Mobility/Ambulation-Chap 10 & 11 skills book

Question 1

The patient has been admitted for hypertension. His blood pressure is normally in the 160/90 range. He has been on bed rest for the past few days, and the doctor has started him on a new blood pressure medication. The nurse is assisting the patient to move from the bed to the chair for breakfast, but when the patient tries to sit up on the side of the bed, he complains of being dizzy and nauseous. The nurse lays the patient down and takes his vital signs. His pulse is 124. His blood pressure is 130/80. This blood pressure is indicative of what?

a. A normal blood pressure for this patient
b. Orthostatic hypotension
c. Orthostatic hypertension
d. Effective baroreceptor function

Answer 1

ANS: B

Question 2

The patient is an elderly gentleman who has been on bed rest for the past several days. When getting the patient up, the nurse should:

a. tell the patient not to move his legs when dangling.
b. tell the patient to hold his breath while dangling.
c. raise the head of the bed and allow a few minutes before dangling.
d. have the patient stand without dangling.

Answer 2

C

Question 3

An appropriate technique for the nurse to use when performing range of motion (ROM) exercises is to:

a. repeat each action five times during the exercise.
b. perform the exercises quickly and firmly.
c. support the proximal portion of the extremity being exercised.
d. continue the exercise slightly beyond the point of resistance.

Answer 3

A

Question 4

A patient is admitted to the medical unit following a cerebrovascular accident (CVA). Evidence of left-sided hemiparesis is noted, and the nurse will be following up on ROM and other exercises performed in physical therapy. The nurse should correctly teach the patient and family members which of the following principles of ROM exercises?

a. Flex the joint to the point of discomfort.
b. Medicate the patient after the ROM exercise session.
c. Move the joints quickly.
d. Provide support for distal joints.

Answer 4

D

Question 5

A nurse should be concerned when observing a patient performing isometric exercises if the patient is:

a. holding his or her breath while exerting.
b. performing the exercises four times per day.
c. tightening each muscle group for 8 seconds, then relaxing.
d. repeating each exercise 8 to 10 times for each muscle group.

Answer 5

A

Question 6

A nurse encourages a patient to prevent venous stasis by:

a. crossing the legs when sitting in a chair.
b. wearing thigh-length nylon stockings or garters.
c. elevating the legs on pillows while in bed.
d. increasing early ambulation.

Answer 6

D

Question 7

Antiembolic stockings (TEDs) are ordered for the patient on bed rest after surgery. The nurse explains to the patient that the primary purpose for the elastic stockings is to:

a. keep the skin warm and dry.
b. prevent abnormal joint flexion.
c. apply external pressure.
d. prevent bleeding.

Answer 7

C

Question 8

When assessing the patient for risk for DVT, the nurse should consider which of the following an indicator of increased risk?

a. A positive Homans’ sign
b. Pallor to the distal area
c. Edema noted in the extremity
d. Fever or dehydration

Answer 8

D

Question 9

An appropriate procedure for the nurse to use when applying an elastic stocking is to:

a. remove the stockings every 24 hours.
b. keep the tops of the stockings rolled down slightly.
c. turn the stocking inside out to apply from the toes up.
d. wash stockings daily and dry in a dryer.

Answer 9

C

Question 10

When using an SCD, the nurse should:

a. apply powder to the patient’s skin if redness and itching are present.
b. leave a two-finger space between the patient’s leg and the compression stocking.
c. keep the patient connected to the compression device when transferring into and out of bed.
d. remove the elastic stockings before putting on the sequential pneumatic compression stockings.

Answer 10

B

Question 11

The patient is a paraplegic who possesses good arm and hand strength. When the following devices are compared, which would be most appropriate for this patient?

a. Axillary crutch
b. Platform crutch
c. Lofstrand crutch
d. Standard crook cane

Answer 11

C

Question 12

An appropriate way for the nurse to measure a patient for crutches is to:

a. have a flexion of 45 degrees at both of the patient’s elbows.
b. have a space of two to three fingers between the top of the crutch and the axilla.
c. place the crutch tips 1 foot to each side of the patient’s feet, and observe the positioning of the crutches.
d. place the crutch tips 1 foot to the front of the patient’s feet, and observe the positioning of the crutches.

Answer 12

B

Question 13

The patient has been using crutches for the past 2 weeks. When she comes for her follow-up examination, she complains of tingling and numbness in her hands and upper torso. Possible causes of these symptoms are:

a. the patient’s elbows are flexed 15 to 30 degrees when using the crutches.
b. crutch pad is approximately 2 inches below the patient’s axilla.
c. patient holds the cane 4 to 6 inches to the side of her foot.
d. handgrip does not allow for elbow flexion.

