Week 4 Flashcards
The nurse recognizes that which organization requires that employers comply with ergonomic recommendations?
The Joint Commission (TJC)
National Institute for Occupational Safety and Health (NIOSH)
National League for Nursing (NLN)
American Nurses Association (ANA)
National institute for occupational safety and health.
A nurse is caring for a client who has had a stroke. The nurse knows that the client could develop contractures. Inactivity of which of the following systems could cause contractures?
musculoskeletal system
peripheral nervous system
endocrine system
central nervous system
Musculoskeletal
A male client is being treated on a neurological unit for the effects of a recent stroke. The client’s family members are participating actively in his care and frequently position him in a supine position. The nurse should teach the family members about the benefits of alternative positions in order to reduce the client’s risk of:
skin breakdown.
dyspnea.
contractures.
peripheral edema.
Skin breakdown
A nurse is assessing a client after knee surgery in a health care facility. Which intervention should the nurse follow to avoid complications associated with disuse syndrome?
follow a rigid daily routine for the client
encourage active exercise with a bed trapeze
reposition the client every 4 hours
use a gel mattress on the bed
Encourage active exercise with a a bed trapeze
A 59-year old female client reports to the nurse that she recently began taking alendronate and has been having stomach cramping, nausea, and diarrhea. How will the nurse educate the client?
“Take this medication monthly instead of weekly.”
“These side effects are normal, so do not worry about them.”
“Be sure to drink 8 ounces of water when you take alendronate, and take it on an empty stomach.”
“Discontinue taking the medication immediately.”
“Be sure to drink 8 ounces of water when you take alendronate, and take it on an empty stomach.”
A nurse is caring for a client with a leg fracture. The client is placed on an adjustable bed in the Trendelenburg position. How will this position help the client?
It helps the client look around without twisting and bending.
It promotes the drainage of the upper lobes of the lungs.
It prevents the client from sliding down toward the foot of the bed.
It prepares the client for the ability to eventually stand and walk.
It prevents the client from sliding down toward the foot of the bed.
A nurse is caring for a client with demobilized respiratory secretions. Which device will best mobilize respiratory secretions?
static air mattress
air-fluidized bed
circular bed
oscillating support bed
Oscillating support bed
The nurse is helping the unlicensed assistive personnel (UAP) to complete several tasks. What action(s) by the UAP requires the nurse to intervene? Select all that apply.
The UAP turns the client as a complete unit.
The UAP has the bed at knee-level when making an occupied bed.
The UAP twists to reach behind oneself for a washcloth.
The UAP asks for assistance when transferring a client from the bed to the chair.
The UAP carries the load of linens in a trash bag close to the body.
The UAP has the bed at knee-level when making an occupied bed.,
The UAP twists to reach behind oneself for a washcloth.
The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?
Sims’
lateral
prone
supine
Supine
A nurse is caring for a client with dyspnea in a health care facility. What intervention should the nurse follow to control the speed when repositioning the client?
lowering the side rail and moving the client to one side of the bed
placing one hand on the client’s shoulder and the other on the hip on the far side
replacing pillows behind the back and between the legs and under the upper arm
shifting hands from the posterior of the shoulder and hip to the anterior as the client rolls toward the client’s abdomen
shifting hands from the posterior of the shoulder and hip to the anterior as the client rolls toward the client’s abdomen
A nurse at an extended care facility is caring for a female resident whose spinal curvature is exaggerated by kyphotic changes. How can the nurse best position this resident to reduce pressure on her vertebrae?
in a slight Trendelenburg position
in a prone position
with a small roll or pillow under her neck
with her knees slightly elevated
With a small roll or pillow under her neck.
The occupational nurse is teaching an administrative assistant about proper posture when sitting. Which teaching will the nurse include?
“Cross your legs alternately throughout the day.”
“Keep your knees bent, with the backs of the knees against your chair.”
“The upper and lower thighs are your base of support.”
“Both of your feet should rest on the floor.”
Both of your feet should rest on the floor
The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?
Fowler’s
prone
supine
Sims’
Sims
A nurse in a health care facility is teaching a client to maintain correct standing posture. Which instruction should the nurse give the client to help avoid strain on the joints?
Hold the abdomen up and in.
Bend the head back slightly.
Extend or stretch the waist.
Bend the knees slightly.
Bend the knees slightly
A nurse is preparing an older adult client for a rectal examination. The nurse uses trochanter rolls to prevent the legs from turning outward. Which intervention would allow the nurse to anchor the body in the correct position?
rolling the sheet around the blanket
placing a roll between the client’s ankles
folding the sheet lengthwise in half and placing it under the hips
permitting the legs to rest against the trochanter rolls
Folding the sheet lengthwise in half and placing it under the hips
A nurse is performing a general physical assessment for a client. What is the most important thing the client can do to promote work endurance?
twist and stretch muscles during work
hold objects closer to the body
keep the feet apart when holding objects
rest between periods of exertion
Rest between periods of exertion
A client is postoperative day 2 following hip replacement surgery, and the nurse is helping the physical therapist ambulate the client for the first time since surgery. How can the nurse and therapist best assist the client from a seated position at the edge of the bed to a standing position?
have the therapist pull the client into a standing position while the nurse gently pushes from behind
apply a transfer belt around the client’s waist
utilize a mechanical ceiling lift
have the nurse and the therapist each grasp one of the client’s arms
Apply a transfer belt around the clients waist
The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?
thrombus formation
skeletal contractures
oliguria
pooling of secretions
Thrombus formation
A nurse is caring for an 85-year-old client in an extended-care facility. What position will the nurse recommend to help prevent skin breakdown?
