Exercise and Activity

1.The nurse working on an orthopedic unit has to assist many of the patients because of limited mobility. The nurse’s goal is to maintain a position that most favors function, requires the least muscular work to maintain, and places the least strain on muscles, ligaments, and bones. What is the term that best describes this goal?

a.
Body alignment
b.
Posture
c.
Center of gravity
d.
Balance

ANS: B

The term posture means maintaining optimal body position. It means a position that most favors function, requires the least muscular work to maintain, and places the least strain on muscles, ligaments, and bones. Center of gravity refers to the term that describes how body balance is achieved, over a wide stable base of support. Body alignment refers to the relationship of one body part to another body part along a horizontal or vertical line. Correct alignment reduces strain on musculoskeletal structures, maintains adequate muscle tone, and contributes to balance.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:678

OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

2.The nurse is taking care of a 78-year-old comatose patient. The nurse has placed the patient in a supine position. To prevent foot drop, the nurse applies which of the following?

a.
Pillows to dorsiflex the foot
b.
Trochanter rolls to the feet
c.
Foot boots as ordered
d.
Pillows to elevate the feet

ANS: C

Avoid pressure on the back of the legs and heels—pillows elevating the feet or dorsiflexing the foot may cause increased pressure. Use a foot boot to prevent footdrop, maintain proper alignment, and provide freedom of movement for the feet. When a patient is immobile, use pillows, trochanter rolls, and hand rolls or arm splints to increase comfort and reduce injury to the skin or musculoskeletal system.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:691

OBJ:Describe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

3.A nurse who works on the orthopedic unit knows that in addition to providing support, bones perform other functions in the body. Besides support, which of the following is an important bone function used during activity and exercise?

a.
Hematopoiesis
b.
Protection
c.
Mineral storage
d.
Movement

ANS: D

Bones perform five functions in the body: support, protection, movement, mineral storage, and hematopoiesis (blood cell formation). Two of these functions—support and movement—are most important during activity and exercise. In support, bones serve as the framework and contribute to the shape, alignment, and positioning of the body parts. In movement, bones with their joints constitute levers for muscle attachment. Hematopoiesis and mineral storage are not involved with bone function during activity and exercise.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:679

OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

4.The patient has been diagnosed with a progressive neuromuscular disease and is having difficulty walking and has decreased awareness of the body’s position. What is the term that best describes this phenomenon?

a.
Balance
b.
Proprioception
c.
Posture
d.
Hemiplegia

ANS: B

Proprioception is the awareness of the position of the body and its parts and is dependent on impulses from the inner ear and from receptors in joints and ligaments. The nervous system also regulates posture. Posture is incorrect because it requires coordination of proprioception and balance. Balance is incorrect because it is controlled by the inner ear and the cerebellum. Hemiplegia is incorrect because this term is used to describe paralysis on one side of the body.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:680

OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

5.As the result of a brain tumor, a patient is having trouble with balance. The patient’s significant other is concerned and asks the nurse how a tumor could affect the patient’s balance. The nurse explains that the tumor is growing in the part of the brain that is responsible for balance. The significant other asks, “Which part of the brain controls balance?” The nurse’s response would be which of the following?

a.
Pons
b.
Cerebrum
c.
Cerebellum
d.
Hypothalamus

ANS: C

The cerebellum and the inner ear control balance through the nervous system. The major function of the cerebellum is to coordinate all voluntary movement. The pons deals with levels of arousal, consciousness, and sleep. The cerebrum controls thoughts, memory, decision making, and communication. The hypothalamus controls the autonomic functions of the peripheral nervous system.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:680

OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

6.Which group of muscles is involved with joint stabilization?

a.
Skeletal muscles
b.
Antigravity muscles
c.
Synergistic muscles
d.
Antagonistic muscles

ANS: B

Antigravity muscles are involved with joint stabilization. Skeletal muscles support posture and carry out voluntary movement. Antagonistic muscles bring about movement at the joint. Synergistic muscles contract to accomplish the same movement. When you flex your arm, you increase the strength of the contraction of the biceps brachii by contraction of the synergistic muscle, the brachialis.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:681

OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

7.The patient is a 46-year-old woman who is a devout Muslim and who is being evaluated for weight-loss surgery. One aspect of the comprehensive bariatric program is that clients begin an exercise program. The patient is self-conscious about her weight and concerned about maintaining her modesty. Which of the following exercise programs would be the best choice for the nurse to suggest?

a.
A private trainer at a local fitness center
b.
An aerobics class at the local YMCA
c.
The evening yoga class at a local country club
d.
Walking 30 minutes a day at the mall with a friend

ANS: D

Exercise and physical fitness are beneficial to all people. When developing a physical fitness program for culturally diverse populations, consider what motivates individuals to exercise and what activities will be appropriate and enjoyable. Modesty and discretion are highly valued in the Muslim culture. Public aerobics and yoga classes may make the devout Muslim uncomfortable and violate her sense of modesty. Based on her religious and cultural background, the use of a private trainer, an aerobics class at the local YMCA, or yoga classes at the local country club are incorrect choices for this patient.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:681

OBJ: Write a nursing care plan for a patient with impaired body alignment and activity.

TOP:Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

8.A small business owner has noted an increase in back injuries at his company in recent years. During a discussion with an occupational health nurse, knowledge of statistical information regarding this trend throughout the country is exchanged. The occupational health nurse explains that the most common back injury is caused by a strain to which of the following muscle groups?

a.
Lumbar
b.
Cervical
c.
Thoracic
d.
Trapezius

ANS: A

The most common back injury is strain on the lumbar muscle group, which includes the muscles around the lumbar vertebrae. Injury to these areas affects the ability to bend forward, backward, and side to side. This also decreases the ability to rotate the hips and lower back. The cervical response is incorrect because it refers to the neck region of the back. The thoracic response is incorrect because it refers to the rib/chest area of the back which has decreased movement. The trapezius is incorrect because it refers to a muscle in the back over the scapula.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:680

OBJ:Discuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

9.The nurse is assigned to a 79-year-old patient who has decreased mobility resulting from a stroke. The nurse understands the interventions to prevent skin breakdown for this bedfast patient is to include repositioning of the patient at least every _____ hour(s).

a.
1
b.
2
c.
3
d.
4

ANS: B

In general, you reposition patients as needed and at least every 2 hours if they are in bed and every 1 hour if they are sitting in a chair.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:689

OBJ: Evaluate the nursing care plan for maintaining body alignment and activity.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

10.The nurse is assigned to take care of a 56-year-old patient with COPD. The patient does not tolerate a supine position for sleeping. In what position should the nurse place the patient?

a.
Lateral
b.
Prone
c.
Semi-Fowler’s
d.
Sims’

ANS: C

In semi-Fowler’s position the head of the bed is at a 30-degree angle. Use this position for patients who cannot tolerate a supine position, such as those with cardiac and respiratory problems. Prone position is incorrect because it can compromise lung expansion. Lateral position is incorrect because patients who are obese or older do not tolerate this position for any length of time. Sims’ position is incorrect because it is a semi-prone position that can compromise lung expansion.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:689 | 691

OBJ: Write a nursing care plan for a patient with impaired body alignment and activity.

TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

11.The nurse is assigned to a 67-year-old comatose patient. To minimize the risk for aspiration, the nurse should avoid placing the patient in what position?

a.
Semi-Fowler’s
b.
Sims’
c.
Supine
d.
Lateral

ANS: C

The risk for aspiration is greater in the supine position; thus avoid this position when the patient is confused, agitated, experiencing a decreased level of consciousness, or is at risk for aspiration. Semi-Fowler’s is an incorrect answer because that is the position of choice to prevent aspiration. Sims’ is incorrect because it is a semi-prone position that would allow the stomach contents to exit the body if the patient experienced emesis. Lateral is incorrect because the patient would be placed on his or her side, which would promote the exit of stomach contents if the patient experiences emesis.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:691

