Activity and Mobility - NCLEX-style

Activity and Mobility - NCLEX-style 5.0 (4 reviews) Students also studied Terms in this set (60) Galen College of Nursing-LouisvilleNUR 155 Save Skin Integrity & Wound Care - NCLE...21 terms P4542Preview Nursing Process Questions and Ans...31 terms SamSabolaPreview Vital Signs Practice for NCLEX Ques...15 terms lizzyohmesPreview CH 28 14 terms jenn Which of the following could put a nurse or healthcare worker at risk for sustaining a back injury?

• Lifting a box of IV supplies up and over the head to

place on a shelf

• Placing the feet 2 feet apart before sliding a patient up

in bed

• Squatting to measure chest tube drainage
• Raising the bed to waist level when starting an IV
• Lifting a box of IV supplies up and over the head to place on a shelf

Lifting an object overhead can strain a person's back or interfere with balance, leading to back injury or a fall. All other options represent the use of proper body mechanics.A patient is restrained at the wrists. At intervals, she is flexing her arm, pulling against the restraint tied to the bed. Technically, what type of exercise is this?

• Aerobic
• Isotonic
• Isometric
• Anaerobic
• Isometric

Isometric exercises involve muscle contraction without motion. They are usually performed against an immovable surface or object—for example, pressing the hand against a wall, or pulling the wrist against a secured restraint.

In addition to proper positioning, which of the following would be an important nursing measure for a patient who is immobile?

• Encouraging a low-calcium diet to prevent kidney

stones

• Limiting fluid intake so she does not have to use the

bedpan as frequently

• Encouraging the patient to lie still so he does not

cause a blood clot to become dislodged

• Performing a skin assessment to dependent areas at

least once every shift

• Performing a skin assessment to dependent areas at least once every shift

An immobile patient is at risk for pressure-related injury to the skin, especially from the patient is incontinent or diaphoretic. Frailty (bony prominences) also increases the risk for pressure injury. Therefore, a skin assessment at least once a shift is important for the early detection of decubitus. Other responses are incorrect. A diet low in calcium will not prevent kidney stones; kidney stones develop only in susceptible people, regardless of calcium intake. Limiting the fluid intake will place the patient at risk for a urinary tract infection. Keeping extremities still will lead to increased venous pooling and risk for the development of blood clots.Mary is working in a small rural hospital and is caring for a comatose patient who is beginning to develop foot drop.If there were no footboard available to use for proper positioning of the feet, Mary could use which of the following?

• Overhead trapeze
• Basketball shoes
• Pillow
• Trochanter roll
• Basketball shoes

Basketball shoes are a type of high-top, athletic footwear that help to keep the foot in flexion. The other responses are incorrect. A trapeze would not be used by a comatose patient. A pillow is too soft to maintain proper position of the feet, allowing rotation of the legs. A trochanter roll prevents external rotation of the hips.Mrs. Williams has severe chronic obstructive pulmonary disease and becomes very short of breath when completing her ADLs. Which of the following nursing diagnoses would most accurately reflect Mrs. Williams's mobility problem?

• Ineffective Coping
• Impaired Physical Mobility
• Activity Intolerance
• Deficient Knowledge
• Activity Intolerance

There is no data to suggest that the patient is not coping or has a knowledge deficit. Although she does have impaired mobility, the most accurate diagnosis is Activity Intolerance related to her poor oxygenation status.A nurse is transferring a patient from a bed to a wheelchar. Which should the nurse do to quickly assess this patients tolerance to the change in position?

• Obtain a blood pressure
• Monitor for bradycardia.
• Determine if the patient feels dizzy.
• Allow the patient time to adjust to the change in

position.

• Determine if the patient feels dizzy.

A nurse turns a patient's ankle so that the sole of the foot moves medially toward the midline. Which word should the nurse use when documenting exactly what was done during range-of-motion exercises?

• Inversion
• Adduction
• Plantar flexion
• Internal rotation
• Inversion

Flexibility training involves moving a muscle against resistance.

• True
• False
• False

Moving a muscle against resistance is resistance training.A 10-year-old boy fell playing ice hockey. He comes to the emergency department reporting pain in his right forearm. The nurse notes that the boy's arm is swelling and tender to touch. There is an area of bruising on the lateral aspect of his arm, which upon palpation is very firm. The nurse suspects a fracture; however, it cannot be

confirmed until:

1) a venous and arterial Doppler is obtained 2) clinical exam of the arm indicates a fracture 3) the swelling is decreased by applying ice 4) an x-ray of the extremity is obtained 4) an x-ray of the extremity is obtained The variation in density evident on an x-ray allows the clinician to visually diagnose a fracture.A venous or arterial Doppler is used to detect blood flow and would not be used to detect a fracture. Although the clinical exam of the arm indicates a fracture, an x-ray of the suspected bone is a cost-effective, reliable test to definitively diagnose fracture. Applying ice would aid in decreasing the swelling at the site.Signs and symptoms associated with a sprain, strain, or fracture are the same A 50-year-old woman had a surgical repair of a fracture of her right tibia 2 days ago. She has been using crutches for ambulation and must remain non-weight-bearing on her right leg, but must learn to use the steps leading into

her house. The nurse should instruct the woman to:

1) set the crutches aside and use the stair rail to bear weight only on the left leg when going up or down stairs 2) use the crutches, maintaining toe-touch weight- bearing on the right leg when going up or down the stairs 3) have someone help her up and down the stairs by allowing her to hold on to that person 4) lead with the left leg when going up steps, and lead with the right leg when going down steps 4) lead with the left leg when going up steps, and lead with the right leg when going down steps To teach the patient how to go down stairs, instruct him to hold his injured leg in front and hop down each stair on his good leg, one step at a time. When going up stairs with no handrail, he should lead with his good leg by standing close to the first step with weight on the crutches, and lift the uninjured leg, landing it solidly on the step. Then bring the crutches up to that same step, and repeat. If there is a handrail, then patient holds the crutches in one hand and handrail with the other.He then brings the good leg up one step, while the injured leg bears no weight.A middle-aged man has no known medical problems, although he is overweight. He tells the nurse that he is a computer programmer and gets little exercise. The nurse suggests to the patient that a fitness program would be beneficial to control his weight and improve his overall health. The patient states, "I would like to exercise but I am afraid I will have a heart attack and die if I strain my

heart too much." The nurse's best response would be:

1) "It sounds like you are fearful of having a heart attack and dying. I understand why you might feel this way." 2) "Your records show there is a health history of heart attack in your family; tell me more about that." 3) "The risk of having a heart attack during strenuous exercise is low, but you still should be checked out first." 4) "The risk of having a heart attack during strenuous exercise increases in a high-risk patient such as you." 3) "The risk of having a heart attack during strenuous exercise is low, but you still should be checked out first." Exercise itself is rarely life threatening, especially when compared with the alternative (not exercising). Before starting an exercise program or significantly increasing the intensity of normal workouts, conditioned athletes as well as novices should be screened for underlying health problems, such as high blood pressure, thickened heart muscle (cardiac hypertrophy), electrical abnormalities (dysrhythmias), and blood vessel abnormalities. Although showing empathy might help establish rapport and asking questions about family medical history might elicit information, neither does anything to address the patient's concern and encourage him to exercise. He is not a "high-risk" patient according to the data in this scenario and would not have a greater risk of heart attack with strenuous physical activity.

A patient is obese and complains of fatigue with activity.She states, "I am so tired, I can't even walk out to my mailbox without resting every 5 minutes." Her vital signs are within normal limits at rest; however, upon minimal exertion she experiences dyspnea, and her pulse rises from 80 to 140 beats/min. She denies chest pain and has full range of motion to all joints. The nurse practitioner explains to the patient that she needs to lose weight and begin a fitness program. The best nursing diagnosis for

this patient is:

1) Impaired Physical Mobility related to obesity 2) Risk for Disuse Syndrome related to musculoskeletal inactivity 3) Activity Intolerance related to obesity and dyspnea secondary to sedentary lifestyle 4) Impaired Physical Mobility related to limited range of motion, secondary to obesity 3) Activity Intolerance related to obesity and dyspnea secondary to sedentary lifestyle In this scenario, Impaired Physical Mobility is the etiology of another problem: Activity Intolerance. Activity Intolerance is a state in which a patient has insufficient physical or psychological energy to carry out daily activities.Subjective characteristics include fatigue, weakness, discomfort with exertion, dyspnea, and verbalization of no interest in activity. Objective characteristics include changes in heart rate, blood pressure disproportionate to activity, dysrhythmias, or evidence of ischemia on electrocardiogram (ECG), and pallor or cyanosis with activity. There is no evidence that this patient has limited range of motion. Disuse syndrome is a more severe complication of immobility, more likely to be seen where there is little to no skeletal muscle activity.A patient is obese and complains of fatigue with activity.The nurse is planning goals for this patient. Which of the following NOC outcome(s) relate(s) directly to the above nursing diagnosis; that is, which outcome(s), if achieved, would demonstrate resolution of her problem? SELECT

ALL THAT APPLY.

1) Endurance 2) Activity Tolerance 3) Active Joint Movement 4) Mobility Level 1) Endurance 2) Activity Tolerance Both Endurance and Activity Tolerance, if demonstrated by this patient, would show that her problem (Activity Intolerance) is improving. Active Joint Movement and Mobility Level relate to part of the etiology of her problem, which is lack of activity. Even if she demonstrates joint movement and other mobility, this would not necessarily indicate that she is tolerating the activity well.A patient is obese wants to lose weight and start exercising. She complaints of fatigue with activity. Which of the following nursing interventions would be appropriate for this patient? Encourage her to (SELECT

ALL THAT APPLY):

1) consult her primary care provider prior to starting a fitness program 2) increase her level of activity within her daily routine.3) refuel with protein and carbohydrate within 45 minute of her workout 4) rest as needed when her perceived level of exertion is high All.