week 8 ati homework & ch 40

Question 1

Immobile clients are at risk for:

Answer 1

atelactasis – shallow breathing
DVT
decreased circulation
GERD
orthostatic hypotension

Question 2

ADL’s include

Answer 2

*toileting
dressing
bathing
feeding

Question 3

client position for pneumonia

Answer 3

prone

Question 4

client position for atelactasis

Answer 4

fowlers

Question 5

correct use of walker

Answer 5

walker moves FIRST
elbows bent 15 degrees
walker held at level of wrist

Question 6

correct use of cane

Answer 6

held on stronger side
move 6 to 10 inches
at level of wrist
elbow bent at 15-30 degree angle
cane first followed by weaker leg

Question 7

MAT score

Answer 7

lower numbers = more assistance

Question 8

orthostatic hypotension

Answer 8

decrease in systolic pressure of 20mmhg

OR

decrease in diastolic of 10mmhg or more within 3 min. of changing positions

Question 9

manifestations of sepsis

Answer 9

hypotension
increased blood glucose
increased white blood cells
nothing to do w BUN

Question 10

positions that put client at risk for shearing

Answer 10

high fowler position
sitting/lying on incline

Question 11

preventing breakdown on an immobile patient

Answer 11

*cleanse & pat dry
*tilt client onto side @ 30 degreed
*sitting position
*head of bed less than 30 degrees at all times

Question 12

hydrogel dressing

Answer 12

used for DEBRIDEMENT of wounds w/ NECROTIZED tissue & eschars

Question 13

Alginate dressing

Answer 13

used for moderate to high exudative wounds & lasts several days

provides hemostasis
needs secondary dressing

Question 14

hyrdrocolloid dressing

Answer 14

for stage 1 PI - gel-like & moist

may cause: dermatitis, foul smelling yellow gelatinous film

Question 15

sterile dressings

Answer 15

kept on incision 24 to 48 hours
**sterile technique if dressing loosens

Question 16

clean technique

Answer 16

used on wounds after 48 hours
used at home

Question 17

dehiscence
vs
evisceration

Answer 17

dehiscence : occurs 7-10 days after surgery –separation of wound edges

evisceration: protrusion of internal organs—sterile saline soaked dressing

Question 18

client with abdomen wound should be

Answer 18

supine
knees bent
covered w sterile saline dressing

Question 19

irrigation for wounds

Answer 19

0.9% sodium chloride

Question 20

Braden Scale

Answer 20

risk assessment for tissue integrity
lowest score (6) = higher risk
high score (23) = no risk

Question 21

maceration
vs
dermatitis

Answer 21

maceration: irritation of epidermis caused by moisture

dermatitis : red skin irritation

Question 22

erythema

Answer 22

redness of skin due to dilation of blood vessels

blanchable: red goes away w pressure

nonblanchable: red does not go away w pressure

Question 23

heat therapy

Answer 23

*increases blood flow & tissue metabolism
*relaxes muscles
*eases joint pain

do not use on pregnant people, immobile clients, first 24 hours after injury

Question 24

cold therapy

Answer 24

decreases inflammation
prevents swelling
reduces fever & bleeding
diminishes muscle spasms

• assess site every 5 to 10 min
  *discontinue after 15 to 30 min

Question 25

1. 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.)
2. The patient keeps the cane on the left side of the body.
3. The patient slightly leans to one side while walking.
4. The patient keeps two points of support on the floor at all times.
5. After the patient places the cane forward, he or she then moves the right leg forward to the cane.
6. The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step.

Answer 25

3. The patient keeps two points of support on the floor at all times.
4. The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step.

Question 26

2. 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?
3. Four-point
4. Three-point
5. Two-point
6. Swing-through

Answer 26

2. Three-point

Question 27

Which of the following motivates a patient to participate in an exercise program? (Select all that apply.)

1. Providing a patient with a pamphlet on exercise
2. Providing information to the patient when he or she is ready to change behavior
3. Explaining the importance of exercise at the time of diagnosis of a chronic disease
4. Having a structured daily plan that incorporates physical activity
5. Having support from significant other to engage in exercise

Answer 27

2. Providing information to the patient when he or she is ready to change behavior
3. Having a structured daily plan that incorporates physical activity
4. Having support from significant other to engage in exercise

Question 28

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?

1. Increase the patient’s risk for falls and injuries
2. Result in less stress on the patient’s joints
3. Decrease the amount of work required for patient movement
4. Allow for mobility in spite of the aging effects on the patient’s joints

Answer 28

1. Increase the patient’s risk for falls and injuries

Question 29

Place in the correct order the steps needed (below) to transfer a patient with sufficient lower body strength to a chair.

1. On count of three, instruct patient to stand while straightening hips and legs and keeping knees slightly flexed.
2. Assist patient to assume proper alignment in sitting position.
3. Help patient apply stable, nonskid shoes/socks.
4. Spread your feet apart. Flex hips and knees, aligning knees with patient’s knees.
5. Apply gait/transfer belt.
6. Maintain patient’s balance as you pivot foot farthest from chair and then help patient ease into chair.
   Place in the correct order the steps needed (below) to transfer a patient with sufficient lower body strength to a chair.
7. On count of three, instruct patient to stand while straightening hips and legs and keeping knees slightly flexed.
8. Assist patient to assume proper alignment in sitting position.
9. Help patient apply stable, nonskid shoes/socks.
10. Spread your feet apart. Flex hips and knees, aligning knees with patient’s knees.
11. Apply gait/transfer belt.
12. Maintain patient’s balance as you pivot foot farthest from chair and then help patient ease into chair. Place in the correct order the steps needed (below) to transfer a patient with sufficient lower body strength to a chair.
13. On count of three, instruct patient to stand while straightening hips and legs and keeping knees slightly flexed.
14. Assist patient to assume proper alignment in sitting position.
15. Help patient apply stable, nonskid shoes/socks.
16. Spread your feet apart. Flex hips and knees, aligning knees with patient’s knees.
17. Apply gait/transfer belt.
18. Maintain patient’s balance as you pivot foot farthest from chair and then help patient ease into chair.
19. Grasp transfer belt along patient’s sides.

