week 8 ati homework & ch 40 Flashcards
1
Q
Immobile clients are at risk for:
A
atelactasis – shallow breathing
DVT
decreased circulation
GERD
orthostatic hypotension
2
Q
ADL’s include
A
*toileting
dressing
bathing
feeding
3
Q
client position for pneumonia
A
prone
4
Q
client position for atelactasis
A
fowlers
5
Q
correct use of walker
A
walker moves FIRST
elbows bent 15 degrees
walker held at level of wrist
6
Q
correct use of cane
A
held on stronger side
move 6 to 10 inches
at level of wrist
elbow bent at 15-30 degree angle
cane first followed by weaker leg
7
Q
MAT score
A
lower numbers = more assistance
8
Q
orthostatic hypotension
A
decrease in systolic pressure of 20mmhg
OR
decrease in diastolic of 10mmhg or more within 3 min. of changing positions
9
Q
manifestations of sepsis
A
hypotension
increased blood glucose
increased white blood cells
nothing to do w BUN
10
Q
positions that put client at risk for shearing
A
high fowler position
sitting/lying on incline
11
Q
preventing breakdown on an immobile patient
A
*cleanse & pat dry
*tilt client onto side @ 30 degreed
*sitting position
*head of bed less than 30 degrees at all times
12
Q
hydrogel dressing
A
used for DEBRIDEMENT of wounds w/ NECROTIZED tissue & eschars
13
Q
Alginate dressing
A
used for moderate to high exudative wounds & lasts several days
provides hemostasis
needs secondary dressing
14
Q
hyrdrocolloid dressing
A
for stage 1 PI - gel-like & moist
may cause: dermatitis, foul smelling yellow gelatinous film
15
Q
sterile dressings
A
kept on incision 24 to 48 hours
**sterile technique if dressing loosens
16
Q
clean technique
A
used on wounds after 48 hours
used at home
17
Q
dehiscence
vs
evisceration
A
dehiscence : occurs 7-10 days after surgery –separation of wound edges
evisceration: protrusion of internal organs—sterile saline soaked dressing
18
Q
client with abdomen wound should be
A
supine
knees bent
covered w sterile saline dressing
19
Q
irrigation for wounds
A
0.9% sodium chloride
20
Q
Braden Scale
A
risk assessment for tissue integrity
lowest score (6) = higher risk
high score (23) = no risk
21
Q
maceration
vs
dermatitis
A
maceration: irritation of epidermis caused by moisture
dermatitis : red skin irritation
22
Q
erythema
A
redness of skin due to dilation of blood vessels
blanchable: red goes away w pressure
nonblanchable: red does not go away w pressure
23
Q
heat therapy
A
*increases blood flow & tissue metabolism
*relaxes muscles
*eases joint pain
do not use on pregnant people, immobile clients, first 24 hours after injury
24
Q
cold therapy
A
decreases inflammation
prevents swelling
reduces fever & bleeding
diminishes muscle spasms
- assess site every 5 to 10 min
*discontinue after 15 to 30 min
25
1. A nurse is instructing a patient who has decreased leg strength on the left side on how to use a cane. Which actions indicate proper cane use by the patient? (Select all that apply.)
1. The patient keeps the cane on the left side of the body.
2. The patient slightly leans to one side while walking.
3. The patient keeps two points of support on the floor at all times.
4. After the patient places the cane forward, he or she then moves the right leg forward to the cane.
5. The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step.
3. The patient keeps two points of support on the floor at all times.
5. The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step.
26
2. A patient is experiencing some problems with joint stability in the right leg. The doctor has prescribed crutches for the patient to use while being allowed to bear weight only on the left leg. Which of the following gaits should the patient be taught to use?
1. Four-point
2. Three-point
3. Two-point
4. Swing-through
2. Three-point
27
Which of the following motivates a patient to participate in an exercise program? (Select all that apply.)
1. Providing a patient with a pamphlet on exercise
2. Providing information to the patient when he or she is ready to change behavior
3. Explaining the importance of exercise at the time of diagnosis of a chronic disease
4. Having a structured daily plan that incorporates physical activity
5. Having support from significant other to engage in exercise
2. Providing information to the patient when he or she is ready to change behavior
4. Having a structured daily plan that incorporates physical activity
5. Having support from significant other to engage in exercise
28
The nurse is caring for an older adult in a long-term care setting. The nurse reviews the medical record to find that the patient has progressive loss of total bone mass. The patient’s history and tendency to take smaller steps with feet kept closer together will most likely result in which of the following?