MSC:Client Needs: Reduction of Risk Potential

12.A 19-year-old patient with cerebral palsy has been admitted to the hospital with pneumonia. The patient has limited voluntary motor control. The student nurse caring for this patient, knows that the easiest intervention to maintain joint mobility would be to perform which of the following exercises?

a.
Active range-of-motion exercises
b.
Weight-bearing exercises
c.
Aerobic exercises
d.
Passive range-of-motion exercises

ANS: D

For the patient who does not have voluntary motor controls, passive range-of-motion exercises are the exercises of choice. Because of limited voluntary motor control, active range of motion exercises, aerobic exercises, and weight-bearing exercises are incorrect responses for this patient.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:692

OBJ:Discuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

13.A patient has been hospitalized for 5 days after pancreatic surgery. The nurse is preparing the patient to ambulate for the first time. What is the best action for the nurse to perform to prevent the patient from suffering orthostatic hypotension?

a.
Have him sit up in bed for a few minutes before standing.
b.
Have him sit up with his legs dangling over the side of his bed for a few minutes before standing.
c.
Place him in a high-Fowler’s position for a few minutes before standing.
d.
Place him in a low-Fowler’s position for a few minutes before standing.

ANS: B

When preparing a patient for ambulation, dangling is an important technique. You assist the patient to a sitting position with the legs dangling off the side of the bed and have the patient rest for 1 to 2 minutes before standing. When the patient has been flat for extended periods, blood pressure drops when the patient stands. Dangling helps to prevent this. Sitting up in bed or placing the patient in high- or low-Fowler’s position does not allow for the changes in circulation to occur before ambulation.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:692 | 693

MSC: Client Needs: Safe and Effective Care Environment

14.A student nurse is assisting a patient who is ambulating with a new walker. Which of the following is appropriate information for student nurse to provide to the patient?

a.
“The top of the walker should line up with the crease on the inside of your elbows.”
b.
“You should walk behind the walker to maintain balance.”
c.
“You should lean forward over the walker to maintain balance.”
d.
“When walking, you should take a step, move the walker forward, and take another step.”

ANS: D

When the person relaxes the arms at the side of their body, the top of the walker should line up with the crease on the inside of the wrist. A walker is fitted correctly by having the patient step inside the walker. The person’s elbow should bend comfortably, about 30 degrees, while holding onto the grips. When walking, the patient holds the handgrips on the upper bars, takes a step, moves the walker forward, and takes another step. The patient should not lean over the walker or walk behind it; otherwise he or she might lose balance and fall.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:693

MSC: Client Needs: Safe and Effective Care Environment

15.A student nurse is caring for 67-year-old patient who is experiencing left-sided weakness caused by a stroke. The student nurse is providing patient teaching regarding the use of a quad-cane for ambulation. Which of the following statements is correct?

a.
“You should use the cane on the stronger side of the body.”
b.
“Move the stronger leg with the cane.”
c.
“When walking, advance the weaker leg past the cane.”
d.
“Your body weight should be supported by the cane and stronger leg.”

ANS: A

Make sure the patient keeps the cane on the stronger side of the body. The patient moves the weaker leg to the cane, which divides body weight between the cane and the stronger leg. The patient then advances the stronger leg past the cane so the weaker leg and the body weight is supported by the cane and weaker leg.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:694

MSC: Client Needs: Health Promotion and Maintenance

16.Which of the following statements is appropriate for a nurse to teach a patient regarding the use of crutches?

a.
“The axillae should support all your body weight.”
b.
“Your elbows should be straight when your hands are on the crutch handgrips.”
c.
“The distance between the crutch pad and axillae should be three to four finger widths.”
d.
“Your elbows should be flexed about 45 degrees when the handgrip position is correct.”

