mod 6 ch 38 activity and movement: assess and rec cues Flashcards
musculoskeletal assessment
unexpected findings
Johns Hopkins Fall Risk Assessment Tool
Score 6–13 (moderate risk)
13 and above (high risk)
Morse Fall Scale
Score 25–44 (moderate risk)
45 and above (high risk)
Hendrich II Fall Risk Model
Score 5 and above
best practice pearl
After any hip replacement surgery, patients should not flex hip past 90 degrees. This movement can cause the new hip to dislocate.
dyssomnia
difficulty sleeping, does not feel rested upon awakening
Which question would the nurse ask a patient to determine symptom-related issues with the musculoskeletal system?
“Have you noticed any differences in your gait?”
Asking about any difference in gait is a symptom-related question.
Which patient finding is expected in a musculoskeletal assessment?
Morse Fall Scale score of 20
A Morse Fall Scale score of 20 is within the normal and expected range of 0 to 24, indicating the patient is not a fall risk.
Which finding is unexpected when assessing effects of immobility?
Skin nonblanches
Skin nonblanching is unexpected because it indicates ischemia.
factors in recognizing cues activity and movement
relevant
- Relevant cues relate to important information about joint movements, gait, coordination, and other musculoskeletal and multisystem information that the nurse obtains from patient interviews, mobility assessments, patient observation and medical record cues, and signs and symptoms.
irrelevant
most important
immediate concern
musculoskeletal alterations with cues
Which cue is relevant to alterations in the musculoskeletal system?
Has a shoulder joint that is edematous
A shoulder joint that is edematous is relevant to the musculoskeletal system because it is a component of the system.
Match the musculoskeletal system alteration to its cause.
Porous, brittle bones
—Pathologic fracture
Deterioration of the muscle itself
—Muscle atrophy
Tissue that is usually easy to move tightens and pulls inward
—Contracture
Which patient would likely be prone to reduced bone density?
One who cannot perform weight-bearing exercises
—-The patient who cannot perform weight-bearing exercises is prone to reduced bone density by allowing calcium to leak out of the bones.
Which cues are relevant for weakness?
Flaccidity
—Flaccidity is a relevant cue for weakness.
Shuffling gait
—Shuffling gait is a relevant cue for weakness.
Feeble handgrip
—Feeble handgrip is a relevant cue for weakness.
cardio and nervous system cues
anorexia vs anorexia nervosa
Anorexia is not the same as anorexia nervosa. Anorexia is a physical disorder; anorexia nervosa is a mental health disorder.
Which patient is prone to paralysis?
A patient with prolonged brain ischemia
—Prolonged ischemia in the brain can lead to paralysis.
Which cues are relevant for activity intolerance?
Struggles to complete activities of daily living
—-Struggling to complete activities of daily living is a relevant cue for activity intolerance.
Exhibits dyspnea on exertion
—Dyspnea on exertion is a relevant cue for activity intolerance.
Has to sit down while doing the dishes
—Having to sit down while doing the dishes is a relevant cue for activity intolerance.
Which graphic record cue indicates the patient has anorexia?
Eats less than 50% of meals
—Anorexia is a lack of appetite; thus a graphic record indicating the patient eats less than 50% of meals is a cue for anorexia.
Which finding is a psychological consequence of bed rest and manifests in the patient becoming lonely or depressed?
Feelings of isolation
—Feelings of isolation are a consequence of bed rest and can manifest in the patient becoming lonely or depressed.
pressure ulcer scale
Stage 1: intact skin with reddened area
Stage 2: break in epidermis or dermis with blistering (blisters ruptured or nonruptured) of skin
Stage 3: break extends into subcutaneous tissue with possible tunneling
Stage 4: break exposes muscle, bone, tendons, cartilage
best pearl
Homans sign (when foot is dorsiflexed, pain occurs) is not a reliable assessment technique for DVT and is no longer performed by nurses.
Pneumonia, Atelectasis, and Urinary Tract Infection
Pneumonia and urinary tract infection (UTI) both involve dependent areas (lungs, kidneys, and bladder are dependent when supine rather than upright, as when standing or sitting) that become excellent environments for growth of microorganisms. Pneumonia and atelectasis are presented together because they are pulmonary complications of immobility, while UTI is a urinary complication.