1. Increase the patient’s risk for falls and injuries
2. Result in less stress on the patient’s joints
3. Decrease the amount of work required for patient movement
4. Allow for mobility in spite of the aging effects on the patient’s joints
1. Increase the patient’s risk for falls and injuries
29
Place in the correct order the steps needed (below) to transfer a patient with sufficient lower body strength to a chair.
1. On count of three, instruct patient to stand while straightening hips and legs and keeping knees slightly flexed.
2. Assist patient to assume proper alignment in sitting position.
3. Help patient apply stable, nonskid shoes/socks.
4. Spread your feet apart. Flex hips and knees, aligning knees with patient’s knees.
5. Apply gait/transfer belt.
6. Maintain patient’s balance as you pivot foot farthest from chair and then help patient ease into chair.
Place in the correct order the steps needed (below) to transfer a patient with sufficient lower body strength to a chair.
1. On count of three, instruct patient to stand while straightening hips and legs and keeping knees slightly flexed.
2. Assist patient to assume proper alignment in sitting position.
3. Help patient apply stable, nonskid shoes/socks.
4. Spread your feet apart. Flex hips and knees, aligning knees with patient’s knees.
5. Apply gait/transfer belt.
6. Maintain patient’s balance as you pivot foot farthest from chair and then help patient ease into chair. Place in the correct order the steps needed (below) to transfer a patient with sufficient lower body strength to a chair.
1. On count of three, instruct patient to stand while straightening hips and legs and keeping knees slightly flexed.
2. Assist patient to assume proper alignment in sitting position.
3. Help patient apply stable, nonskid shoes/socks.
4. Spread your feet apart. Flex hips and knees, aligning knees with patient’s knees.
5. Apply gait/transfer belt.
6. Maintain patient’s balance as you pivot foot farthest from chair and then help patient ease into chair.
7. Grasp transfer belt along patient’s sides.
5. Apply gait/transfer belt.
3. Help patient apply stable, nonskid shoes/socks.
4. Spread your feet apart. Flex hips and knees, aligning knees with patient’s knees.
7. Grasp transfer belt along patient’s sides.
1. On count of three, instruct patient to stand while straightening hips and legs and keeping knees slightly flexed.
6. Maintain patient’s balance as you pivot foot farthest from chair and then help patient ease into chair.
Place in the correct order the steps needed (below) to transfer a patient with sufficient lower body strength to a chair.
2. Assist patient to assume proper alignment in sitting position.
30
. Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.)
1. Patient’s weight
2. Patient’s activity tolerance
3. Patient's level of mobility
4. Recent laboratory values
5. Nutritional intake
1. Patient’s weight
2. Patient’s activity tolerance
3. Patient's level of mobility
31
8. Which of the following indicates that additional assistance is needed to transfer a patient from the bed to the stretcher? (Select all that apply.)
1. The patient is 5 feet, 6 inches and weighs 120 lb.
2. The patient speaks and understands English.
3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation.
4. The patient has a history of being able to stand independently.
5. The patient received analgesia for pain 30 minutes ago.
3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation.
5. The patient received analgesia for pain 30 minutes ago.
32
A 51-year-old adult comes to a medical clinic for an annual physical exam. The patient is found to be slightly overweight and reports being inactive, walking only 2 to 3 times a week with his wife after work. He has good muscle strength and coordination of lower extremities. Which of the following recommendations from the Physical Activity Guidelines for Americans should the nurse suggest? Choose all that apply
1. Move more and sit less throughout the day.
2. Participate in at least 90 minutes a week of moderate-intensity aerobic physical activity.
3. Perform muscle-strengthening activities using light weights on 2 or more days a week.
4. Walk at a vigorous pace with wife at least 150 minutes over five days a week.
5. Focus on balance training.
1. Move more and sit less throughout the day.
3. Perform muscle-strengthening activities using light weights on 2 or more days a week.
4. Walk at a vigorous pace with wife at least 150 minutes over five days a week.
33
Family members have asked for a meeting with the nursing staff of an assisted-living residential center to discuss the feasibility of their mother using a walker. The family is worried that her health is declining; they wonder whether she can use the walker safely. Which of the following instructions should the nurse give the family after assessing that it is safe for the woman to use a walker? (Select all that apply.)
