Deck 6: Supporting Mobility and Immobilization

Question 1

A nurse is assessing a client's ability to use a cane correctly. What assessment by the nurse indicates more collaboration with physical therapy is needed?

A) Client has removed the rubber tips for ease when using the cane.
B) The client's elbow is flexed at 25 degrees when using the cane.
C) The client uses nonslip slippers when ambulating with the cane.
D) The client holds the cane on the stronger side of the body.

Answer 1

Client has removed the rubber tips for ease when using the cane.

Question 2

The nurse is assisting a client to walk using a walker. Which technique indicates the client needs further education?

A) The client advances the walker 15 to 30 cm (6 to 12 inches).
B) The client steps into the walker while all 4 feet are on the ground.
C) The client steps forward with the stronger side first.
D) The client steps completely into the walker.

Answer 2

The client steps forward with the stronger side first.

Question 3

The nurse is assisting clients when walking with crutches. Which client demonstrates the correct technique?

A) Four-point gait: Left crutch, right foot, right crutch, left foot
B) Three-point gait: Client puts <50% weight on the affected leg
C) Three-point plus gait: Client does not bear weight on the affected leg
D) Swing-through gait: Client supports weight with axillae on crutches

Answer 3

Four-point gait: Left crutch, right foot, right crutch, left foot

Question 4

The nurse assesses a client shortly after having an arm sling applied. What assessment is the priority?

A) Airway and breathing
B) Neurovascular status
C) Sling for proper fit
D) Gait and ambulation

Question 5

The nurse applied an elastic wrap around a client's arm. Later, on hourly rounds, what assessment takes priority?

A) Distal circulation
B) Dampness of dressing
C) Pain
D) Immobility

Question 6

A student nurse is caring for a client in skin traction. What action by the student indicates good understanding of this client's needs?

A) Gathers supplies for pin care
B) Ensures weights are free-hanging
C) Assesses skin on shoulders and chest
D) Keeps walkways clear

Question 7

An unlicensed assistive staff member reports to the nurse that a client with a recent arm amputation wants pain medication for hand pain in the missing limb. The staff member states the client is "obviously drug seeking since there can't be pain in the fingers." What response by the nurse is best?

A) "You're right. I will ask the provider for a psychiatric consultation."
B) "The client must be hallucinating. Was the client oriented at all?"
C) "Phantom nerve pain is a real phenomenon and very important to treat."
D) "Thanks. I'll go give the client some pain medication right now."

Question 8

A client with a lower leg amputation needs to perform abduction exercises. Which procedure would the nurse teach the client?

A) Contract gluteal muscles to lift the extremity off the bed while lying prone.
B) Squeeze a small pillow between the thighs while supine or sitting up.
C) From a chair, straighten the limb and hold that position for 10 seconds.
D) In a side-lying position, lift the affected leg up and hold for 5 to 10 seconds.

Question 9

The nurse is caring for a client 3 days after a lower leg amputation. What positioning strategy is best?

A) Rest the residual limb on a pillow to prevent edema and reduce pain.
B) Have client lay prone several times a day to prevent hip flexion contractures.
C) Encourage the client to rest with the knee flexed to prevent joint "freezing."
D) Provide twice the amount of knee flexor time than extension time.

Question 10

A father calls the clinic to report his 6-year-old child is putting things under a cast to relieve itching. What response by the nurse is best?

A) "Don't allow your child to put anything under the cast."
B) "You can relieve itching by blowing cool air under the cast."
C) "Does the cast have an unusual or bad odor to it?"
D) "Are you checking your child's pulses regularly like I taught you?"

Question 11

A client is complaining of increasing pain under a plaster cast that is not relieved with pain medication. What action by the nurse is most important?

A) Assess distal circulation.
B) Notify the provider.
C) Document the findings.
D) Request more pain medication.

Question 12

The student nurse asks why a child's cast needed petaling. What response by the nurse is best?

A) To prevent skin burns from the heat reaction
B) To relieve severe itching under the cast
C) To relieve pain in the fracture under the cast
D) To prevent skin damage at the edge of the cast

Question 13

Which definition is correct?

A) Eversion: Turning inward
B) Atrophy: Enlargement of an organ or tissue
C) Fascia: A fibrous membrane covering
D) Strain: Joint damage from ligament injury

Question 14

The nurse is caring for a patient after an ORIF to repair a fracture. What action demonstrates correct nursing care?

A) Performs pin care according to facility policy
B) Applies new dressings after assessing and cleaning the incision
C) Ensures the proper amount of weight is attached to the bed
D) Assesses the skin underneath the traction boot

Question 15

A client has halo traction. What action by the nurse is most important for the client's safety?

A) Ensure all connections within the halo traction are secure.
B) Administer pain medication around the clock.
C) Order thickened liquids to prevent choking.
D) Provide pin care according to agency policy.

Question 16

A client is in the Emergency Department having an arm cast applied. The client tells the nurses they may not remove the wedding rings. What response by the nurse is best?

A) "I understand they are important to you but they have to come off."
B) "We will give them to security to lock up until you are discharged."
C) "OK, we will pad them so they don't rub against the edge of the cast."
D) "They can cut off the circulation to that finger when your arm swells."

Question 17

A nurse has applied an arm sling to a client. What assessment findings indicate the nurse has done this correctly?

A) Client's elbow fits snugly in the cuff of the sling.
B) Client's elbow is flexed at 70 degrees.
C) Client's thumb is positioned facing down.
D) Client's elbow is above the level of the hand.

Question 18

The nurse is assessing a client with a short arm cast. What findings indicate that goals for the priority nursing diagnosis have been met? (Select all that apply.)

A) Skin is warm and dry.
B) Fracture is healing.
C) Capillary refill is <3 seconds.
D) Distal pulses are palpable.
E) Cast is completely dry.

Question 19

The nurse is teaching a client about the benefits of exercising. What information does the nurse include? (Select all that apply.)

A) Walking improves blood lipids.
B) Jogging is the most common exercise.
C) Exercise reduces depression.
D) Mobility helps prevent bone absorption.
E) Activity improves sleep quality.
F) Vigorous exercise is needed for benefits.

Question 20

The student learns that mobility assists body systems in which ways? (Select all that apply.)

A) Improves gas exchange
B) Helps mobilize secretions
C) Improves insulin uptake
D) Boosts immune function
E) Prevents urinary stasis

Question 21

The nurse is assessing the 5 Ps in a client who has an arm cast. Which of the following does the nurse assess? (Select all that apply.)

A) Pain
B) Paralysis
C) Pricking sensations
D) Puffiness
E) Pulses

Question 22

When assisting a client with range of motion, which joints are paired with proper movement? (Select all that apply.)

A) Neck: lateral flexion
B) Elbow: adduction
C) Thumb: opposition
D) Leg: external rotation
E) Knee: dorsiflexion
F) Ankle: rotation

Question 23

A new nurse is providing care to a client 2 days after the client had his leg amputated. What actions by the nurse indicate a need for further education? (Select all that apply.)

A) Allows client to choose a position of comfort
B) Wraps the residual limb in a diagonal fashion
C) Measures client's leg for a commercial shrinker
D) Wraps elastic bandage around client's waist
E) Wrapping the leg in a lateral fashion

Question 24

Which of the following statements about cast material are true? (Select all that apply.)

A) Plaster casts are no longer used.
B) Fiberglass casts are much cheaper.
C) Plaster casts need 24 hours to dry.
D) Fiberglass casts melt if they get wet.
E) Plaster casts can cause skin burns.
F) Fiberglass casts are not as strong.