Question 1

The nurse knows active assistive range of motion is:&#10;A) when the patient is able to independently move all joints.&#10;B) when the patient is able to partially move all joints.&#10;C) when the caregiver must move the patient's joints.&#10;D) when the patient is performing isotonic exercises.

Accepted Answer

Active assistive range of motion occurs when the caregiver minimally assists the patient or the patient minimally assists himself or herself in the movement of joints through a full motion. Active range of motion occurs when the patient has full independent movement of all joints; this is also known as isotonic exercise. Passive range of motion occurs when the caregiver moves the patient's joints through a full motion. This exercise does not maintain or improve strength but maintains flexibility and prevents contractures and atrophy.

Question 2

The nurse has delegated to the UAP to assist a patient with ambulating in the hallway with a cane. Which statement by the UAP indicates a need for further education?&#10;A) &#34;I should report any complaints of soreness to the nurse.&#34;&#10;B) &#34;I should watch for indications that the patient has difficulties using the cane.&#34;&#10;C) &#34;I should let the nurse or PT know if the cane doesn't seem to fit correctly.&#34;&#10;D) &#34;I should teach the patient how to walk with the cane.&#34;

Accepted Answer

Educating patients on how to walk with assistive devices may not be delegated to unlicensed assistive personnel (UAP). UAP should report any of the following: noticeable incorrect usage or fit of assistive devices, complaints of soreness or weakness, difficulties involving balance or strength, or difficulties in performing the procedure or other concerns verbalized by the patient.

Question 3

The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicates a good understanding?&#10;A) &#34;An example of this type of exercise is walking.&#34;&#10;B) &#34;An example of this type of exercise is running.&#34;&#10;C) &#34;An example of this type of exercise is Kegels.&#34;&#10;D) &#34;An example of this type of exercise is weight lifting.&#34;

Accepted Answer

Isometric exercise requires tension and relaxation of muscles without joint movement. An example is tension and relaxation of pelvic floor muscles (i.e., Kegel exercise). Isotonic exercise involves active movement with constant muscle contraction, such as walking, turning in bed, and self-feeding. Aerobic exercise requires oxygen metabolism to produce energy. Patients may engage in rigorous walking or repeated stair climbing to achieve the positive effects of aerobic exercise. Anaerobic exercise builds power and body mass. Without oxygen to produce energy for activity, anaerobic exercise takes place, such as heavy weight lifting.

Question 4

The nurse is teaching a patient about ways to decrease her risk of bone fractures. The following statements by the patient indicate a good understanding. (Select all that apply.)&#10;A) &#34;I should do weight-bearing exercises.&#34;&#10;B) &#34;I should get adequate intake of calcium and vitamin D.&#34;&#10;C) &#34;I should exercise regularly.&#34;&#10;D) &#34;I need to do yoga exercises.&#34;

Accepted Answer

Inadequate dietary intake of calcium and vitamin D or impaired calcium metabolism may result in osteoporosis, which increases bone fragility and may lead to fractures. Decreased physical exercise and lack of weight-bearing exercise also contribute to bone fragility, deterioration, and loss of strength. Any type of exercise will help; it does not need to be yoga, but it does need to include weight-bearing exercise.

Question 5

The nurse is performing passive range-of-motion exercises on his patient when the patient begins to complain of pain. What is the first thing the nurse should do?&#10;A) Notify the health care provider.&#10;B) Hyperextend the joint.&#10;C) Stop the range of motion.&#10;D) Switch to active range of motion.

Accepted Answer

Stop range-of-motion exercises if the patient begins to complain of pain or if resistance to movement is experienced. Never hyperextend or flex a patient's joints beyond the position of comfort. Active range of motion is when the patient moves the joint. Notifying the health care provider would happen after you stopped.

Question 6

The nurse knows that manual lifting should only be done in the following situations:&#10;A) Patients who are less than 150 lb&#10;B) Life-threatening situations&#10;C) Postsurgical patients&#10;D) Patients who are less than 200 lb

Accepted Answer

The National Institute for Occupational Safety and Health (NIOSH) and the American Nurses Association (ANA) support the Safe Patient Handling and Movement Guidelines released in March 2010. Under these guidelines and position statements, manual lifting should be used in a few extreme situations instead of using mechanical lift devices, such as in life-threatening situations, for pediatric or small patients, or for patients who mostly are bearing their own weight. Postsurgical patients may not fit the criteria. Patients less than 150 or 200 lb may not fit the criteria.

