Mobility/Ambulation-Chap 10 & 11 skills book Flashcards Preview

NP3 - LAB > Mobility/Ambulation-Chap 10 & 11 skills book > Flashcards

Flashcards in Mobility/Ambulation-Chap 10 & 11 skills book Deck (64)
Loading flashcards...
1

The patient has been admitted for hypertension. His blood pressure is normally in the 160/90 range. He has been on bed rest for the past few days, and the doctor has started him on a new blood pressure medication. The nurse is assisting the patient to move from the bed to the chair for breakfast, but when the patient tries to sit up on the side of the bed, he complains of being dizzy and nauseous. The nurse lays the patient down and takes his vital signs. His pulse is 124. His blood pressure is 130/80. This blood pressure is indicative of what?
a. A normal blood pressure for this patient
b. Orthostatic hypotension
c. Orthostatic hypertension
d. Effective baroreceptor function

ANS: B

2

The patient is an elderly gentleman who has been on bed rest for the past several days. When getting the patient up, the nurse should:
a. tell the patient not to move his legs when dangling.
b. tell the patient to hold his breath while dangling.
c. raise the head of the bed and allow a few minutes before dangling.
d. have the patient stand without dangling.

C

3

An appropriate technique for the nurse to use when performing range of motion (ROM) exercises is to:
a. repeat each action five times during the exercise.
b. perform the exercises quickly and firmly.
c. support the proximal portion of the extremity being exercised.
d. continue the exercise slightly beyond the point of resistance.

A

4

A patient is admitted to the medical unit following a cerebrovascular accident (CVA). Evidence of left-sided hemiparesis is noted, and the nurse will be following up on ROM and other exercises performed in physical therapy. The nurse should correctly teach the patient and family members which of the following principles of ROM exercises?
a. Flex the joint to the point of discomfort.
b. Medicate the patient after the ROM exercise session.
c. Move the joints quickly.
d. Provide support for distal joints.

D

5

A nurse should be concerned when observing a patient performing isometric exercises if the patient is:
a. holding his or her breath while exerting.
b. performing the exercises four times per day.
c. tightening each muscle group for 8 seconds, then relaxing.
d. repeating each exercise 8 to 10 times for each muscle group.

A

6

A nurse encourages a patient to prevent venous stasis by:
a. crossing the legs when sitting in a chair.
b. wearing thigh-length nylon stockings or garters.
c. elevating the legs on pillows while in bed.
d. increasing early ambulation.

D

7

Antiembolic stockings (TEDs) are ordered for the patient on bed rest after surgery. The nurse explains to the patient that the primary purpose for the elastic stockings is to:
a. keep the skin warm and dry.
b. prevent abnormal joint flexion.
c. apply external pressure.
d. prevent bleeding.

C

8

When assessing the patient for risk for DVT, the nurse should consider which of the following an indicator of increased risk?
a. A positive Homans’ sign
b. Pallor to the distal area
c. Edema noted in the extremity
d. Fever or dehydration

D

9

An appropriate procedure for the nurse to use when applying an elastic stocking is to:
a. remove the stockings every 24 hours.
b. keep the tops of the stockings rolled down slightly.
c. turn the stocking inside out to apply from the toes up.
d. wash stockings daily and dry in a dryer.

C

10

When using an SCD, the nurse should:
a. apply powder to the patient’s skin if redness and itching are present.
b. leave a two-finger space between the patient’s leg and the compression stocking.
c. keep the patient connected to the compression device when transferring into and out of bed.
d. remove the elastic stockings before putting on the sequential pneumatic compression stockings.

B

11

The patient is a paraplegic who possesses good arm and hand strength. When the following devices are compared, which would be most appropriate for this patient?
a. Axillary crutch
b. Platform crutch
c. Lofstrand crutch
d. Standard crook cane

C

12

An appropriate way for the nurse to measure a patient for crutches is to:
a. have a flexion of 45 degrees at both of the patient’s elbows.
b. have a space of two to three fingers between the top of the crutch and the axilla.
c. place the crutch tips 1 foot to each side of the patient’s feet, and observe the positioning of the crutches.
d. place the crutch tips 1 foot to the front of the patient’s feet, and observe the positioning of the crutches.

