mod 6 activity and movement ch 38

Question 1

The principles of safe patient transfer and handling include:

Answer 1

• -Training nursing staff about mechanical lift equipment and use
• -Maximizing patient assistance in movement
• -Teaching patients with some mobility to shift their position every 15 minutes while awake
• -Leaving top side rails up to allow patients to self-position
• -Using leverage, rolling, turning, or pivoting rather than lifting
• -Reducing friction between the patient and the transfer surface
• -Following proper body mechanics

Question 2

body mechanics

Answer 2

• bend at the knees
• shift weight- close to body
• keep truck erect
• avoid twisting
• engage core

Question 3

fall precautions

Answer 3

background

- fall risk assessment must be done on all admissions and daily for acute care

Question 4

fall cont generalized precautions

Answer 4

• -Always return the bed to its lowest position.
• –Keep the call light within reach of the patient.
• -Remind the patient how to use the call light.
• -Immediately answer the call light if it is sounded.
• -Keep the wheels of any wheeled device (e.g., bed, wheelchair) in the locked position.
• -Leave lights on or off at night, depending on the patient’s cognitive status and personal preference.
• -Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient’s reach.
• -Frequently orient and reorient the patient.
• -If the patient is ambulatory, require the use of nonskid footwear.
• -Clear potential obstructions from the walking areas.
• -Ensure that the patient’s clothing fits properly; improper fit can cause tripping.

Question 5

positioning

Answer 5

important musculoskeletal and nervous systems intervention for patients. Proper positioning maintains body and joint alignment, promotes blood flow, maintains skin integrity, and ensures comfort
- keep legs uncrossed - stop pooling and occlusion blood

Question 6

side lying position

Answer 6

Pillow Placement:

Between the legs and arms and behind back

Benefit:

Reduces pressure on bony prominences of the elbows and knees
Prevents movement of the femur when rolling a patient after hip surgery
Prevents the patient from moving onto back
Modification:

Sim’s: semi-prone position on left side with right knee pulled slighter higher than in side-lying

Question 7

supine

Answer 7

Pillow Placement:

Under the calves and heels

Benefit:

Reduces heel pressure; should not obstruct circulation in the calves

Modification:

Dorsal recumbent: lying supine with knees bent

Question 8

fowler’s

Answer 8

Pillow Placement:

Under the knees

Benefit:

Reduces pressure; should not hinder circulation

Modification:

Semi-Fowler’s: semi-sitting with head of bed slightly lower than in Fowler’s
High-Fowler’s: sitting at a 90-degree angle; similar to Fowler’s but with head of bed elevated higher

Question 9

transfer aids

Answer 9

• -transfer boards - hard plastic to slide pt
• friction-reducing sheets
• trapeze bars - if upper extremity strength
• mechanical lifts

Question 10

ambulation and aids

Answer 10

-transfer/gait belts- The nurse stands on the weakest side of the patient and holds the belt at the small of the patient’s back.
If patient has osteoporosis, the nurse does not use a gait belt. Pressure from the belt may cause vertebral compression fractures.

-canes- The correct height of the cane is even with the hip joint, and the correct arm placement is comfortably bent at 30 degrees.

-crutches- Underarm crutches are commonly used for short-term use; forearm (Lofstrand) crutches tend to be used for long-term impairments. Two-point walking gait moves one crutch forward simultaneously with opposite leg.
Three-point walking gait places both crutches forward, bringing legs to the center.
Four-point walking gait moves one crutch forward, followed by opposite leg, and then repeats with the opposite crutch and then the leg.

-walkers - height pt’s waist

Question 11

classification of exercise

Answer 11

Muscle status

• isotonic- contraction for joint movement
• isometric- contraction w no joint movement

energy status

• aerobic- o2
• anaerobic- no o2

Question 12

ROM

Answer 12

active- done by pt

passive- done w ass. from someone else

Question 13

Which action would the nurse take for a newly admitted patient who is unsteady when transferring from the wheelchair to the bed?

Answer 13

Initiate a fall prevention plan for the patient.