ANS: C

Make sure you position the handgrips so the axillae do not support all patients’ body weight. Pressure on the axillae increases risk to underlying nerves, which sometimes results in partial paralysis of the arm. You determine the correct position of the handgrips with the patient upright, supporting weight by the handgrips with the elbows slightly flexed (20 to 25 degrees). You verify elbow flexion with a goniometer. When you have determined the height and placement of the handgrips, you again verify that the distance between the crutch pad and the patient’s axilla is three to four finger widths.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:693-694

OBJ:Discuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

17.A nurse is teaching a crutch walking technique that requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. What is the term for this gait?

a.
Four-point gait
b.
Three-point gait
c.
Two-point gait
d.
Three-point alternating gait

ANS: A

Four-point alternating or four-point gait gives stability to the patient but requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. The two-point gait requires at least partial weight bearing on each foot. Three-point alternating or three-point gait requires the patient to bear all of the weight on one foot. In a three-point gait, the patient puts weight on both crutches and then on the uninvolved leg, and then repeats the sequence. The affected leg does not touch the ground during the early phase of the three-point gait. Gradually the patient progresses to touchdown and full weight bearing on the affected leg.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:696

OBJ:Discuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

18.The nurse is in charge of caring for five orthopedic patients during ashift. Nursing assistive personnel are available to assist the nurse with care of the patients. Which of the following tasks is most appropriate for the nurse to delegate to the nursing assistive personnel?

a.
Moving a 45-year-old patient who had a CVA toward the head of the bed
b.
Transferring an 85-year-old patient for the first time after a total hip replacement
c.
Providing discharge teaching for a 49-year-old patient who had a stroke
d.
Preparing a 77-year-old patient for hip replacement surgery

ANS: A

The skill of moving and positioning patients in bed can be delegated to nursing assistive personnel. Patients whom you are transferring for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma require supervision by professional nurses. Nursing assistive personnel are unable to give preoperative teaching or discharge teaching to a patient.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:707

OBJ:Discuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

19.A nurse and another staff member are preparing to reposition a patient in bed. To prevent back strain, these two health care providers must do which of the following?

a.
Keep their knees stiff to enhance their lifting strength potential.
b.
Keep the weight of the patient as close to their bodies as possible.
c.
Loosen their stomach muscles to keep from injuring the pelvic region.
d.
Twist their upper torsos to enhance the use and strength of their upper extremities.

ANS: B

To prevent lifting-related injuries, always follow these steps:

1. Keep weight as close to the body as possible.

2. Bend at the knees.

3. Tighten abdominal muscles, and tuck pelvis.

4. Maintain the trunk erect and knees bent.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:681 | 708

MSC: Client Needs: Safe and Effective Care Environment

20.A nurse is caring for a patient who has pneumonia. To facilitate respiration and lung drainage this patient should be placed in what position?

a.
Sims’
b.
Prone
c.
Lateral
d.
Supine

ANS: B

When prone, the patient is in the face-down position. This facilitates respiration and drainage of oral secretions. Place a pillow under the head for comfort and relief from pressure. The Sims’ position is used to place the patient in a semiprone position on the right or left side with the opposite arm, thigh, and knee flexed and resting on the bed. In the lateral position, the patient is placed in a side-lying position, supported on the right or left side. This position can compromise chest expansion. In the supine position the patient rests on the back. The risk for aspiration is greater with this position; thus avoid the supine position when the patient is confused, agitated, experiencing a decreased level of consciousness, or at risk for aspiration.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:691

OBJ:Discuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Implementation

MSC:Client Needs: Physiological Integrity

21.A patient presents to the emergency department with a fractured leg that requires a full leg cast. The nurse needs to teach the patient to ambulate with crutches using which of the following?

a.
Two-point gait
b.
Three-point gait
c.
Four-point gait
d.
Tripod alternating position

ANS: B

Three-point gait requires the patient to bear all of the weight on one foot. In a three-point gait, the patient puts weight on both crutches and then on the uninvolved leg. A two-point gait requires at least partial weight bearing on each foot. A four-point gait gives stability to the patient but requires weight bearing on both legs. The tripod position is the basic crutch stance.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:696

OBJ: Assess patients for impaired body alignment, exercise, and activity.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

22.A nurse is caring for a patient with a neuromuscular condition. The nurse needs to assess the patient’s muscle movement and strength. In doing so, the nurse recalls that chemicals that transfer electrical impulses from the nerve across the myoneural junction are called which of the following?