Fowler position
Sims position
prone position
lateral position
Prone position
A client with a diagnosis of chronic obstructive pulmonary disease has been experiencing debilitating periods of dyspnea since being admitted to the health care facility. What position is most likely to alleviate this client’s shortness of breath?
Prone position
Lateral oblique position
High Fowler position
Sims position
High Fowler position
The nurse is performing discharge teaching with the family of a male client who has limited mobility and a significant cognitive deficit. The nurse has described the phenomenon of foot drop to the client’s family and should describe what intervention to prevent its development?
applying a foot splint correctly to maintain neutral foot positioning
flexing the client’s feet at the ankles three to four times daily
providing vigilant skin care to the client’s feet and keeping his toenails trimmed
using a transfer belt correctly when repositioning the client
applying a foot splint correctly to maintain neutral foot positioning
The nurse is caring for an 84-year-old client. While assessing the client, the nurse notes that the client has an unsteady gait and weak muscle strength and tires easily with physical exertion. How will the nurse document this finding?
poor alignment
disuse syndrome
functional position
low energy
Disuse syndrome
The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client?
Sims’
prone
supine
slight Trendelenburg
Slight trendelenburg
Which definition best describes functional ability?
A- the physical, psychological, cognitive, and social ability to carry on the normal activities of life
B- the ability to effectively adapt physically, psychologically, cognitively, and socially to an illness state
C- the ability to function as a contributing member of society
D- the ability of the human body to carry out necessary functions to live.
A- the physical, psychological, cognitive, and social ability to carry on the normal activities of life
_________ refers to the amount of assistance needed to meet life activities
Dependency
Which concepts represent major determinants of functional ability? (Select all that apply) A- family dynamics and coping B- mobility and gas exchange C- elimination and sexually D- cognition and culture
All of the above
Which of the following would be included in a functional assessment screening? A- martial status B- financial stability C- gender D- social participation
D- social participation
Which of the following are considered instrumental activities of daily living? Select all that apply A-bathing B- cleaning house C- grocery shopping D- managing money E- eating
B- cleaning house
C- grocery shopping
D- managing money
Functional ability is a crucial consideration in virtually all areas of health care. In the rehabilitation setting, what is the primary focus of functional ability?
A- determining the cost of assisting the patient with basic activities of daily living and IADLd
B- determining how the rehabilitation team will assist the patient with achieving total independence with BADLs or ADLs
C- restoring the patients functional ability and evaluating the functional outcomes of treatment by means of a functional assessment
D- getting the patient ready for discharge to a long term facility
C- restoring the patients functional ability and evaluating the functional outcomes of treatment by means of a functional assessment
The nurse explains to the client that an advantage to a performance based functional assessment tool is:
A- it can be performed quickly
B- that objective information provides a more accurate measurement of status
C- it involves answering a series of questions and can easily be performed in the office
D- the nurse must observe the patient performing various tasks of daily living
B- that objective information provides a more accurate measurement of status
Which patient would least likely be at risk for impaired functional ability?
A- a 71 year old patient with a 10 year history of rheumatoid arthritis
B- a 25 year old patient recently diagnosed with postpartum depression
C- a 21 year old patient admitted to the hospital with acute gastroenteritis
D- a 12 year old patient with Down syndrome
C- a 21 year old patient admitted to the hospital with acute gastroenteritis
Which functional assessment tool would be beneficial for the nurse to use when assessing a patient who has recently been treated for breast cancer with chemotherapy and radiation therapy?
A- functional activities questionnaire
B- folstein mini mental status examination
C-functional status scale
D- the Edmonton functional assessment tool
D- the Edmonton functional assessment tool
Which of the following diseases/disorders is most closely associated with a primary functional problem? A- multiple sclerosis B- cerebral palsy C- osteoarthritis D- Parkinson’s disease
B- cerebral palsy
The nurse is caring for a client with an above-the-knee amputation who has just received a new prosthesis. Which crutch-walking gait will the nurse teach?
four-point
swing-through
two-point
three-point partial weight-bearing
Three point partial weight bearing
The nurse is caring for a client with postural hypotension. Which nursing intervention is appropriate?
applying antiembolism stockings before rising
using a gait belt to quickly get the client out of bed
using a tilt table to move from supine to standing
asking the client to dangle before moving from a reclining position
Asking the client to dangle before moving from a reclining position.
Later today, a client will mobilize for the first time since surgery. The client has a history of orthostatic hypotension and experienced a fall prior to admission. How can the nurse best normalize the client’s blood pressure to ensure safety during mobilization?
Withhold beta-blockers, diuretics or ACE inhibitors until the client has successfully mobilized.
Obtain a walker for the client to use when mobilizing for the first time.
Encourage the client’s fluid intake throughout the morning.
Have the client dangle at the edge of the bed for several minutes prior to standing.
Have the client dangle at the edge of the bed for several minute prior to standing
The nurse is evaluating a client’s use of a leg prosthetic. Which client behavior indicates that further nursing teaching is necessary?
cleanses the stump each morning
cleans the valve on the prosthesis with a small brush
uses clean wool stump socks daily
lies supine periodically throughout the day
Cleanses the stump each morning
Which client would benefit the most from the use of a walker to assist in ambulation?
client who needs brief, temporary assistance ambulating
client who requires considerable assistance with balance
client who needs permanent assistance when walking
client who has weakness on one side of the body
Client who requires considerable assistance with balance
A male client with a history of type 1 diabetes has had a below-the-knee (BK) amputation. The client states that he is eager to be fitted for his prosthesis and to resume activities of daily living. When assisting the client with his adjustment to using his prosthesis, the nurse should prioritize what nursing diagnosis?