Answer 13

D

Question 14

The patient has a leg injury and is being fitted for a cane. The patient should be taught to:

a. hold the cane on the uninvolved side.
b. hold the cane on the weaker side.
c. extend the cane 15 inches from the foot when used.
d. maintain approximately 60 degrees of elbow flexion.

Answer 14

A

Question 15

While ambulating, the patient becomes light-headed and starts to fall. What should the nurse do first?

a. Call for help.
b. Try to reach for a chair.
c. Ease the patient down to the floor.
d. Push the patient back toward the bed.

Answer 15

C

Question 16

When the four gaits listed below are compared, which is the most stable of the crutch gaits?

a. Four-point gait
b. Three-point gait
c. Two-point gait
d. Swing-to gait

Answer 16

A

Question 17

The nurse is caring for a patient who has just been treated for a broken leg. She needs to teach the patient how to use crutches. Which crutch gait is most appropriate for this patient?

a. Four-point gait
b. Three-point gait
c. Two-point gait
d. Swing-to gait

Answer 17

B

Question 18

When teaching the use of a three-point crutch gait, the nurse should instruct the patient to move:

a. both crutches and the affected leg first, then the stronger leg.
b. the right crutch, left foot, left crutch, and right foot in sequence.
c. the left crutch and right foot, then move the right crutch and left foot.
d. both crutches, then lift and swing the legs forward as far as the crutches.

Answer 18

A

Question 19

A patient with left hemiparesis is using a quad cane for ambulation. Which of the following is the correct technique for the nurse to use in teaching the patient?

a. Use the cane on the right side, with the cane moving forward first.
b. Use the cane on the left side, with the left leg moving forward with the cane.
c. Use the cane in either hand, with the right leg moving forward first.
d. Use the cane in either hand, with the left leg moving beyond the forward placement of the cane.

Answer 19

A

Question 20

The patient had a stroke and is currently immobile. The nurse realizes that increasing mobility is critical because immobility can result in alterations in which of the following? (Select all that apply.)

a. Cardiovascular function
b. Pulmonary function
c. Skin integrity
d. Elimination

Answer 20

ALL OF THE ABOVE

Question 21

The nurse is caring for an immobile patient. Which of the following may help reduce the hazards associated with immobility? (Select all that apply.)

a. A high-fiber diet
b. Frequent repositioning
c. Muscle and joint exercises
d. Increased fluid intake

Answer 21

ALL OF THE ABOVE

Question 22

The nurse is applying a CPM machine to the patient’s leg. To do so, she must: (Select all that apply.)

a. provide analgesia 1 hour before starting the CPM.
b. stop the CPM when in extension and place a sheepskin on the machine.
c. align the patient’s joint with the CPM’s mechanical joint.
d. secure the patient’s extremity tightly with Velcro straps.

Answer 22

B, C

Question 23

Factors that contribute to the development of DVT are: (Select all that apply.)

a. elevated sodium (Na+) levels.
b. hypercoagulability of the blood.
c. venous wall damage.
d. stasis of blood flow.

Answer 23

B, C, D

Question 24

____________ refers to an ability to move about freely.

Answer 24

Mobility

Question 25

A person’s inability to move about freely is known as _______________.

Answer 25

Immobility

Question 26

A drop in blood pressure that occurs when the patient changes position from a horizontal to a vertical position is known as _________________.

Answer 26

Orthostatic Hypotension

Question 27

A drop in blood pressure that occurs when the patient changes position from a horizontal to a vertical position is known as _________________.

Answer 27

Orthostatic Hypotension

Question 28

The patient is performing ROM exercises independently. These are known as __________ exercises.

Answer 28

Acrtive ROM

Question 29

Static exercises that involve tightening or tensing of muscles without moving a body part are known as ______________.

Answer 29

Isometric Exercises

Question 30

_________________ increase muscle tension but do not change the length of muscle fibers

Answer 30

Isometric Contractions

Question 31

Virchow’s triad (hypercoagulability of blood, venous wall damage, and stasis of blood flow) has been found to contribute to ________________.

Answer 31

DVT

Question 32

The nurse is concerned that the patient may fall while he is ambulating. To help her maintain control while the patient walks, the nurse may apply a ______________ around the patient’s waist.

Answer 32

Gait Belt -Booorrriiinnnggggg

Question 33

The nurse is concerned that the patient may fall while he is ambulating. To help her maintain control while the patient walks, the nurse may apply a ______________ around the patient’s waist.