B

13

The patient has been using crutches for the past 2 weeks. When she comes for her follow-up examination, she complains of tingling and numbness in her hands and upper torso. Possible causes of these symptoms are:
a. the patient’s elbows are flexed 15 to 30 degrees when using the crutches.
b. crutch pad is approximately 2 inches below the patient’s axilla.
c. patient holds the cane 4 to 6 inches to the side of her foot.
d. handgrip does not allow for elbow flexion.

D

14

The patient has a leg injury and is being fitted for a cane. The patient should be taught to:
a. hold the cane on the uninvolved side.
b. hold the cane on the weaker side.
c. extend the cane 15 inches from the foot when used.
d. maintain approximately 60 degrees of elbow flexion.



A

15

While ambulating, the patient becomes light-headed and starts to fall. What should the nurse do first?
a. Call for help.
b. Try to reach for a chair.
c. Ease the patient down to the floor.
d. Push the patient back toward the bed.

C

16

When the four gaits listed below are compared, which is the most stable of the crutch gaits?
a. Four-point gait
b. Three-point gait
c. Two-point gait
d. Swing-to gait

A

17

The nurse is caring for a patient who has just been treated for a broken leg. She needs to teach the patient how to use crutches. Which crutch gait is most appropriate for this patient?
a. Four-point gait
b. Three-point gait
c. Two-point gait
d. Swing-to gait

B

18

When teaching the use of a three-point crutch gait, the nurse should instruct the patient to move:
a. both crutches and the affected leg first, then the stronger leg.
b. the right crutch, left foot, left crutch, and right foot in sequence.
c. the left crutch and right foot, then move the right crutch and left foot.
d. both crutches, then lift and swing the legs forward as far as the crutches.

A

19

A patient with left hemiparesis is using a quad cane for ambulation. Which of the following is the correct technique for the nurse to use in teaching the patient?
a. Use the cane on the right side, with the cane moving forward first.
b. Use the cane on the left side, with the left leg moving forward with the cane.
c. Use the cane in either hand, with the right leg moving forward first.
d. Use the cane in either hand, with the left leg moving beyond the forward placement of the cane.

A

20

The patient had a stroke and is currently immobile. The nurse realizes that increasing mobility is critical because immobility can result in alterations in which of the following? (Select all that apply.)
a. Cardiovascular function
b. Pulmonary function
c. Skin integrity
d. Elimination

ALL OF THE ABOVE

21

The nurse is caring for an immobile patient. Which of the following may help reduce the hazards associated with immobility? (Select all that apply.)
a. A high-fiber diet
b. Frequent repositioning
c. Muscle and joint exercises
d. Increased fluid intake

ALL OF THE ABOVE

22

The nurse is applying a CPM machine to the patient’s leg. To do so, she must: (Select all that apply.)
a. provide analgesia 1 hour before starting the CPM.
b. stop the CPM when in extension and place a sheepskin on the machine.
c. align the patient’s joint with the CPM’s mechanical joint.
d. secure the patient’s extremity tightly with Velcro straps.

B, C

23

Factors that contribute to the development of DVT are: (Select all that apply.)
a. elevated sodium (Na+) levels.
b. hypercoagulability of the blood.
c. venous wall damage.
d. stasis of blood flow.

B, C, D

24

____________ refers to an ability to move about freely.

Mobility

25

A person’s inability to move about freely is known as _______________.

Immobility

26

A drop in blood pressure that occurs when the patient changes position from a horizontal to a vertical position is known as _________________.

Orthostatic Hypotension

27

A drop in blood pressure that occurs when the patient changes position from a horizontal to a vertical position is known as _________________.

Orthostatic Hypotension

28

The patient is performing ROM exercises independently. These are known as __________ exercises.

Acrtive ROM

29

Static exercises that involve tightening or tensing of muscles without moving a body part are known as ______________.

Isometric Exercises

30

_________________ increase muscle tension but do not change the length of muscle fibers

Isometric Contractions