Ch 11 Flashcards
The nurse is caring for a client who uses a mechanical aid for walking. The device extends only to the forearm. The device stabilizes the wrists and this makes walking safer and easier. Which device is this client using?
- An axillary crutch
- A walker
- A Lofstrand crutch
- A quad cane
3
A home care nurse is assessing a new client regarding safety issues for ambulation in the home. Which statement, if made by the client’s wife, indicates the need for further teaching?
- ‘My husband should wear nonskid shoes to ambulate’
- ‘I should help my husband to stand up in the shower’
- ‘I should remove any loose objects on the floor’
- ‘My husband should not ambulate on unfastened rugs’
2
The nurse is assessing the client’s technique after teaching the client how to use crutches. Which situation would require intervention by the nurse?
- The weight of the client’s body is put on the axillae
- The client maintains an erect posture
- The client is wearing rubber soled shoes
- The shoulder rest is three finger widths below the axillae
1
A nurse is assisting a client into a wheelchair. Which practice guidelines are important to follow for this client? Select all that apply
- The nurse locks the brakes on both wheels of the wheelchair when the client transfers in and out of it
- The nurse lowers the footplates before transferring the client into the wheelchair
- The nurse raises the footplates after transferring the client into the wheelchair
- The nurse ensures that the client is positioned toward the front of the wheelchair seat
- The nurse backs the wheelchair into or out of the elevator, rear large wheels first
1 and 5
A nurse is deciding which client to assign to the UAP for ambulation. Which client would be most suited for the UAP?
- A client who has just been admitted for syncope
- A client with orthostatic hypotension
- A client just returned from the recovery room after surgery
- A client who had surgery 2 days ago
4
The nurse is preparing to document the client’s ambulation. Which components are important to include in the documentations. Select all that apply
- The distance of ambulation
- The duration of ambulation
- The clients gait
- The baseline blood pressure only
- The degree of support needed
1, 2, 3, and 5
The nurse working in a long term care facility is assigned a client who requires three people to transfer. The unit has been extremely busy and everyone is busy at this time. The nurse needs to assist the client back into bed now because the client is complaining of discomfort and wants to return to bed. Which action should the nurse take?
- Assist the client back to bed without assistance
- Encourage the client to wait until help is available
- Transfer the client with on other person assisting
- Use a hydraulic lift to transfer the client with the assistance of another person
4
The nurse is caring for a client who is required to remain in bed for an extended period of time while in traction for a fractured femur. How can the nurse prepare the client for ambulation?
- Place the bed in reverse Trenelenburg position so the client can put some weight on the feet in bed
- Encourage the client to be as independent as possible while in bed
- Encourage the client to exercise both legs while in bed
- Perform range of motion of all extremities every 4 hours
2
The nurse observes an UAP pushing a client in a wheelchair. Which action would require the nurse to correct the UAPs performance?
- The UAP raises the footrests for the client to get into the wheelchair
- The UAP pushes the wheelchair into the elevator with the client facing forward so they can see where they are going
- The UAP locks the brakes and holds the wheelchair while the client sits in the seat
- The UAP holds the handle of the wheelchair while unlocking the brakes before moving the chair forward
2
The nurse assesses a client newly fitted for a cane and recognizes that the cane is well fitted when observing which action?
- The client’s arm is straight and the client is standing upright
- The client’s elbow is flexed and the client is flexing the knees
- The client’s elbow is flexed slightly and the client is standing upright
- The client elbow is flexed 45° and the client is standing upright
3