Tissue ischemia related to immobility can directly lead to the development of which complication?
Pressure injuries
Tissue ischemia related to immobility can directly lead to the development of pressure injuries.
Which patient situation is a medical emergency?
Pulmonary embolus
A patient with a pulmonary embolus is having a medical emergency because the condition is life-threatening.
Which cues are relevant for a deep vein thrombosis (DVT)?
Redness
–Redness occurs with a DVT.
Edema
–Edema occurs with a DVT.
Cramping
–Cramping occurs with a DVT.
Which complication from immobility causes the alveoli to collapse?
Atelectasis
—Atelectasis causes the alveoli in the lungs to collapse.
In which areas would the patient experience pain if a urinary tract infection is present?
Back
—The patient may experience pain in the back because of the location of the kidneys.
Bladder
—The patient may experience pain in the bladder with a urinary tract infection.
Lower abdomen
—The patient may experience pain in the lower abdomen because of the location of the bladder.
Which response would the nurse make to an immobile patient who says, “I am just not hungry. I don’t understand it. I am always hungry”?
“You have been immobile for several days, which can decrease your metabolism and appetite.”
—-Decreased activity decreases the body’s basal metabolic rate and appetite.
Which fall risk score would the nurse anticipate in a patient who is weak?
Hendrich II Fall Risk Model score of 8
A patient with weakness is at risk for falls. A score of 8, which is in the 5 or above range, indicates the patient is at high risk for falls.
Patients on bed rest are likely at risk for which physiologic effects and conditions?
Increased venous return
—Patients on bed rest are at risk for increased venous return due to supine positioning.
Decreased lung expansion
—Patients on bed rest are at risk for decreased lung expansion due to pressure on the rib cage.
Atelectasis
—Patients on bed rest are at risk for atelectasis due to dependent positioning and limited lung expansion.
Pneumonia
—Patients on bed rest are at risk for pneumonia due to pooling of secretions in the lungs.
Which changes in vital signs are indicative of postural hypotension when a patient stands up?
Systolic blood pressure drops from 120 to 100 mm Hg
—A drop in systolic blood pressure of 20 mm Hg when a patient stands is classified as postural hypotension.
—Heart rate increases from 65 to 85 beats/min
An increase in heart rate of 20 beats/min when a patient stands is classified as postural hypotension.
—Diastolic blood pressure drops from 70 to 60 mm Hg
A drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as postural hypotension.
Which parameters would the nurse assess to determine if a urinary tract infection (UTI) has developed?
Chills
—Chills are a cue for a urinary tract infection.
Urinary frequency
—Assessment of urinary elimination would include the frequency of urination to determine a UTI.
Presence of dysuria
—Pain upon urination (dysuria) is a cue for a UTI.
Match the pressure injury stage to its cues.
Blistering of epidermis or dermis
Stage 2
Intact skin with reddened area
Stage 1
Exposure of muscle and bone
Stage 4
Subcutaneous injury with possible tunneling
Stage 3
Which action by the nurse initiates the physical assessment of a patient’s mobility?
Observing the patient
–Observing the patient initiates the physical assessment of the patient’s mobility; inspection is the first step in a physical assessment.
Which patient finding would alert the nurse to stop passive range-of-motion exercises?
Resistance to movement is felt.
Range-of-motion exercises are stopped when resistance to movement is experienced.
Which finding would be unexpected when the nurse is assessing for mobility issues?
Joint crepitus
Joint crepitus (air trapped under the skin that makes a crackling sound when palpated) is an unexpected finding.
Patient reports of shortness of breath and fatigue while performing activities of daily living are indicative of which alteration?
Activity intolerance
Patient reports of shortness of breath and fatigue while performing activities of daily living are cues for activity intolerance.
Which nutritional alteration is associated with immobility?
Decreased basal metabolic rate
Immobility is associated with a decreased metabolic rate due to a diminished activity level.
Which interpretation would the nurse make when observing a darkened or reddened area of skin in an immobile patient?
Tissue ischemia has occurred.
Skin that appears darkened or reddened is indicative of tissue ischemia.
A patient with redness, warmth, and swelling in the right lower leg is at risk for which complication?