a.
Isometrics
b.
Synergistics
c.
Proprioceptors
d.
Neurotransmitters

ANS: D

Transmission of the impulse from the nervous system to the musculoskeletal system is an electrochemical event that requires a neurotransmitter, a chemical that transfers the electric impulse from the nerve to the muscle. Isometrics is a type of exercise using muscles. Synergistics are opposite effects. Proprioceptors are located in nerve endings.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:679 | 680

OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

23.A nurse is assisting a patient with right-sided hemiplegia to transfer from the bed to a chair. The most appropriate action for the nurse is to do which of the following?

a.
Use a transfer belt.
b.
Grab the patient under the arms while assisting with the transfer.
c.
Stand on the unaffected side of the patient to ensure less strain on the nurse’s back.
d.
Encourage the patient not to use the hand rests because of their restrictions on movement.

ANS: A

A patient with neurological deficits sometimes has paresis (muscle weakness) or paralysis unilaterally or bilaterally, which complicates safe transfer. A flaccid arm sustains injury during transfer if unsupported. As a general rule, use a transfer belt and obtain assistance for mobilization of such patients. Use patient-handling equipment and devices, such as height-adjustable beds, ceiling-mounted lifts, friction-reducing slide sheets, air-assisted devices, and encourage the patient to help as much as possible. Grasping the patient under his or her arms could cause damage to this delicate area and does not allow for a firm hold, as the arms could lift up. A transfer belt is more secure. Always be aware of the patient’s motor deficits, ability to aid in transfer, and body weight. As a rule of thumb, GET HELP to transfer a patient.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:692 | 693

MSC: Client Needs: Safe and Effective Care Environment

24.A patient with arthritis is complaining of sensitivity and warmth in the elbow and wrist joints. To determine the degree of limitation or injury, the nurse can assess which of the following?

a.
Posture
b.
Activity tolerance
c.
Body mechanics
d.
Range of motion

ANS: D

The easiest intervention to maintain or improve joint mobility for patients and one that you are able to coordinate with other activities is the use of range-of-motion exercises. Joints that are not moved periodically develop contractures, a permanent shortening of a muscle followed by the eventual shortening of associated ligaments and tendons. Over time the joint becomes fixed in one position, and the patient loses normal use of the joint. The term posture means maintaining optimal body position. Activity tolerance assesses the patient’s ability to become fatigued, lightheaded, dizzy, or short of breath related to activity. Body mechanics require knowledge of proper walking, turning, and lifting and carrying objects in a way to prevent injury.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:692

OBJ: Assess patients for impaired body alignment, exercise, and activity.

TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

25.The nurse delegates the task of ambulating a patient to the assistive personnel. The nurse ascertains that the assistive personnel understands how to intervene when the patient complains of dizziness when the assistive personnel verbalizes which of the following?

a.
“I call for help.”
b.
“I gently lower the patient to the floor.”
c.
“I support the patient and walk quickly back to the room.”
d.
“I lean the patient against the wall and wait until the episode passes.”

ANS: B

When a patient begins to fall, the nurse should assume a wide base of support with one foot in front of the other to support the patient’s weight, gently lower the patient to the floor, and protect the patient’s head. Assess the patient for injuries at this time and notify the patient’s health care provider. Even if the patient is stable, get the assistance of a lift team to help you get the patient off the floor and back in bed or a chair.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:693

MSC: Client Needs: Safe and Effective Care Environment

26.A nurse is caring for a patient with osteogenesis imperfecta. The nurse needs to assess the patient’s muscle movement and strength. In doing so, the nurse recalls that osteogenesis imperfecta is characterized by fractures and bone deformities. This condition is known as which of the following?

a.
A form of osteoporosis
b.
A form of arthritis
c.
A congenital defect
d.
A neurological defect