Risk for Sedentary Lifestyle
Risk for Impaired Skin Integrity
Risk for Impaired Bed Mobility
Risk for Disuse Syndrome
Risk for impaired skin integrity
The nurse is educating a client who will be using crutches for approximately 6 weeks. Which exercise would be beneficial to help with crutch use?
flexion and extension of the arms and the wrists
quadriceps setting exercises
gluteal setting exercises
sit-ups
Flexion and extension of the arms and wrists
The nurse is caring for an older adult client who is recovering from hip surgery. Which assistive device will the nurse use to facilitate client ambulation?
crutches
walker
gait belt
cane
Walker
Which client would benefit the most from the use of a forearm crutch to assist in ambulation?
client who requires considerable assistance with balance
client who needs permanent assistance when walking
client who cannot bear weight with the hands and wrists
client who has weakness on one side of the body
Client who needs permanent assistance when walking
A nurse is caring for a client who is on complete bed rest while recovering from hip surgery 12 hours ago. When the client is able to start walking, which ambulation aid will most likely be recommended for use?
cane
forearm crutch
walker
axillary crutch
Walker
The nurse is caring for a client who has generalized weakness and requires crutches to ambulate. Which crutch-walking gait will the nurse teach?
three-point partial weight-bearing
swing-through
four-point
two-point
Four point
An older adult client with weakness on one side of the body needs to use a cane for walking. How should the nurse determine the correct height of the cane to be used by the client?
The cane’s handle should be at waist level.
The cane should provide elbow flexion of 50.
The cane’s handle should be straight with a hand grip.
The cane’s handle should be parallel with the hip.
The canes handle should be parallel with the hip
A nurse is caring for a client whose fractured leg is in a cast. Which ambulatory device could the nurse suggest for the client to use at the health care facility?
walker
cane
axillary crutch
platform crutch
Axillary crutch
A 91-year-old female client was admitted to the geriatric unit of the hospital with diagnoses of Hyponatremia, Dehydration, and Failure To Thrive. The care team is aware of the importance of early ambulation and has taken steps to facilitate this. How can the client be best prepared to begin ambulating?
Teach the client about energy conservation techniques.
Use a mechanical ceiling lift when transferring the client into or out of bed.
Educate the client on the correct use of forearm crutches.
Assist the client with the performance of isometric exercises.
Assist the client with the performance of isometric exercises
A client with a right lower limb prosthesis uses a cane for additional stability. Which behavior demonstrates to the nurse that the client is ambulating appropriately?
raises hip to swing prosthesis forward
holds cane in left hand
looks at cane while walking
places right limb on first step when going downstairs
Holds cane in left hand
The nurse is preparing to assist the client from a supine to a standing position using a tilt table. What action by the nurse will prevent the client from fainting when using the table?
apply elastic stockings to both lower extremities
If the client develops hypotension, maintain the upright position.
tilt the table at once until the client is in a vertical position
have the client’s feet 2 inches (5 centimeters) above the footboard during transfer
Apply elastic stocking to both lower extremities
A nurse is assisting a client to ambulate at the health care facility using a walking belt. How does the walking belt assist the client when ambulating?
It aids the client in extending the leg.
It enables the client to stand and support body weight.
It helps the client to practice ambulating.
It allows the nurse to support the client.
It allows the nurse to support the client
A client’s plan of care specifies the goal that the client perform quadriceps setting four times daily. The nurse has explained the rationale for this exercise to the client and is now teaching the client to perform the exercises safely and effectively. What instructions should the nurse provide to the client?
“Flex the muscles in your thighs and then slowly rotate your feet outward.”
“Slowly alternate between tightening the muscles in your thighs and then relaxing them.”
“Slowly bend your leg at the knee then gradually return it to a straight position.”
“Progressively tighten your muscles in your toes and then your calves.”
“Slowly alternate between tightening the muscles in your thighs and then relaxing them.”
A nurse is caring for an older client with osteoarthritis who is recovering from the West Nile virus. Isometric exercises have been prescribed. What will the nurse teach the client about isometric exercises?
Isometric exercises will improve muscle tone and strength.
Isometric exercises promote tissue perfusion for quick recovery.
Isometric exercises measure the extent of muscle weakness caused by the virus.
Isometric exercises will promote cardiovascular conditioning.
Isometric exercises will improve muscle tone and strength
When preparing to teach a client about quadriceps setting, the nurse recognizes that which muscles will be involved? Select all that apply.
gluteus medius
vastus intermedius
vastus medialis
gluteus minimum
gluteus maximus
vastus lateralis
rectus femoris
vastus intermedius,
vastus medialis,
vastus lateralis,
rectus femoris
A nurse uses a tilt table to assist a client who is recovering from a spinal injury. Just before using the tilt table, the nurse applies an elastic stocking to the client. What is the purpose of applying this stocking?
It enables the client to stand and support the body.
It aids the client in extending the legs.
It helps to compress the vein walls.
It helps the client to normalize blood pressure.
It helps to compress the vein walls.
A client presents with a flare of lupus. Which statement made by the client would cause the nurse to suspect a stress reaction?
“I have a fever with this flare.”
“I just had a baby 3 weeks ago.”