An unsteady gait places the patient at risk for falling, and the nurse would initiate fall prevention measures to ensure the patient’s safety.

Question 14

Which action would the nurse take first when assisting a patient who has been in bed for several days after surgery to transfer from the bed to the chair?

Answer 14

Allow the patient to dangle.

The first action the nurse would take to assist the patient to transfer is to allow the patient to dangle.

Question 15

Match each type of exercise to its example.

Answer 15

Ambulating
--Isotonic
Kegel exercises
--Isometric
Heavy weight-lifting
--Anaerobic
Repeated stair-climbing
--Aerobic

Question 16

Which interventions would the nurse implement for a patient with lower extremity Paralysis?

Answer 16

Turn every 2 hours.

The patient with lower extremity Paralysis is turned every 2 hours to prevent skin breakdown.

Arrange for a special bed.

Patients with Paralysis need a special bed to prevent pressure injuries and to make turning easier.

Perform range-of-motion (ROM) exercises at least two times per day.

ROM exercises are needed to maintain joint and muscle movements.

Question 17

Which evaluative cue alerts the nurse that a patient with Activity Intolerance is improving?

Answer 17

Has a pulse oximetry reading of 94% when standing to brush teeth

A pulse oximetry reading above 90% when brushing teeth indicates the patient with Activity Intolerance is improving because the patient is performing activities of daily living without adverse effects.

Question 18

respiratory interventions

Answer 18

coughing- 2 deep breaths and hold 3-5 secs, when release, try cough 2-3 times during

deep breathing- slow and deep, 305 secs, exhale using pursed lips, 3-5 times in row, 10x every hr

incentive spirometer- slowly inhale and hold 3-5 secs, take mouthpiece out and exhale, 5-12 times every 1-2 hrs as prescribed, cough 2 times at end procedure

Question 19

cardio system interventions

Answer 19

SCDs, antiembolism stockings (TED hose)

Question 20

GI interventions

Answer 20

anorexia- monitor serum albumin levels

constipation- encourage fiber, mobility

Question 21

best practice pearl

fluids

Answer 21

Urinary system, by preventing urine stasis, urinary tract infections, and stone formation
Vascular system, by keeping blood from thickening, which helps prevents stasis and DVT formation
Pulmonary system, by keeping lung secretions thin, which prevents pooling of secretions, leading to pneumonia

Question 22

skin protectors

Answer 22

heel and elbow protectors and pressure-relief ankle-foot orthotic (PRAFO) boots

Question 23

skin interventions

Answer 23

prevent breakdown or promote healing if breakdown already in progress

• Conduct regular and frequent patient repositioning and turning (at least every 2 hours)
• Use special mattresses as needed
• Regularly assess for pressure injury development using a skin assessment tool (Braden Scale)
• Maintain clean, dry, and nonwrinkled bed linens
• Ensure adequate nutrition
• Use devices and protective supplies properly to protect and heal compromised skin

Question 24

psychosocial interventions

Answer 24

focus preventing social isolation

Question 25

Which instruction would the nurse share with the patient about coughing techniques?

Answer 25

Take two deep breaths in and out to start.

Taking two deep breaths in and out is part of the instructions for teaching coughing techniques.

Question 26

Which action would the nurse take when caring for a patient with sequential compression devices (SCDs)?

Answer 26

Monitor the patient’s toes for impaired circulation.

Because SCDs can impair circulation if too tight, it is important for the nurse to check the patient’s circulation to the toes.

Question 27

Which action would the nurse take to improve an immobile patient’s nutritional intake?

Answer 27

Allow the patient to make food choices.

Allowing the patient to make food choices will enable the patient to select foods that are likely to be consumed, improving nutritional intake.

Question 28

Which evaluative findings will alert the nurse an immobile patient with a left hip stage 1 pressure injury is declining?

Answer 28

Has a Braden Scale score that indicates a high risk for skin breakdown

This indicates the patient is declining because the score indicates a high risk for skin breakdown.

Develops a Stage 1 pressure injury on the buttocks

This indicates the patient is declining because another pressure injury has developed.

