both feet together when the client begins to fall.
C. Protect the client’s extremities while lowering them to the floor.
D. Extend one leg and allow the client to slide down the leg to the floor.

Answer 29

D. Extend one leg and allow the client to slide down the leg to the floor.

Rationale: This action helps prevent injury to the client. As the client gets close to the floor, the nurse should bend both legs to continue supporting the client.

Question 30

A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique?

A. Positioning the chair slightly behind the nurse so that the seat faces the client’s bed
B. Placing the client’s left leg in front of the right leg just prior to the transfer
C. Aligning the nurse’s knees with the client’s knees just before the transfer
D. Grasping the client under the axillae to assist them to their feet

Answer 30

C. Aligning the nurse’s knees with the client’s knees just before the transfer.

Rationale: This is a correct strategy that helps the nurse safely stabilize the client while moving to a standing position.

Question 31

A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?

A. Adducting the arm so that it lies next to the client’s side
B. Flexing the shoulder by raising the arm from a side position to a 180° angle
C. Abducting the arm to a 90° angle from the side of the body
D. Circumducting the shoulder in a 180° half circle

Answer 31

B. Flexing the shoulder by raising the arm from a side position to a 180° angle

Rationale: This demonstrates full ROM of shoulder. The client’s fingers should be pointing directly upward.

circumduct = 360* circle

Question 32

A nurse is observing an assistive personnel (AP) who is using a mechanical lift w/ a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene?

A. Places a removable cover over the sling
B. Leaves the bed in the lowest position throughout the procedure
C. Locks the hydraulic valve before attaching the sling to the lift
D. Raises the head of the bed to a sitting position just before transfer

Answer 32

B. Leaves the bed in the lowest position throughout the procedure

Rationale: The bed should be raised to a comfortable working position in order to prevent injury to nursing staff and to properly position the lift under the client’s bed.

Question 33

A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include?

A. “Lean on the crutches to support your body weight when standing.”
B. “Fully extend your arms when holding onto the hand grips.”
C. “Hold the crutches on your unaffected side when preparing to sit in a chair.”
D. “Hold the crutches 9 inches in front of and to the side of each foot.”

Answer 33

C. “Hold the crutches on your unaffected side when preparing to sit in a chair.”

Rationale: The crutches should be held on the unaffected side when preparing to sit in a chair.

Incorrect Rationale:
A. Leaning on the crutches when standing puts excessive pressure on the axillae and can cause nerve injury
B. The crutches should be fitted so the client’s arms are flexed about 30° at elbows when holding onto hand grips.
D. The crutches should be held only 6 inches in front of & to side of each foot to assist w/ balance.

Question 34

A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?

A. Place the stockings on the client after the client ambulates to the restroom.
B. Ensure the client’s toes are visible after placing the stockings on the client.
C. After applying the stockings, place two fingers between the client’s leg and stocking to check the fit.
D. Measure the client’s calf circumference and leg length from heel to knee.

Answer 34

D. Measure the client’s calf circumference and leg length from heel to knee.

Rationale: To ensure proper fit, the nurse should measure the widest part of the client’s calf as well as the length of client’s leg from heel to knee. Antiembolic stockings that are too large will not apply the pressure needed to prevent DVT. Antiembolic stockings that are too small could impair circulation in the client’s legs.

Question 35

A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?

A. Move their leg behind their body.
B. Move their leg forward and up.
C. Move their leg medially toward their other leg.
D. Turn their foot and leg away from their other leg.

Answer 35

A. Move their leg behind their body.

Rationale: This movement demonstrates hyperextension of the hip.

B. flexion
C. adduction
D. external rotation

Question 36

A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take?

A. Wrap both arms around the client’s arms and shoulders.
B. Move both feet together when the client begins to fall.
C. Protect the client’s extremities while lowering them to the floor.
D. Extend one leg and allow the client to slide down the leg to the floor.

Answer 36

D. Extend one leg and allow the client to slide down the leg to the floor.

Rationale: This action helps prevent injury to the client. As the client gets close to the floor, the nurse should bend both legs to continue supporting the client.

Question 37

A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique?

A. Positioning the chair slightly behind the nurse so that the seat faces the client’s bed
B. Placing the client’s left leg in front of the right leg just prior to the transfer
C. Aligning the nurse’s knees with the client’s knees just before the transfer
D. Grasping the client under the axillae to assist them to their feet

Answer 37

C. Aligning the nurse’s knees with the client’s knees just before the transfer.

Rationale: This is a correct strategy that helps the nurse safely stabilize the client while moving to a standing position

Question 38

A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?

A. Adducting the arm so that it lies next to the client’s side
B. Flexing the shoulder by raising the arm from a side position to a 180° angle
C. Abducting the arm to a 90° angle from the side of the body
D. Circumducting the shoulder in a 180° half circle

Answer 38

B. Flexing the shoulder by raising the arm from a side position to a 180° angle

Rationale: This demonstrates full ROM of shoulder. The client’s fingers should be pointing directly upward.

circumduct = 360* circle