“My lupus typically flares twice a year.”
“My joints hurt more with this flare.”
“I just had a baby 3 weeks ago”
A nurse is trying to assess a client’s stress type; however, the client is very depressed and quiet and does not reply to the nurse’s questions. The nurse is unable to maintain her calm while repeating the questions. Where is the nurse going wrong in assessing the client?
The nurse should demonstrate confidence and expertise.
The nurse should not assess the client’s stress type.
The nurse should take help from the senior physician.
The nurse should calm him first by giving him a sedative.
The nurse should demonstrate confidence and expertise
The nurse is obtaining data for a client experiencing a sympathetic response to a medication. Which symptom(s) will the nurse document that will correlate with the medication effects? Select all that apply.
heart rate is 58 beats/min
skin is pale
bowel sounds are hypoactive in all quadrants
pupils are constricted and pinpoint
urine output is decreased to less than 30 ml/h
skin is pale,
bowel sounds are hypoactive in all quadrants,
urine output is decreased to less than 30 ml/h
A nurse is sent to care for a client who recently had a stroke and is unable to perform activities of daily living. How should the nurse assist the client to get back to performing normal activities?
by suggesting certain medications
by exercising the client regularly
by asking the client’s family to be near
by suggesting complete bed rest
By exercising the client regularly
An adolescent client is brought to the clinic by the parents, who inform the nurse that they are concerned that the adolescent is using maladaptive coping mechanisms to deal with a bullying issue at school. Which statement(s) by the parents should the nurse report to the health care provider as correlating with the use of maladaptive coping mechanisms? Select all that apply.
“Friends come over frequently to watch television or play video games.”
“We have found evidence of drug use, which is very unlike our adolescent.”
“The school counselor is seeing our adolescent once a week to check in and see how things are going in school.”
“We have tried to discuss the issues so we can find a solution but are met with anger and hostility.”
“Our adolescent is sleeping a lot more than usual.”
“We have found evidence of drug use, which is very unlike our adolescent.”,
“We have tried to discuss the issues so we can find a solution but are met with anger and hostility.”
“Our adolescent is sleeping a lot more than usual.”
After failing a nursing exam, the nursing student states, “That exam was written terribly.” What coping strategy would the nursing instructor identify?
suppression
repression
rationalization
denial
Rationalization
The mission statement of a large health care organization states the objective of providing holistic care for clients. A nurse should be aware that holism is important for which reason?
Interplay between the mind and the body can have a profound influence on health.
Health is promoted when clients receive as few interventions as possible.
The nurse must address deficits in clients’ spiritual knowledge.
Each individual has an intuitive understanding of what he or she must do to maintain health.
Interplay between the mind and the body can have a profound influence on health.
A physician, while treating a client, asks the nurse to use the social readjustment rating scale tool. What does this tool predict?
potential for developing a stress-related disorder
potential ways to assess the level of stress
potential ways to assess the type of stressor
potential diagnosis to treat the stressor
Potential for developing a stress related disorder
While conducting the physical assessment of a client, the nurse notes an increase in the blood glucose level. Upon inquiry, the client discloses that lately he has been under a lot of stress at work. Which stage of stress is the client experiencing?
resistance stage
exhaustion stage
alarm stage
tertiary stage
Alarm stage
A nurse is caring for a client with decreased secretory immunoglobulin A (sIgA). Which health problem might the client face because of this condition?
The client is at a risk for severe infections or cancer.
The client is in the final stages of cancer.
The client’s immune system is damaged.
The client is at risk for allergic eruptions on the body.
The client is at risk for sever infections of cancer
A nurse has been caring for a client who experienced a physical assault a year ago. The client now describes being “totally recovered from it.” Which stage of stress is the client currently experiencing?
primary stage
exhaustion stage
resistance stage
alarm stage
Resistance stage
A community health nurse is discussing coping strategies with a group of clients who are all experiencing significant transitions in their lives. What coping strategy should the nurse identify as being potentially nontherapeutic?
use of assertiveness behaviors
use of religious practices
conflict avoidance
progressive relaxation
Conflict avoidance
Which statement made by the client indicates a need for further teaching regarding stress management?
“I manage my stress by taking antianxiety medication.”
“I manage my stress by exercising once a week.”
“I manage my stress with occasional alcohol and alprazolam.”
“I manage my stress by going out with friends for an occasional drink.”
“I manage my stress with occasional alcohol and alprazolam”
A client who is recently divorced reports sleeping during the day and an inability to adapt to the life change. Which teaching by the nurse will promote healthy adaptation?
“Try making a list to prioritize what needs to be done.”
“Thinking about the past will help you move forward.”
“Save tasks until evening so you can conserve your energy.”
“You should get a dog so you will feel needed.”
“Try making a list to prioritize what needs to be done.”
A student nurse has learned about the role of endorphins in stress management and their potential to foster a sense of well-being. A client with a history of depression has initiated a discussion with the student about nonpharmacologic stress management techniques. What activity should the nurse recommend that may result in the release of endorphins?
meditation
aerobic exercise
adequate night-time sleep
socialization with other clients
Aerobic exercise
A nurse is teaching a client regarding effective coping strategies. Which teaching will the nurse include? Select all that apply.
practicing yoga and relaxation
sleeping during the day
making an appointment with a counselor
writing a list of pros and cons
praying
avoiding crowds and social activity
practicing yoga and relaxation,
making an appointment with a counselor,
writing a list of pros and cons,
praying
A client has been prescribed a medication that affects their levels of the neurotransmitter serotonin. Serotonin may contribute to adaptation in what way?
by altering the client’s stress response
by stabilizing the client’s mood
by promoting healthy immune function
by protecting the client from infection
By stabilizing the clients mood
A client who has been working with an organization for several years did not get a promotion. As a result, the client has gone into depression. Which suggestion should the nurse make in order to help the client with his stress?