Develops a Stage 2 pressure injury on the left hip

This indicates the patient is declining because the pressure injury is worsening (from Stage 1 to Stage 2).

Question 29

Which action would the nurse take for an immobile patient who needs help maintaining a normal sleep-wake cycle?

Answer 29

Open the window blinds during the day.

Opening the window blinds during the day can assist the patient with maintaining a normal sleep-wake cycle.

Question 30

Which exercise benefit would the nurse likely emphasize to a patient who has limited mobility to help facilitate normal movement?

Answer 30

promotes muscle strength

Question 31

Which interventions would the nurse select for a patient who is on bed rest?

Answer 31

Have the patient shift weight every 15 minutes while awake.
—Teaching patients with some mobility to shift their position every 15 minutes while awake is recommended.

Reduce hallway light at night.
—The hallway light should be reduced at night for patients on bed rest to assist with restful sleep and maintain a normal sleep-wake cycle.

Apply a pressure-relief ankle-foot orthotic (PRAFO) boot.
—A PRAFO boot keeps heels protected by relieving pressure off heels.

Question 32

Which instructions about respiratory and range-of-motion measures would the nurse share with a patient who has limited mobility?

Answer 32

Use the incentive spirometer 5 to 12 times every 1 to 2 hours.
—The incentive spirometer is used 5 to 12 times every 1 to 2 hours to promote deep breathing and expansion of the lungs.

Deep breathe 10 times every hour.
—Deep breathing is performed 10 times every hour to prevent pneumonia and atelectasis.
Correct

Cough two to three times every 2 hours.
—Coughing is performed two to three times every 2 hours to promote pulmonary health.

Move each joint three to five times during range-of-motion exercises.
—Each joint is moved three to five times during range-of-motion exercises to prevent complications from being stationary for a long period of time.

Question 33

Which actions by the nurse caring for patients with mobility problems would require correction by the charge nurse?

Answer 33

Places a gait belt on a patient with osteoporosis to assist with ambulation
—-action would cause the charge nurse to correct the nurse. The nurse does not use a gait belt on a patient with osteoporosis because it can cause vertebral compression fractures.

Allows the patient’s elbows to be bent at a 45-degree angle when using a cane
—-This action would cause the charge nurse to correct the nurse. The angle is 30 degrees, not 45 degrees.

Tells the patient with a four-point crutch gait to move one crutch forward simultaneously with the opposite leg
—A four-point walking gait moves one crutch forward, followed by opposite leg, and then repeats with the opposite crutch and leg. The two-point walking gait moves one crutch forward simultaneously with the opposite leg.

Question 34

Which actions would the nurse take if the patient falls while ambulating in the hall?

Answer 34

Call for help.
—The nurse calls for help so he or she can stay with the patient.

Assess the patient’s physical and neurologic status.
—The nurse assesses the patient’s physical and neurologic state to determine the extent of injuries.

Notify charge nurse and primary health care provider.
—The charge nurse and primary health care provider are notified to determine the next course of action.

Complete occurrence report.
—Anytime an unusual event happens, an occurrence report is completed.

Question 35

To which other member of a multidisciplinary team would the nurse delegate the task of moving an immobile patient to maintain skin integrity?

Answer 35

Unlicensed assistive personnel
Unlicensed assistive personnel provide hands-on care for patients as directed by the nurse. Nurses delegate turning to unlicensed assistive personnel.

Question 36

In which area would the nurse place a pillow for a patient in the supine position?

Answer 36

Under the calves
When a patient is in the supine position a pillow is placed under the calves to alleviate pressure off the heels, preventing pressure injuries.

Question 37

Which device would be most appropriate for a patient who has had surgery on a fractured femur and needs help repositioning in bed?

Answer 37

Trapeze bar
A trapeze bar would allow the patient to assist with repositioning, as the patient can grasp the bar to pull his or her own weight when repositioning.

Question 38

Which ambulation aid would the nurse suggest for a patient who has a history of falls, is displaying generalized weakness, and requires some assistance with ambulation?