Question 7

The nurse correctly selects which intervention to avoid causing shear or friction when moving a patient in bed?&#10;A) Using an airflow bed&#10;B) Using a slide board&#10;C) Using a trochanter roll&#10;D) Using a gel mattress

Accepted Answer

A transfer or slide board is made of plastic-like material that reduces friction. Linens easily slide over the board, facilitating bed linen changes. Patients can be repositioned or transferred with a minimum of force required. A trochanter roll prevents outward rolling of the hip when a patient is lying on his/her back. An air-fluidized bed uses airflow to move silicone particles in the bed, creating a watery, fluid-like movement and resulting in lower pressure to avoid or alleviate decubitus ulcers. A foam or gel combination mattress reduces pressure.

Question 8

The nurse is preparing to assist her patient to walk to the bathroom after medicating her with a narcotic for pain management. Of what possible adverse effect should the nurse be immediately aware?&#10;A) Constipation&#10;B) Depression&#10;C) Dizziness&#10;D) Pain relief

Accepted Answer

Potential adverse side effects of narcotics include respiratory depression, hypotension, confusion, sedation, constipation, and dizziness. The nurse should be immediately aware of dizziness during ambulation because of the safety risks. Pain relief is expected. Depression is not an immediate adverse side effect. Constipation will not impact the nurse's ability to safely ambulate the patient.

Question 9

The nurse is preparing to reposition the patient in bed. What is the first step in this process?&#10;A) Position the patient's arms across his/her chest.&#10;B) Lower the side rails.&#10;C) Grasp the draw sheet.&#10;D) Raise the bed to a working height.

Accepted Answer

Raising the bed to a working height is the first step before beginning the procedure. Proper positioning of equipment prevents provider discomfort and reduces the chance of possible injury. Then lower the side rails as appropriate and safe, and ensure that the bed wheels are locked. Then you can have the patient position his/her arms and/or grasp the draw sheet.

Question 10

An appropriate goal for the patient who is postoperative day one from abdominal surgery and on bed rest with the nursing diagnosis Impaired skin integrity is:&#10;A) the patient will ambulate twice a day.&#10;B) the patient will eat 50% of meals.&#10;C) the patient will have no further skin breakdown.&#10;D) the patient will interact with others.

Accepted Answer

The patient already has a wound, so the goal is focused on no further skin breakdown as a result of the bed rest and immobility. Although nutrition is important to wound healing, it is not the focus of this nursing diagnosis. Ambulating and interacting with others are not goals for this diagnosis.

Question 11

The nurse is educating the family of a patient on falls risk precautions. Which of the following statements by the family indicates a need for further education?&#10;A) &#34;I should keep the wheelchair locked unless using it to move Mom.&#34;&#10;B) &#34;I should always leave the bathroom light on.&#34;&#10;C) &#34;I should use nonskid socks, not shoes.&#34;&#10;D) &#34;I should keep her cell phone close to her bed.&#34;

Accepted Answer

The answer of The nurse is educating the family of...

Question 12

The nurse knows the following indicates orthostatic hypotension: (Select all that apply.)&#10;A) A decrease in systolic blood pressure by 30 mm Hg&#10;B) A decrease in diastolic blood pressure by 10 mm Hg&#10;C) An increase in heart rate by 30 beats/min&#10;D) An increase in systolic blood pressure by 20 mm Hg

Accepted Answer

The answer of The nurse knows the following indicates orthostatic...

Question 13

The nurse appropriately delegates care to the UAP when she:&#10;A) instructs the UAP to assess the patient's skin during a bath.&#10;B) instructs the UAP to reposition the patient using the trapeze.&#10;C) instructs the UAP to assess the patient's ability to perform range-of-motion exercises.&#10;D) instructs the UAP to notify the health care provider of any changes.

Accepted Answer

The answer of The nurse appropriately delegates care to the...

Question 14

The nurse is educating the patient about the effects of immobility on the body. The following statements by the patient indicate a need for further education: (Select all that apply.)&#10;A) &#34;I can become very weak.&#34;&#10;B) &#34;I will gain weight.&#34;&#10;C) &#34;I will lose muscle tone.&#34;&#10;D) &#34;I can get bed sores.&#34;

Accepted Answer

The answer of The nurse is educating the patient about...