Seek professional help.
Take a break from the job.
Accept the changes.
Change the job.
Seek professional help
A nurse is performing a comprehensive assessment of a new resident of a long-term care home. When asked about ways in which the resident manages stress, the client admits he drinks “five or six stiff martinis each afternoon.” How will heavy alcohol use affect the client’s stress management?
The client may ultimately experience more stress.
Alcohol use will influence their physical health but is unlikely to influence stress.
The client will probably experience less stress than nondrinkers or light drinkers.
The client will experience long-term relief from stress but still experience short-term stress.
The client may ultimately experience more stress
A client who has a history of sexual abuse is demonstrating repression. What client behavior does the nurse expect?
refusing to believe that the sexual abuse occurred
blaming others for the sexual abuse
behaving like a young child
having no memory of the sexual abuse
Having no memory of the sexual abuse
The nurse is caring for a client who is experiencing stress while weighing two good job offers. The nurse suggests that the client use therapeutic coping strategies. What does the suggestion of the nurse imply?
It means that the client needs to defer the decision as long as possible.
It means that the client is asked to resort to using mood-altering substances.
It means that the client is asked to seek professional assistance.
It means that the client should reject both of the offers that are causing stress.
It means that the client is asked to seek professional assistance.
True or false
Muscle spasms occur when muscles are strained and forced to work beyond their capacity
True
True or false, an oscillating support bed promotes a sense of control among otherwise dependent clients
False
True or false
A cradle bed is sometimes used for clients with burns, painful joint disease, and fractures of the leg.
True
True or false
Cushions and mattresses made of foam suspend and support the body parts.
False
True or false.
Sitting for a prolonged period in the Fowlers position can decrease blood flow to tissues in the coccyx area as well as increase the risk of pressure ulcers
True
Placement of a limb so that it is neither toward nor away from the body’s midline is called a ________ position
Neutral
_______ are permanently shortened muscles that resist stretching of the fingers
Contractures
_______ is the position of the body that affects the clients appearance, stamina, and ability to use the musculoskeletal system efficiently.
Posture
Skin ______ is an injury that results from exerted force against the surface and layers of the skin as tissues slide in opposite but parallel directions
Shearing
Proper body mechanics is an efficient utilization of the ______ system that increases muscle effectiveness and fatigue
Musculoskeletal
Which of the following statements best defines impaired physical mobility? Impaired physical mobility:
A- refers to the inability to change positions in bed independently
B- refers to the quality of being immobile
C- is a state in which a person has a limitation in physical mobility
D- is a state in which an individual has a total inability to move
C- is a state in which a person has a limitation in physical mobility
________ is the term used to describe a loss of physical fitness. This term applies to patients who experience extended immobility, such as prolonged bed rest
Conditioning
How do skeletal muscles differ from other muscles in the human body?
A- skeletal muscles require more adequate nerve impulses
B- skeletal muscles are voluntarily controlled
C- skeletal muscles require better oxygenation to function appropriately
D- only skeletal muscles experience fatigue
B- skeletal muscles are voluntarily controlled
Why are older adults at increased risk for bone fractures?
A- bone density decreases and bones become more brittle
B- cartilage becomes softer and more fragile
C- muscle mass increases, but muscle tone decreases significantly
D- bone joints become more flexible and loose
A- bone density decreases and bones become more brittle
What statements are true regarding consequences of immobility? Select all that apply
A- results in decreased cardiac output
B- results in secondary hypertension
C- contributes to the formation of deep vein thrombosis
D- causes increased calcium respiration into the skeletal bones
E- contributes to the development of pressure ulcers
A- results in decreased cardiac output
C- contributes to the formation of deep vein thrombosis
E- contributes to the development of pressure ulcers
Which of the following statements are true regarding psychological effects associated with immobility? Select all that apply
A- immobility has been linked to increased verbal and decreased nonverbal
B- psychological effects associated with immobility are more concerning for older adults than any other age group
C- immobilization in children can interfere with intellectual and psychomotor functioning
D- immobility can hamper physical growth and development in children
E- for adults, being unable to work or perform activities of daily living due to immobility often causes a loss of self worth.
C
D
E
A nurse is assisting with data collection regarding a patients history as it relates to mobility. Which of the following questions would be least helpful in assessing mobility?
A- “do you have any pain with movement”
B- “have you experienced any recent falls”
C- “have you had any changes in your mobility or problems with balance”
D-“ how many times a week do you get to visit with friends or family?
D-“ how many times a week do you get to visit with friends or family?
A patient arrives to the clinic with significant pain in the right lower leg. The patient explains that he fell off a ladder while painting his house. The physician suspects the patient has sustained a fracture of the tibia. Which test will the physician most likely order to detect the tibial fracture? A- a bone mineral density (BMD) test B- a bone scan C- an x-ray D- magnetic resonance imaging (MRI)
C- an X-ray
What is the best reason bed exercises should be encouraged for those patients on bed rest?
A- to prevent pneumonia
B- to prevent skin breakdown
C- to minimize atrophy and maintain joint movement
D- to minimize pain and discomfort
C- to minimize atrophy and maintain joint movement
Muscle relaxants are classified as analgesics?