Answer 38

Walker

A walker would provide the patient with support to prevent falls and provides a wide base of support.

Question 39

In which position would the nurse place the patient to perform coughing and deep breathing?

Answer 39

Fowler’s
The patient must be upright (Fowler’s position) to perform coughing and deep breathing to allow full expansion of the lungs.

Question 40

Which action would the nurse take when using a mechanical lift for a patient who is experiencing limited mobility?

Answer 40

Obtains two unlicensed assistive personnel to help
The total personnel are three: the nurse and two other personnel (in this case, two unlicensed assistive personnel). To use a mechanical lift, two personnel are needed but three are better.

Question 41

Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills?

Answer 41

Notify the health care provider that the patient may have pneumonia.

The nurse would notify the health care provider that the patient may have pneumonia as a consequence of prolonged immobility, decreased lung expansion, and pooling of secretions in the lungs.

Question 42

Which action would the nurse take for a patient on bed rest who is concerned about developing constipation?

Answer 42

Increase the patient’s dietary fiber and fluid intake.

The patient’s dietary fiber and fluid intake would be increased to prevent constipation in the immobile patient.

Question 43

Which safety measures would the nurse implement for a patient who is a fall risk?

Answer 43

Use a low bed.
–The nurse would use a low bed to decrease the distance if a patient falls.

Frequently orient the patient.
—The nurse would frequently orient the patient who is at risk for falls to promote safety by familiarizing the patient to the environment, date, and time.

Place floor mats beside the bed.
—The nurse would place floor mats beside the bed to cushion a possible fall.

Question 44

Which evaluative cues indicate the patient with a Risk for Deep Vein Thrombosis is deteriorating?

Answer 44

Experiences a pulmonary embolus
—A pulmonary embolus indicates the patient is declining/deteriorating because the clot developed, broke free, and traveled to the lung.

Has dusky toes
—Dusky toes indicate the patient is deteriorating/declining because this cue indicates circulation is impaired.

Has coagulation laboratory results that indicate the patient is clotting too fast
—A patient who is clotting too fast is deteriorating/declining because the patient with Risk for Deep Vein Thrombosis should have laboratory results that indicate the patient takes longer to clot.

Question 45

Which cues alert the nurse that the patient with Paralysis is declining?

Answer 45

Develops disuse osteoporosis
—Disuse osteoporosis indicates the patient is declining from loss of bone.

Does not participate in physical therapy
—Not participating in physical therapy indicates the patient is declining and withdrawing from measures that would increase independence and functioning to the best of the patient’s abilities.

Question 46

Which cues prompt the nurse to determine the patient with impaired mobility who needs a one-person assist is improving?

Answer 46

Needs no assistance to transfer
—Needing no assistance indicates the patient improved. The patient went from one-person assist to no-person assist.

Ambulates unassisted down the corridor and back
—Ambulating without assistance indicates the patient is improving because he or she used to need a one-person assist.

Ambulates with no slips on the floor
—Ambulating with no slips on the floor indicates the patient is improving. The patient did not need a one-person assist and did not slip.

Question 47

When providing care to patients, which safety and body mechanic aspects would the nurse consider to prevent injury to him- or herself and the patient?

Answer 47

Leave top side rails up.
—Leaving the top side rails up allows patients to self-position and is a safety action the nurse would implement.

Bend at the knees.
—Bending at the knees maintains the center of gravity and lets leg muscles do the lifting; it is a body mechanics action the nurse would implement.

Carry weight close to the body.
—Carrying weight close to the body places the weight in the same plane as the lifter and near the center of gravity for balance; it is a body mechanics action the nurse would implement.

Use mechanical lift equipment.
—Using mechanical lifts is a safe action to implement when moving patients.

Question 48

The nurse would inform unlicensed assistive personnel to turn the patient how often (in hours) to maintain skin integrity? Record your answer as a whole number. __ hour(s)

Answer 48

2 hrs

Question 49

Place the steps in the order the nurse would follow to teach a patient how to use a cane.