ANS: C

Osteogenesis imperfecta is a congenital defect that affects the bone. Osteoporosis is a well-known and well-publicized disorder of aging in which the density or mass of bone is reduced. Inflammatory and noninflammatory joint diseases and articular disruption all alter joint mobility. Some characteristics of inflammatory joint disease (e.g., arthritis) are inflammation or destruction of the synovial membrane and articular cartilage and systemic signs of inflammation. Damage to any component of the central nervous system that regulates voluntary movement results in impaired body alignment and mobility.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:680

OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

27.A nurse is caring for a patient with a broken tibia and fibula. The patient is in a half cast to his knee and is unable to bear weight. The nurse has instructed the patient on how to walk and climb stairs with his injuries. What is the best way to assess the patient’s knowledge of how to ascend and descend stairs?

a.
Incorrectly re-demonstrate the procedure and have the patient point out any errors.
b.
Have the family member explain the procedure.
c.
Have the patient explain the procedure.
d.
Have the patient demonstrate the procedure.

ANS: D

Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with members of the health care team, assess and incorporate the patient’s priorities of care and preferences, and use the best evidence when making decisions about your patient’s care. Explain the procedure, and describe what you expect of the patient. Demonstration is the most accurate way for the nurse to assess understanding of the skill.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:697

OBJ:Discuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Evaluation

MSC: Client Needs: Safe and Effective Care Environment

MULTIPLE RESPONSE

1.Which of the following actions are effective in reducing friction when repositioning a patient in bed? (Select all that apply.)

a.
Lifting rather than pushing
b.
Pushing the patient up in bed
c.
Asking the patient to bend his or her knees and lift the hips when moving up in bed
d.
Asking the patient to lie still as you reposition him or her; even when the patient offers to help
e.
The use of a draw sheet
f.
The use of a transfer board

ANS: A, C, E, F

You reduce friction by lifting rather than pushing a patient. Lifting has an upward component and decreases the pressure between the patient and the bed or chair. The use of a draw sheet reduces friction because you are able to move the patient more easily along the bed’s surface. However, there are several commercially available products to assist in the task of positioning and moving patients in bed such as transfer boards and Maxi Slides. Pushing the patient up in bed is incorrect because pushing increases the friction between the patient and the bed. Asking the patient to lie still is incorrect because a passive or immobilized patient produces greater friction to movement.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:679

MSC: Client Needs: Safe and Effective Care Environment

2.The nurse manager is concerned with the safety of the staff as they transfer patients. Facility policy reinforces the principles of appropriate body mechanics, which include which of the following? (Select all that apply.)

a.
A wide base of support increases stability
b.
A higher center of gravity increases stability
c.
Facing the direction of movement prevents abnormal twisting of the spine
d.
Pivoting requires less work than lifting
e.
Manually lift the patient in sections
f.
Dividing balanced activity between arms and the legs

ANS: A, C, D, F

Principles of body mechanics include the following: A wide base of support increases stability; a lower center of gravity increases stability; the equilibrium of an object is maintained when the line of gravity passes through its base of support; facing the direction of movement prevents abnormal twisting of the spine; dividing balanced activity between arms and legs reduces the risk for back injury; and leverage, rolling, turning, or pivoting requires less work than lifting. Manual lifting is the last resort, and it is only used when it does not involve lifting most or all of the patient’s weight.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:680 | 681

MSC: Client Needs: Safe and Effective Care Environment

3.Which of the following trouble points are common in the side-lying position? (Select all that apply.)

a.
Lack of support for the feet
b.
Lack of protection for pressure points for the ears, shoulders, anterior iliac spine, trochanter, and ankles
c.
Adduction of the shoulder and hip joints
d.
Hyperextension of the neck
e.
Spinal curves out of normal alignment

ANS: A, B, C, E

The following are trouble points that are common in the side-lying position:

• Lateral flexion of the neck

• Spinal curves out of normal alignment

• Shoulder and hip joints internally rotated, adducted, or unsupported

• Lack of support for the feet

• Lack of protection for pressure points at the ear, shoulder, anterior iliac spine, trochanter, and ankles

• Excessive lateral flexion of the spine if the patient has large hips and a pillow is not placed superior to the hips at the waist

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:691

MSC: Client Needs: Safe and Effective Care Environment