A- true
B- false
False
True or false
Stress related disorders cannot be treated without the use of medications
False
True or false
Homeostasis is associated with a persons emotional status
False
True or false
In the positive feedback mechanism, when the hormone level increases, the releasing gland is inhibited
True
True or false
The parasympathetic nervous system prepares the body for flight or fight in time of danger
False
True or false
At the immediate onset of a stress response, the first neurotransmitter released by the storage vesicles within the sympathetic nervous system is norepinephrine.
True
_____ is a relatively stable of physiologic equilibrium
Homeostasis
_________ is the means by which an organism responds to change
Adaptation
__________ mediate homeostatic adaptive responses of the central nervous system, autonomic nervous system, and endocrine system
Neurotransmitter
__________ are changes with the potential to disturb the equilibrium of the body
Stressors
Stressors may be physiologic, ________, social, or spiritual.
Psychological
True or false
Forearm crutches are generally used by experienced clients who need permanent assistance with walking
True
True or false
Axillary crutches are generally used by clients who cannot bear weight with their hands and wrists
False
True or false
An immediate postoperative prosthesis is a type of permanent artificial limb
False
True or false
Limiting a clients mobility can prevent the development of a swaying or shuffling gait
False
True or false
A home safety evaluation is recommended before discharging an older client who will be using a mobility device
True
Clients who require considerable support and assistance with balance use a _____, the most stable form of ambulatory aid
Walker
______ crutches are known as the standard and the most familiar type of crutches
Axillary
The act of _____ helps to normalize blood pressure, which may drop when the client rises from a reclining position
Dangling
______ are an ambulatory aid generally used in pairs, and which are constructed of wood or aluminum
Crutches
Quadriceps setting and gluteal setting exercises are two types of ______ exercises
Isometric
Know examples of functional assessment tools
TABLE 2.1 PAGE 16 THESE ARE ONLY THE MOST IMPORTANT
Functional assessment tool——————function assessed/ target population
Functional activities questionnaire————- older adults: assesses IADLs
Long term care minimum data set——— nursing home residents
Folstein mini mental status examination———- older adults; cognitive function
Be able to discern who would be at the most risk for impaired functional ability
Most at risk for impaired functional ability.
List from top to bottom.
Dementia will be more at risk than a younger adult.
Functional assessment concept
Vision - observe for signs of impaired vision during interaction with patient: turning head to one side in an effort to see better; non-applicable comments about room seeming dark
Hearing- note patients apparent hearing during your interaction with him or her
Mobility- observe general movements
Fall history
Continence
Nutrition- well nourished, obtain weight and determine body mass index
Cognition- ability to respond appropriately to questions and directions
Affect- note patients expression and if this matches mood
Home environment
Social participation
Activities of daily living (basic and instrumental)
Exemplars of impaired functional ability
Causes of primary problems????
Causes of secondary problems????
Primary- angelman syndrome, autism spectrum disorder, cerebral palsy, Down syndrome, duchenne muscular dystrophy, fetal alcohol syndrome, hypoplastic limb, malnutrition, receptive or expressive language disorder
Secondary- Alzheimer disease, blindness, brain injury, cardiovascular disease, chronic pain, chronic fatigue, chronic obstructive pulmonary disease, deafness, malnutrition, multiple sclerosis, osteoarthritis, Parkinson’s disease, rheumatoid arthritis, schizophrenia, spinal cord injury, skeletal fracture, stroke.
age related differences?
-Infant •Child •Adolescent •Adult •Elderly
Significant changes to the musculoskeletal system occur throughout infancy and childhood as a function of growth and development. Appendicular skeletal grows faster than the axial skeletal. Bones change, when older they become brittle. Cartilage becomes fragile.
Consequences of immobility.
-Cardiovascular complications- reduced cardiac capacity decreased cardiac output. Orthostatic hypotension. Venous stasis. Deep vein thrombosis.
- Respiratory complications-rescued lung expansion. Atelectasis. Pooling of respiratory secretions.
- Musculoskeletal complications- reduction in muscle mass and atrophy. Contracture of joints. Bone demineralization.
- Integument system complications- skin breakdown.
- Gastrointestinal complications- reduced peristaltic motility. Constipation. Renal calculi.
- Urinary complications- urinary stasis. Infection.
- Psychological effects
Diagnostic tests??
X ray- evaluates the integrity of bones and joints and is the most common radiographic test used to diagnose fractures.
Computed tomography scan- identifies soft tissue and bony abnormalities and evaluates musculoskeletal trauma.
Magnetic resonance imaging- uses radio waves and magnetic fields to provide an image of soft tissues. This Is used most efficiently to evaluate soft tissues such as vertebral disk, tumor, ligaments, and cartilage.
Myelogram- a radiographic study of the spinal cord and nerve root using a contrast dye. This is particularly useful in the evaluation of individuals with back pain.
Arthrography
Bone mineral density
Bone scan
Arthroscopy
Electromyography
Laboratory tests
What is impaired physical mobility and how do you assess it?
Impaired physical mobility describes a state in which a person has a limitation in physical movement but is not immobile.
Check for functional level of mobility. Evaluate patients ability to perform ADLs. Assess ROM
What are the pharmacologic agents to treat mobility?
Anti inflammatory agents- corticosteroids and nonsteroidal drugs.