Answer 33

Gait Belt -Booorrriiinnnggggg

Question 34

According to the National Association of Orthopaedic Nurses (NAON), which of the following is possibly the most effective cleansing solution for pin-site care?

a. Normal saline
b. Hydrogen peroxide
c. Chlorhexidine
d. None of the above

Answer 34

C

Question 35

The patient has a broken leg and needs to have a cast applied. When plaster of Paris is compared and contrasted versus the newer synthetic casts, which of the following statements is true?

a. Plaster of Paris can tolerate earlier weight bearing than synthetic casts.
b. Plaster of Paris is more expensive than synthetic casts.
c. Synthetic casts can withstand contact with water better than plaster of Paris.
d. Synthetic casts are lighter but take longer to set than plaster of Paris.

Answer 35

C

Question 36

An expected outcome of cast application that the nurse evaluates is:

a. skin irritation at the cast edges.
b. decreased capillary refill and pallor.
c. tingling and numbness distal to the cast.
d. slight edema, soreness, and limited range of motion.

Answer 36

D

Question 37

The patient is admitted for a fractured tibia. The nurse is preparing for cast application and expects to administer a(n) _____ to the patient minutes before the procedure.

a. oral analgesic 10
b. intramuscular (IM) analgesic 10
c. intravenous (IV) analgesic 2 to 5
d. muscle relaxant 10

Answer 37

C

Question 38

An appropriate technique for the nurse to implement for the patient who is being casted is to:

a. apply ice to the top of the cast.
b. maintain the extremity below heart level.
c. handle the wet cast with the fingertips.
d. fold the stockinette or padding over the outer cast edges.

Answer 38

D

Question 39

When teaching cast care, the nurse instructs the patient to:

a. blow dry the wet cast on the “hot” setting.
b. report changes in sensation or mobility to the area.
c. use only soft objects to slide down the cast for scratching.
d. cut away the edges of the cast if the skin becomes irritated.

Answer 39

B

Question 40

For cast removal, which of the following instructions should the nurse provide to the patient?

a. Discomfort will be felt from the cast saw.
b. An enzyme wash may be applied to intact skin.
c. The skin will be scrubbed very well after the removal.
d. Aggressive range-of-motion exercises will be performed after removal.

Answer 40

B

Question 41

The patient is brought into the emergency department after falling on the ice in her driveway. She is suspected of having a fractured hip. After comparing different available types of traction, she anticipates that which of the following will be used?

a. Bryant’s traction
b. Dunlop’s traction
c. Buck’s extension
d. Gallows traction

Answer 41

B

Buck’s extension provides temporary immobilization of a hip fracture until open reduction and internal fixation (ORIF) can be performed. It also reduces muscle spasms, contractures, and dislocations and occasionally is used as an interim treatment for lumbosacral muscle spasms that cause low back pain. Bryant’s traction (called Gallows in England) is no longer used because of the risk for gravitational vascular draining of the extremities and the possible tourniquet effect of bandages, triggering vasospasms and avascular necrosis. Dunlop’s traction is a simultaneous horizontal form of Buck’s extension to the humerus with an accompanying vertical Buck’s extension to the forearm.

Question 42

Which type of traction does the nurse anticipate will be used for an adult patient with a fractured humerus?

a. Bryant’s traction
b. Dunlop’s traction
c. Gallows traction
d. Buck’s extension

Answer 42

B

Dunlop’s traction is a simultaneous horizontal form of Buck’s extension to the humerus with an accompanying vertical Buck’s extension to the forearm. Bryant’s traction (called Gallows in England) is no longer used because of the risk for gravitational vascular draining of the extremities and the possible tourniquet effect of bandages, triggering vasospasms and avascular necrosis. Buck’s extension provides temporary immobilization of a hip fracture until ORIF can be performed. It also reduces muscle spasms, contractures, and dislocations and occasionally is used as an interim treatment for lumbosacral muscle spasms that cause low back pain.

Question 43

For a patient who is to be placed in Russell’s traction, the nurse prepares the:

a. occipital area.
b. arm and forearm.
c. back and abdomen.
d. lower extremities.

Answer 43

D

Russell’s traction is a modification of Buck’s extension in which Newton’s third law of motion (for each force in one direction, there is an equal force in the opposite direction) is used to double the amount of pull through the arrangement of ropes, pulleys, and weights.

Question 44

The nurse places the patient in traction. Expected outcomes would include which of the following?

a. Alignment of fracture fragments with formation of callus within 24 hours
b. Verbalization of pain level as a “4” on a scale of 0 to 10
c.
d. Distal skin tissue becoming cooler, with capillary refill greater than 3 secondsVerbalization of immediate relief of symptoms

Answer 44

B

Question 45

While in Buck’s extension traction, the patient may be positioned on the back:

a. with the head of the bed elevated 45 degrees.
b. turning to the unaffected side for 10- to 15-minute periods.
c. with the buttocks slightly elevated off of the bed.
d. with the bed tilted toward the side that is opposite the traction.