Answer 49

1. Place cane on the patient’s stronger side.
2. Move the cane.
3. Move the weaker leg.
4. Move the stronger leg.

The cane is placed on patient’s stronger side; the patient moves the cane first, then the weaker leg, followed by the stronger leg.

Question 50

Which actions would the nurse take for a patient who is immobile?

Answer 50

Suggest drinking at least 2000 mL during a 24-hour period.
—The nurse would encourage the patient to drink at least 2000 mL in a 24-hour period.

Encourage passive range-of-motion exercises.
—Range-of-motion exercises must be done to prevent complications from being stationary for a long period of time.

Place high-top tennis shoes on feet.
—High-top tennis shoes can be used to prevent foot drop.

Question 51

1. A patient has been on bed rest for over 5 days. Which of these findings during the nurse’s assessment may indicate a complication of immobility?

Answer 51

1. Decreased peristalsis

Question 52

2. An older-adult patient has been bedridden for 2 weeks. Which of these complaints by the patient indicates to the nurse that he or she is developing a complication of immobility?

Answer 52

4. Left ankle joint stiffness

Question 53

3. A patient is receiving 40 mg of enoxaparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for what signs of bleeding? (Select all that apply.)

Answer 53

1. Bruising
2. Bleeding gums
3. Coffee ground–like vomitus

Question 54

4. Place the following steps in the correct order for positioning a patient in the 30-degree lateral side-lying position.

Answer 54

3. Lower head of bed flat if patient can tolerate it.
4. Lower side rail and position patient on side of bed opposite the direction toward which patient is to be turned.
5. Raise side rail and go to opposite side of bed.
6. Lower side rail and flex patient’s knee that will not be next to mattress. Keep foot on mattress and place one hand on patient’s upper bent leg near hip and other hand on shoulder.
7. Roll patient onto side toward you.
8. Place hands under patient’s dependent shoulder and bring shoulder blade forward.
9. Place hands under patient’s dependent hip and bring hip slightly forward so that angle from hip to mattress is approximately 30 degrees.

Question 55

5. The effects of immobility on the cardiac system include which of the following? (Select all that apply.)

Answer 55

1. Thrombus formation
2. Increased cardiac workload
3. Orthostatic hypotension

Question 56

6. A 46-year-old patient is admitted to the emergency department following an automobile accident. The patient has a pelvic fracture and is ordered on bed rest and placed in an immobilization device to limit further injury until the fracture can safely be repaired. Which measures would be appropriate for this patient to prevent complications of bed rest? (Select all that apply.)

Answer 56

2. Have patient perform incentive spirometry.
3. Support patient in active assistive ROM exercises of upper extremities.
4. Apply sequential compression devices to legs.

Question 57

7. A patient has an order for application of compression stockings. Place the following steps for application of the stockings in the correct order:

Answer 57

2. Use tape measure to measure patient’s leg for proper stocking size.
3. Turn elastic stocking inside out, keeping hand inside holding heel. Take other hand and pull stocking inside out until reaching the heel.
4. Place patient’s toes into foot of stocking up to the heel; keep smooth.
5. Slide remaining portion of stocking over patient’s foot, covering toes. Be sure foot fits into toe and heel of stocking.
6. Slide stocking up over patient’s calf until sock is completely extended.

Question 58

8. An older-adult patient is admitted following a hip fracture and surgical repair. Before ambulating the patient postoperatively on the evening of surgery, which of the following would be most important to assess? (Select all that apply.)

Answer 58

3. Preadmission activity tolerance

4. Baseline heart rate

Question 59

9. A nurse is helping a patient perform active assisted range of motion in the right elbow. Which statement describes the correct technique?

Answer 59

1. Support elbow by holding distal part of extremity.

Question 60

10. A middle-aged adult patient has limited mobility following a total knee arthroplasty. During assessment, the nurse notes that the patient is having difficulty breathing while lying supine. Which assessment data support a pulmonary issue related to immobility? (Select all that apply.)

Answer 60

1. Oxygen saturation of 89%
2. Diminished breath sounds bilateral bases on auscultation
3. Respiratory rate of 26