dewit- chapter 32 Flashcards
The nurse is discussing actions that can be taken to best prevent osteoporosis with a patient. The nurse’s teaching should include:
A. taking an extra calcium supplement.
B. eating a balanced diet.
C. exercising throughout life.
D. eating daily amounts of milk products.
ANS: C A lifetime of even mild daily exercise will delay or prevent osteoporosis.
When the patient asks what the purpose of goniometry is, the nurse replies that goniometry measures:
A. bone strength.
B. muscle density.
C. muscle strength.
D. range of motion.
ANS: D Goniometry measures joint mobility, described as the number of degrees that the joint can move from the 0-degree mark.
The nurse is aware that positioning and range-of-motion (ROM) exercises most help the immobilized patient to prevent:
a. increased pain.
b. Contractures.
c. pressure ulcers.
d. compromised circulation.
ANS: B Although positioning may help decrease pain and increase circulation, anatomical alignment and ROM exercises are most helpful in preventing contractures in the immobilized patient. Pressure ulcers are prevented by frequent position changes.
The nurse adds interventions for range-of-motion (ROM) and isometric exercises for the new patient with a stroke because the nurse is aware that contracture formation begins as early as _____ day(s) of immobilization.
a. 1
b. 2
c. 3
d. 10
ANS: C Contracture-related muscle changes occur as early as 3 days of immobilization.
The nurse explains that, if muscles are not regularly stretched and contracted, the muscles will become:
A. longer and flexed.
B. fibrosed and spastic.
C. shorter and less elastic.
D. shorter and painful.
ANS: C The formation of contractures (shortening of skeletal muscle tissue causing deformity), loss of muscle tone, and fixation of joints can be prevented in most cases by consistent nursing intervention. The major components of the intervention are gradual mobilization, an exercise program, proper positioning, and instruction of the patient and family. Within a matter of a few days, the structures of immobilized muscles and joints begin to undergo changes. If no effort is made to prevent these changes, the patient will become permanently disabled.
The nurse uses a visual aid to show the pathologic muscle tone changes that result in footdrop. Those changes are:
A. calf muscles are stretched.
B. flexor muscles are stretched.
C. toes curl downward.
D. thigh muscles contract.
ANS: B Th e most frequent contractures occurring in patients immobilized for long periods are “footdrop,” knee and hip flexion contractures, “wrist drop,” and contractures of the fingers and arms. Calf muscles contract and flexor muscles are stretched, allowing the unbraced foot to drop toward the surface of the bed.
The nurse informs the patient that the frequency of range-of-motion (ROM) exercises should be:
A. once a day.
B. once in the morning and once in the afternoon.
C. 3 to 4times a day.
D. 4 to 6 times a day.
ANS: C ROM exercises, both passive and active, are planned and carried out as soon as feasible after immobilization occurs as a result of disease, injury, or surgery. The exercises are done to maintain functional connective tissue within the joint and thereby ensure that every joint retains its function and mobility. ROM exercises should be done three to four times a day.
The physician has prescribed isometric exercises for a patient. The patient asks the nurse how these exercises work. The nurse uses an example to explain the physiology of isometric exercises, which is:
A. flexing the lower arm while trying to straighten it with the other hand.
B. pulling the knees up to chest with the arms.
C. forcefully flexing the neck to make the chin touch the chest.
D. flexing the toes up toward the head while lying flat.
ANS: A Isometric exercises are based on the energy of opposing muscles working against each other. DIF: Cognitive Level: Analysis REF: 728-729 OBJ: 2 (clinical)
When the patient returns to the unit from having had an arthrogram, which intervention will the nurse perform first?
A. Ambulate the patient in the room.
B. Apply ice packs to the knee.
C. Perform passive range-of-motion exercises.
D. Wrap the knee in an elastic bandage.
ANS: B Ice packs applied to the knee will reduce swelling. The patient will ambulate at some point but not before the application of ice. There is not going to be a significant loss of mobility for the patient so range-of-motion exercises will not likely be included in the plan of care. There is no indication that an elastic bandage is needed.
The nurse encourages the patient to use the four-point crutch gait technique. This technique is most likely indicated because it:
A. allows non–weight bearing on one leg.
B. is the most stable gait.
C. mimics normal walking pattern.
D. allows the most rapid pace.
ANS: B The four-point crutch gait is the most stable, requires that there be partial weight bearing on both legs, and does not mimic normal walking pattern.
The nurse is assessing the patient’s cane for appropriate length. The nurse affirms that the appropriate cane has been selected when the:
A. hand grip is at the level of the hip.
B. elbow is flexed at 45 degrees when weight is placed on the cane.
C. cane tip is placed touching outside the good foot.
D. rubber tip has been removed when measuring cane length.
ANS: A The hand grip should be at hip level to allow for proper flexion of the arm to bear weight. The cane tip should be placed 6 inches from the good foot. The elbow angle should be 30 degrees
The nurse is instructing the patient on quadriceps and gluteal muscle exercises. The instructions will include:
A. while lying down, straightening the leg and tensing leg muscles while raising heel.
B. flexing the leg and holding it with the hands while pulling the leg back toward the hip.
C. straightening the legs and raising the head.
D. flexing both legs and doing an abdominal crunch up toward the knees.
ANS: A The quad setting exercise is to straighten the leg and tense the leg muscles while raising the heel.
The anatomical structure that joins the bones of a joint together is referred to as:
A. a ligament.
B. a tendon.
C. a muscle.
D. cartilage.
ANS: A Ligaments hold the bones of a joint together. Tendons are connective tissues that provide joint movement. Cartilage is a type of connective tissue in which fibers and cells are embedded in a semisolid gel material.
When a 90-year-old patient says, “My old bones are just about done in,” the nurse reminds him that his bones are being constantly renewed through the action of:
A. osteoblasts.
B. stem cells.
C. free circulating calcium ions.
D. combination of phosphorus and vitamin D.
ANS: A Osteoblasts build bone as the old bone is reabsorbed into the body.
The patient’s plan of care includes using the continuous passive motion (CPM) machine. Which statement by the patient indicates the need for further teaching?
A. “I marched in the Marines for 20 years, and now I’m marching flat on my back!”
B,My new knee will be glad to rest at night.”
C.I can make my new knee stronger if I reset this thing to go faster and flex my knee more.”
D.I almost wish this CPM ran at night. The motor noise is soothing.”
ANS: C The continuous passive motion machine is used to provide movement to a joint in recovery. The apparatus is driven by a motor and requires no effort on the part of the patient or nurse to move the limb. It usually is left on all day and is discontinued at night while the patient sleeps. CPM is preset as to speed and the degree of flexion that is determined by the physician and should not be adjusted by the patient.