Answer 29

5. Apply gait/transfer belt.
6. Help patient apply stable, nonskid shoes/socks.
7. Spread your feet apart. Flex hips and knees, aligning knees with patient’s knees.
8. Grasp transfer belt along patient’s sides.
9. On count of three, instruct patient to stand while straightening hips and legs and keeping knees slightly flexed.
10. Maintain patient’s balance as you pivot foot farthest from chair and then help patient ease into chair.
    Place in the correct order the steps needed (below) to transfer a patient with sufficient lower body strength to a chair.
11. Assist patient to assume proper alignment in sitting position.

Question 30

. Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.)

1. Patient’s weight
2. Patient’s activity tolerance
3. Patient’s level of mobility
4. Recent laboratory values
5. Nutritional intake

Answer 30

1. Patient’s weight
2. Patient’s activity tolerance
3. Patient’s level of mobility

Question 31

8. Which of the following indicates that additional assistance is needed to transfer a patient from the bed to the stretcher? (Select all that apply.)
9. The patient is 5 feet, 6 inches and weighs 120 lb.
10. The patient speaks and understands English.
11. The patient is returning to unit from recovery room after a procedure requiring conscious sedation.
12. The patient has a history of being able to stand independently.
13. The patient received analgesia for pain 30 minutes ago.

Answer 31

3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation.
4. The patient received analgesia for pain 30 minutes ago.

Question 32

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

1. Move more and sit less throughout the day.
2. Participate in at least 90 minutes a week of moderate-intensity aerobic physical activity.
3. Perform muscle-strengthening activities using light weights on 2 or more days a week.
4. Walk at a vigorous pace with wife at least 150 minutes over five days a week.
5. Focus on balance training.

Answer 32

1. Move more and sit less throughout the day.
2. Perform muscle-strengthening activities using light weights on 2 or more days a week.
3. Walk at a vigorous pace with wife at least 150 minutes over five days a week.

Question 33

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.)

1. A walker is useful for patients who have impaired balance.
2. The patient uses a walker by pushing the device forward.
3. Leaning over the walker improves the patient’s balance.
4. Walkers should not be used on stairs.
5. If the patient has difficulty advancing the walker, a walker with wheels is an option.

Answer 33

1. A walker is useful for patients who have impaired balance.
2. Walkers should not be used on stairs.
3. If the patient has difficulty advancing the walker, a walker with wheels is an option.

Question 34

. 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?

1. Decreased peristalsis
2. Decreased heart rate
3. Increased blood pressure
4. Increased urinary output

Answer 34

1. Decreased peristalsis

Question 35

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?

1. Increase of appetite
2. Gum soreness
3. Difficulty in swallowing
4. Left ankle joint stiffness

Answer 35

4. Left ankle joint stiffness

Question 36

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.)

1. Bruising
2. Pale yellow urine
3. Bleeding gums
4. Coffee ground–like vomitus
5. Light brown stool

Answer 36

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

Question 37

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

1. Raise side rail and go to opposite side of bed.
2. 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.
3. Lower head of bed flat if patient can tolerate it.
4. Roll patient onto side toward you.
5. Lower side rail and position patient on side of bed opposite the direction toward which patient is to be turned.
6. Place hands under patient’s dependent shoulder and bring shoulder blade forward.
7. Place hands under patient’s dependent hip and bring hip slightly forward so that angle from hip to mattress is approximately 30 degrees.

Answer 37

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 38

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

1. Thrombus formation
2. Increased cardiac workload
3. Weak peripheral pulses
4. Irregular heartbeat
5. Orthostatic hypotension

Answer 38

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

Question 39

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.)

1. Administer intravenous analgesic as ordered.
2. Have patient perform incentive spirometry.
3. Support patient in active assistive ROM exercises of upper extremities.
4. Provide patient a low-calorie diet.
5. Apply sequential compression devices to legs.

Answer 39

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 40

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

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

Answer 40

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 41

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.)

1. Patient’s usual dietary intake
2. Time and date of the patient’s last bowel movement
3. Preadmission activity tolerance
4. Baseline heart rate
5. Patient’s home living situation

Answer 41

3. Preadmission activity tolerance
4. Baseline heart rate

Question 42

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

1. Support elbow by holding distal part of extremity.
2. Grasp joint with fingers to provide support.
3. Have patient move joint independently.
4. Move the joint past the point of resistance.
5. Perform the exercise a few times only, and gradually build up to more.

Answer 42

1. Support elbow by holding distal part of extremity.

Question 43

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.)

1. Oxygen saturation of 89%
2. Irregular radial pulse
3. Diminished breath sounds bilateral bases on auscultation
4. BP: 132/84
5. Pain reported at 3 on scale of 0 to 10 following medication
6. Respiratory rate of 26

Answer 43

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