Question 15

The nurse knows the following items should be included in the documentation of the patient on falls precautions: (Select all that apply.)&#10;A) History of any falls&#10;B) Falls risk assessment scores&#10;C) Patient and family education&#10;D) Use of assist devices&#10;E) Any fall or reported fall&#10;F) None of the above

Accepted Answer

The answer of The nurse knows the following items should...

Question 16

The nurse correctly teaches the patient to rise from a chair using crutches when the following interventions are used:&#10;A) Patient starts from the back of the chair.&#10;B) The weak leg is closest to the chair.&#10;C) The hand on the strong side holds the handbar of the crutch.&#10;D) The strong leg is closest to the chair.

Accepted Answer

The answer of The nurse correctly teaches the patient to...

Question 17

The nurse knows rheumatoid arthritis affects the musculoskeletal system by causing:&#10;A) muscle weakness.&#10;B) muscle wasting.&#10;C) muscle inflammation.&#10;D) muscle mobility.

Accepted Answer

The answer of The nurse knows rheumatoid arthritis affects the...

Question 18

An appropriate goal for the patient who is postoperative day one from a hip fracture with the nursing diagnosis Impaired physical mobility is:&#10;A) the patient will interact with others.&#10;B) the patient will ambulate to the bathroom with assistance.&#10;C) the patient will have no skin breakdown.&#10;D) the patient will have a physical therapy consult.

Accepted Answer

The answer of An appropriate goal for the patient who...

Question 19

The nurse knows that a patient with a compromised cardiopulmonary system has a diminished capacity for exercise because of the following: (Select all that apply.)&#10;A) Decreased tissue perfusion&#10;B) Loss of sensation&#10;C) Hemiparesis&#10;D) Diminished respiratory capacity

Accepted Answer

The answer of The nurse knows that a patient with...

Question 20

The nurse is implementing generalized falls precautions for his patients who are at risk for falls. Which intervention indicates a lack of understanding of these precautions?&#10;A) The bed is placed in the low position.&#10;B) The patient is wearing socks.&#10;C) The patient's cell phone is by the bedside.&#10;D) The patient's call light is within reach.

Accepted Answer

The answer of The nurse is implementing generalized falls precautions...

Question 21

The nurse is providing discharge education for her patient who is going home with a walker. Which statement by the patient indicates a good level of understanding of safety in the home? (Select all that apply.)

A) "I need to remove the throw rugs."
B) "I should make sure I only take a bath."
C) "I cannot use the stairs."
D) "I need to place a nonskid mat in front of the kitchen sink."

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Accepted Answer

The answer of The nurse is providing discharge education for...

Question 22

The nurse knows the knee-high SCD sleeves are correctly placed on the patient when the following conditions are met: (Select all that apply.)&#10;A) Both sleeves are connected to the SCD device.&#10;B) Two fingers fit inside when the SCDs are inflated.&#10;C) There are no kinks in the tubing.&#10;D) The ankle pressure is 55 to 65 mm Hg.&#10;E) The cooling control is on.

Accepted Answer

The answer of The nurse knows the knee-high SCD sleeves...

Question 23

The nurse appropriately delegates care of her patient to the properly trained UAP when she: (Select all that apply.)&#10;A) assigns the UAP to reposition the patient.&#10;B) assigns the UAP to complete the MORSE falls risk scale.&#10;C) assigns the UAP to provide range-of-motion exercises.&#10;D) assigns the UAP to ambulate the patient in the hallway.

Accepted Answer

The answer of The nurse appropriately delegates care of her...

Question 24

The nurse is correctly assisting the patient in using a cane when the patient demonstrates the following: (Select all that apply.)&#10;A) The top of the cane is level with the patient's bent elbow.&#10;B) The patient holds the cane on his/her weaker side.&#10;C) The patient moves the cane forward first.&#10;D) The patient's arm is comfortably bent when walking.

Accepted Answer

The answer of The nurse is correctly assisting the patient...

Question 25

The nurse is correctly demonstrating the use of a transfer belt when engaging in the following: (Select all that apply.)&#10;A) The belt is placed around the patient's hips.&#10;B) The belt is secure, leaving only enough room for the nurse to grasp the belt.&#10;C) The nurse stands on the weaker side.&#10;D) The nurse holds the belt on the side of the patient.

Accepted Answer

The answer of The nurse is correctly demonstrating the use...

Deck 28: Activity, Immobility, and Safe Movement