Pulmonary embolism
Redness, warmth, and swelling in an extremity is indicative of a deep vein thrombosis, which places the patient at risk for developing a pulmonary embolism.
Which graphic record cue is associated with constipation?
Infrequent stools
Infrequent stools is a graphic record cue for constipation.
Which musculoskeletal alterations does immobility predispose a patient to developing?
Weakness
—Immobility predisposes a patient to weakness due to inactivity.
Decreased muscle tone
–Immobility predisposes a patient to decreased muscle tone due to inactivity.
Decreased muscle mass
—Immobility predisposes a patient to decreased muscle mass due to inactivity.
Reduced bone density
Immobility predisposes a patient to reduced bone density due to lack of weight-bearing on bones.
Which cues would likely occur with atelectasis?
Cyanosis
—Cyanosis occurs with atelectasis.
Dyspnea
—Dyspnea occurs with atelectasis.
Diminished breath sounds noted in nurse’s notes
—Diminished breath sounds occur with atelectasis.
Match the alteration to its patient cues.
—Unable to move joints because of foot drop
Contracture
—Decreased muscle size with weak handgrip
Muscle atrophy
—Inability to move, with a loss of sensation
Paralysis
—Irregular patterns of behavior from inadequate coping
Altered self-concept
- A nurse is instructing a patient who has decreased leg strength on the left side on how to use a cane. Which actions indicate proper cane use by the patient? (Select all that apply.)
- The patient keeps two points of support on the floor at all times.
- The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step.
- A patient is experiencing some problems with joint stability in the right leg. The doctor has prescribed crutches for the patient to use while being allowed to bear weight only on the left leg. Which of the following gaits should the patient be taught to use?
- Three-point
- Which of the following motivates a patient to participate in an exercise program? (Select all that apply.)
- Providing information to the patient when he or she is ready to change behavior
- Having a structured daily plan that incorporates physical activity
- Having support from significant other to engage in exercise
- Which of the following is the proper sequence for a four-point crutch gait?
a, has darkened footprint every other box and darkened cane print every other box
- The nurse is caring for an older adult in a long-term care setting. The nurse reviews the medical record to find that the patient has progressive loss of total bone mass. The patient’s history and tendency to take smaller steps with feet kept closer together will most likely result in which of the following?
- Increase the patient’s risk for falls and injuries
- Place in the correct order the steps needed (below) to transfer a patient with sufficient lower body strength to a chair.
- Apply gait/transfer belt.
- Help patient apply stable, nonskid shoes/socks.
- Spread your feet apart. Flex hips and knees, aligning knees with patient’s knees.
- Grasp transfer belt along patient’s sides.
- On count of three, instruct patient to stand while straightening hips and legs and keeping knees slightly flexed.
- Maintain patient’s balance as you pivot foot farthest from chair and then help patient ease into chair.
- Assist patient to assume proper alignment in sitting position.
- Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.)
- Patient’s weight
- Patient’s activity tolerance
- Patient’s level of mobility
- Which of the following indicates that additional assistance is needed to transfer a patient from the bed to the stretcher? (Select all that apply.)
- The patient is returning to unit from recovery room after a procedure requiring conscious sedation.
- The patient received analgesia for pain 30 minutes ago.
- A 51-year-old adult comes to a medical clinic for an annual physical exam. The patient is found to be slightly overweight and reports being inactive, walking only 2 to 3 times a week with his wife after work. He has good muscle strength and coordination of lower extremities. Which of the following recommendations from the Physical Activity Guidelines for Americans should the nurse suggest? Choose all that apply
- Move more and sit less throughout the day.
- Perform muscle-strengthening activities using light weights on 2 or more days a week.
- Walk at a vigorous pace with wife at least 150 minutes over five days a week.
- Family members have asked for a meeting with the nursing staff of an assisted-living residential center to discuss the feasibility of their mother using a walker. The family is worried that her health is declining; they wonder whether she can use the walker safely. Which of the following instructions should the nurse give the family after assessing that it is safe for the woman to use a walker? (Select all that apply.)
- A walker is useful for patients who have impaired balance.
- Walkers should not be used on stairs.
- If the patient has difficulty advancing the walker, a walker with wheels is an option.