Answer 45

B

Question 46

An appropriate technique for the nurse to implement for a patient who is being placed in traction is to:

a. apply a traction boot tightly.
b. drop the weights after the traction is attached.
c. assess neurovascular status every 1 to 2 hours for the first day.
d. shave the hair off the area where traction is to be placed.

Answer 46

C

Question 47

For a patient in traction who has skeletal pins, the nurse should:

a. use povidone-iodine to cleanse the pin site.
b. apply antiseptic ointment and cover with a split dressing.
c. use hydrogen peroxide as a rinse before a dressing is applied.
d. do both pin sites at the same time, with the same swab and solution.

Answer 47

B

Question 48

For a patient with a fractured femur, a nurse is alert to the possibility of a fat embolus. What should the nurse specifically watch for?

a. Bradypnea
b. Restlessness
c. Bradycardia
d. Calf pain

Answer 48

B

Question 49

In planning nursing care, the nurse knows that she will need to provide an abduction pillow for which patient?

a. A patient who will be immobilized for a long time
b. A patient who has undergone repair of a fractured right arm
c. A patient who is post hip replacement surgery
d. A patient who has a severely sprained ankle

Answer 49

C

Question 50

The nurse is caring for a patient who has had a new cast applied. The nurse is performing a neurovascular assessment so as to detect signs of possible compartment syndrome. Which of the following are signs of compartment syndrome? (Select all that apply.)

a. Inability to move body parts distal to the cast
b. Pain on passive motion of distal body parts
c. Hyperventilation
d. Tachycardia

Answer 50

ALL OF THE ABOVE

Question 51

The nurse is caring for a patient who has had a new cast applied. The nurse is performing a neurovascular assessment so as to detect signs of possible compartment syndrome. Which of the following are signs of compartment syndrome? (Select all that apply.)

a. Inability to move body parts distal to the cast
b. Pain on passive motion of distal body parts
c. Hyperventilation
d. Tachycardia

Answer 51

ALL OF THE ABOVE

Question 52

The patient is in traction and is at risk for fat embolism syndrome. Signs and symptoms of fat embolism include which of the following? (Select all that apply.)

a. Chest pain
b. Tachypnea
c. Tachycardia
d. Apprehension
e. Altered LOC

Answer 52

ALL OF THE ABOVE

Question 53

The patient has been in skeletal traction for external fixation of his femur for 2 days. Suddenly, he calls the nurse complaining of chest pain and shortness of breath. The nurse notes that the patient appears anxious, and that his pulse and respirations are elevated. She should do which of the following? (Select all that apply.)

a. Massage the lower extremity
b. Elevate the head of the bed
c. Administer oxygen
d. Notify the physician

Answer 53

B, C, D

Question 54

Skeletal traction is implemented primarily for: (Select all that apply.)

a. simple fracture.
b. multiple trauma.
c. fractured ankle.
d. acetabular fracture.
e. cervical fracture.

Answer 54

B, C, D, E

Question 55

__________________ involves monitoring for the five Ps (pain, pallor, pulselessness, paresthesia, and paralysis).

Answer 55

Neurovascular Assessment

Question 56

The patient has fallen and broken her leg. To keep the leg bones aligned and to reduce muscle spasms, the physician orders the patient to be placed in ____________.

Answer 56

Buck’s Traction

Question 57

A _______________ is an externally applied structure that holds musculoskeletal tissues in a specific position to permit healing of injuries or fractures or to align malpositioned tissues.

Answer 57

Cast

Question 58

After application of the cast, the nurse ensures that plaster crumbs are removed and rough edges are _________ to prevent skin breakdown.

Answer 58

petaled

Question 59

When applying a plaster of Paris cast, it is important to keep the cast exposed for at least _____________ minutes.

Answer 59

15 min

Question 60

After applying a cast, the nurse should be able to insert _______ fingers between the cast and the limb.

Answer 60

2

Question 61

_________________ may occur when pressure within a casted extremity increases.

Answer 61

Compartment Syndrom

Question 62

_____________________ applies a pull indirectly to the bone via straps attached to the skin around the structure.

Answer 62

Skin Traction

Question 63

____________________ consists of a metal frame that secures pins inserted through the bone above and below the fracture site. It stabilizes a fracture with hardware visible outside the body.

Answer 63

External Fixation

Question 64

An immobilization device used to immobilize and protect a body part is known as a ________.

Answer 64

Splint