Analgesics-opioids (morphine) and aspirin
Muscle relaxants- reduce nerves transmission to skeletal muscles thus promoting muscle relaxation. Baclofen, chlorazoxazone, carisoprodol, cyclobenaprine, dantrolene, and tizanidine
Supplements- nutritional supplements with vitamin d and calcium.
Know everything about using a cane
Patient who has weakness on one side of the body uses a cane.
Minimal support- use a cane with a half circle handle
T handle canes has a handgrip with a slightly bent shaft offering more stability
Quad cane has 4 supports at the base and provides even more stability than the other types.
Must be the right height.
Know about ergonomics
Ergonomics is a speciality field of engineering science devoted to promoting comfort, performance, and health in the workplace.
Examples are using assistive devices to life or transport heavy items or clients. Using alternative equipment for tasks that require repetitive motion.
Know all the laying postitions how to describe them and who and why we would be put in those positions and the degrees of all the fowlers positions
Lying positions are supine, lateral, lateral oblique, prone, sims, fowlers.
Supine- person lies on his back. Recommended to reduce the incidence of sudden infant death syndrome among new borns.
Lateral- side lying position. Foot drop is less of a concern.
Lateral oblique- a variation of the side lying position. The patient lies on the side with the top leg placed in 30 degrees of hip flexion and 35 degrees of knee flexion. This position puts less pressure on the hip and reduces the potential for skin breakdown.
Prone- patient lies on the abdomen. Alternative position for patient with pressure ulcer. Provides good drainage from bronchioles, stretches the trunk and extremities, and keeps hips in extended position. Improves arterial oxygenation. Interferes with eating.
Sims- semi prone position. Patient lies on the left side with the right knee drawn up toward the chest. Arm is positioned along the clients back, and the chest and abdomen are allowed to lean forward. Position is used for procedures involving the rectum and vagina.
Fowlers-semi sitting position. Makes it easier to eat, talk, and look around. Low Fowler is 30 degrees. Mid or semi Fowler is 45 degrees and high Fowler is 60 to 90 degrees. Knees may not be elevated, but doing so will relieve strain on the lower spine. Relieves pressure on diaphragm.
Know about trapeze and bed cradles
A trapeze is a triangular piece of metal hung by a chain over the head of a bed. Patient uses it to grab and lift body to move in bed.
Bed cradle is a metal frame secured to or placed on top of the mattress. Forms a shell over the patients lower legs to keep bed linen off the feet or legs.
Know about mechanical lifts, foot boards/splints, foot cradle tilt table, parralell bars,
Mechanical lifts- helps move heavy patients or those with limited ability to assist from the bed to a chair. Capacity of 350-600 pounds.
Footboards/splints- used to prevent foot drop by keeping the feet in a functional position. If patient can’t reach a footboard, a foot splint is used. Foot splint allows for more variety in body positioning while maintain the foot in a functional position.
Tilt table- a device that raises the client from a supine to a standing position. Patient wears elastic stockings first.
Parallel bars- a double row of stationary bars as handrails to gain practice in ambulating.
Know about gluteal/quad setting and modified hand pushups know what the purpose of gluteal muscles
Quadriceps setting is an isometric exercise in which the client alternately tenses and relaxes the quadriceps muscles. Enables patient to stand and support their body weight.
Gluteal setting is the contraction and relaxation of the gluteal muscles to improve their strength and tone. Essential to walking.
Modified hand pushups- exercises that support the upper body on the hands and arms. Extending the elbows and flexing the wrists to life the buttocks slightly off the mattress.
Know what to look out for when ambulating a patient especially when they are first starting with the parallel bars.
The nurse observes the ambulating client for pallor, weakness, or dizziness.
Know all the different points like stated in class.
2 point, 3 point swing through, not only know what these are but who would use them and why
PAGE 575 !!
Four point-one crutch, opposite foot, other crutch, remaining foot. Bilateral weakness or disability such as arthritis or cerebral palsy.
Two point- one crutch and opposite foot moved in unison followed by the remaining pair. Same as for four point but patients have more strength, coordination, and balance
Three point non weight bearing- both crutches move forward followed by the weight bearing leg. One amputated, injured, or disabled extremity(fractured leg or sever ankle sprain)
3 point partial weight bearing- both crutches are advanced with the weaker leg; the strong leg is placed parallel to the weaker leg. Amputee learning to use prosthesis, minor injury to one leg, or previous injury showing signs of healing.
Swing through- both crutches are moved forward; one or both legs are advanced beyond the crutches. Injury or disorder affecting one or both legs, such as a paralyzes client with leg braces or an amputee before being fitted with a prosthesis
Know about the parasympethic and sympathetic nervous system physiological manifestations and how you would help a patient go from sympathetic to parasympathetic.
The parasympathetic system restores equilibrium after danger is no longer apparent. Freeze response. Constricted pupils, no sweat glands, increased salivation. Stimulated secretions. Decreased rate and force of contraction. Dilated, causing blushed or flushed appearance. Decreased tone. Contracted(bronchoconstriction) increased digestive mobility. Urge to urinate.
Sympathetic is prepares the Body for flight or fight. Dilated pupils. Increased perspiration. Inhibited salvation. Inhibited secretions. Increased rate and force of contraction. Constricted blood vessels causing pale appearance. Increased tone. Relaxed(bronchodilation). decreased digestive mobility. Decreased filtration. Inhibited (suppressed urination) release of glucose. Stimulated adrenal medulla.
How you help a patient would be reduce stress, yoga, therapy, modeling, progressive relaxation, biofeedbak, meditation and prayer, placebo effect.
Knows what happens to the body when there is stress and stress reduction techniques
When there is stress the body goes into sympathetic mode- fight or flight.
Stress reduction techniques are methods that promote physiologic comfort and emotional well being. Examples are keeping the family informed, demonstrating confidence and expertise when proving nursing care, remaining calm during crises.
Know about disuse syndrome and how to prevent it
Disuse syndrome is signs and symptoms that result from inactivity. Positioning and moving clients reduces the potential for disuse syndrome.
Know the stages of the general adaptation syndrome
This syndrome occurs repeatably and consistently regardless of the nature of the stressor. the body’s physical response is always the same and is follows a one- two- or three- stage pattern: alarm stage, stage of resistance, and stage of exhaustion.
Alarm stage- the storage vesicles Within the sympathetic nervous system neurons rapidly release norepinephrine. The adrenal glands secrete additional norepinephrine and epinephrine. The hypothalamus releases corticotropin releasing factor. The pituitary gland secretes adrenocorticotropic hormone. The adrenal cortex releases cortisol, a stress hormone.
Stage of resistance- characterized by physiologic changes designed to restore homeostasis. Activated via the endocrine system.
Stage of exhaustion- occurs when one or more adaptive or resistive mechanisms are no longer able to protect the person experiencing a stressor. Adaptation is unsuccessful and death ensues.
Know all the different beds and what kind of client’s will need each bed
Low air loss bed- contains inflated air sacs within the mattress. Maintains capillary pressure well below that which can interfere with blood flow. Used for impaired skin, continued existence of risk factors for further skin breakdown, alternative positions limited, less than adequate, or impossible. Assistance required for FREQUENT TRANSFERS FROM BED.
Air fluidized bed- contains a collection of tiny beads Within a mattress cover. Allows client to float on lifted beads. Prevents skin irritation and maceration from moisture. Better for patients who are likely to remain in bed for long periods. SELDOM TRANSFERRED FROM BED
Oscillating support bed- slowly and continuously rocks the client from side to side in a 124 degree arc. Relieves skin pressure and helps mobilize respiratory secretions. Foam covered supports prevent shearing. PNEUMONIA
Circular bed- supports client on a 6-7 ft anterior or posterior platform suspended across the diameter of the frame. Allows patient to remain passively immobile during a position change. Used for current of high risk skin breakdown because of traumas, especially if it involved the head, neck, or SPINE. Burns that require frequent dressing changes or topical applications.
Know what coping mechanisms, homeostasis, neurotransmitters,cortex, subcortex
Coping mechanisms- unconscious tactics to defend the psyche; used to prevent their ego, or reality base, from feeling inadequate.
Homeostasis is “staying the same”
Neurotransmitters- chemical messengers synthesized in the neurons; allow communication across the synaptic cleft between neurons. Binds to receptor sites. Common neurotransmitters include serotonin, dopamine, epinephrine, norepinephrine.
Cortex is in the central nervous system it’s the higher functioning portion of the brain. Enables people to think abstractly, use and understand language, accumulate and store memories.
Subcortex consists of the structures in the midbrain and brainstem. Midbrain includes basal ganglia, thalamus, and hypothalamus. Brainstem contains cerebellum, medulla, and pons. Primary responsible for regulating and marinating physiologic activities that promote survival. Ex is regulation of breathing, heart contraction, BP, body temp, sleep.
Know about the feedback loop
Feedback loop is mechanism for controlling hormone production. Can be positive or negative feedback
Positive feedback- Childbirth, Ovulation
Negative feedback- B/P, Body temp, diabetes
What assessment tool measures comprehensive functional and social health in adults and adolescents?
Dartmouth COOP functional health assessment charts
What assessment Questionnaire assesses IADL’s?
Functional Activities Questionnaire
What assessment tool assesses Older adults cognitive function?
Folstein Mini-Mental Status Examination (MMSE)
What assessment tool assesses Nursing Home Residents?
Long-term Care Minimum Data Set (MDS)
What assessment tool is used for hospitalized children?
Functional Status Scale (FSS)
What assessment tool is used for cancer patients functional performance?
The Edmonton Functional Assessment Tool
What questionnaire tool is used for outpatient postoperative functional ability?
24-h Functional ability questionnaire (24hFAQ)
What assessment tool is used for older adult depression?
Geriatric Depression Scale
What is the mechanism used for controlling hormone production?
Feedback loop
What is alternative thinking techniques??
Those that facilitate a change in a persons perceptions from negative to positive.
Know about foam and gel mattresses
Foam acts like a layer of subcutaneous tissue because it conforms to the clients body and acts like a cushion.
Egg crate of waffle
Gel is an alternative substance used to fill cushions and mattress. It differs from foam in that it suspends and supports the body part.
Nurses place gel and foam cushions in wheelchairs to prevent “hammock effect”
Know about static mattress
Filled with a fixed volume of air. It suspends the client on a buoyant surface distributing the pressure on the underlying tissue. It molds and contours around the body
Know about alternating air mattress
Similar to a static mattress with one expectation: every other channel inflates as the next one deflates. The process is then reversed. Promotes blood flow and keeps the tissues supplied with oxygen.
Know about water mattress
Support the body and equalizes the pressure per square inch over its surface. Pressure reliving is maintained regardless of any shift in clients position.
BED MATCHING
- Low air loss bed
- Oscillating support bed
- Circular bed
- Air fluidized bed
A. Frequent transfers
B. Spinal injury
C. Pneumonia
D. Seldom transferred from bed
- A
- C
- B
- D