1. A walker is useful for patients who have impaired balance.
2. The patient uses a walker by pushing the device forward.
3. Leaning over the walker improves the patient’s balance.
4. Walkers should not be used on stairs.
5. If the patient has difficulty advancing the walker, a walker with wheels is an option.
1. A walker is useful for patients who have impaired balance.
4. Walkers should not be used on stairs.
5. If the patient has difficulty advancing the walker, a walker with wheels is an option.
34
. A patient has been on bed rest for over 5 days. Which of these findings during the nurse’s assessment may indicate a complication of immobility?
1. Decreased peristalsis
2. Decreased heart rate
3. Increased blood pressure
4. Increased urinary output
1. Decreased peristalsis
35
An older-adult patient has been bedridden for 2 weeks. Which of these complaints by the patient indicates to the nurse that he or she is developing a complication of immobility?
1. Increase of appetite
2. Gum soreness
3. Difficulty in swallowing
4. Left ankle joint stiffness
4. Left ankle joint stiffness
36
A patient is receiving 40 mg of enoxaparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for what signs of bleeding? (Select all that apply.)
1. Bruising
2. Pale yellow urine
3. Bleeding gums
4. Coffee ground–like vomitus
5. Light brown stool
1. Bruising
3. Bleeding gums
4. Coffee ground–like vomitus
37
Place the following steps in the correct order for positioning a patient in the 30-degree lateral side-lying position.
1. Raise side rail and go to opposite side of bed.
2. Lower side rail and flex patient’s knee that will not be next to mattress. Keep foot on mattress and place one hand on patient’s upper bent leg near hip and other hand on shoulder.
3. Lower head of bed flat if patient can tolerate it.
4. Roll patient onto side toward you.
5. Lower side rail and position patient on side of bed opposite the direction toward which patient is to be turned.
6. Place hands under patient’s dependent shoulder and bring shoulder blade forward.
7. Place hands under patient’s dependent hip and bring hip slightly forward so that angle from hip to mattress is approximately 30 degrees.
3. Lower head of bed flat if patient can tolerate it.
5. Lower side rail and position patient on side of bed opposite the direction toward which patient is to be turned.
1. Raise side rail and go to opposite side of bed.
2. Lower side rail and flex patient’s knee that will not be next to mattress. Keep foot on mattress and place one hand on patient’s upper bent leg near hip and other hand on shoulder.
4. Roll patient onto side toward you.
6. Place hands under patient’s dependent shoulder and bring shoulder blade forward.
7. Place hands under patient’s dependent hip and bring hip slightly forward so that angle from hip to mattress is approximately 30 degrees.
38
The effects of immobility on the cardiac system include which of the following? (Select all that apply.)
1. Thrombus formation
2. Increased cardiac workload
3. Weak peripheral pulses
4. Irregular heartbeat
5. Orthostatic hypotension
1. Thrombus formation
2. Increased cardiac workload
5. Orthostatic hypotension
39
A 46-year-old patient is admitted to the emergency department following an automobile accident. The patient has a pelvic fracture and is ordered on bed rest and placed in an immobilization device to limit further injury until the fracture can safely be repaired. Which measures would be appropriate for this patient to prevent complications of bed rest? (Select all that apply.)
1. Administer intravenous analgesic as ordered.
2. Have patient perform incentive spirometry.
3. Support patient in active assistive ROM exercises of upper extremities.
4. Provide patient a low-calorie diet.
5. Apply sequential compression devices to legs.
2. Have patient perform incentive spirometry.
3. Support patient in active assistive ROM exercises of upper extremities.
5. Apply sequential compression devices to legs.
40
. A patient has an order for application of compression stockings. Place the following steps for application of the stockings in the correct order:
1. Place patient’s toes into foot of stocking up to the heel; keep smooth.
2. Use tape measure to measure patient’s leg for proper stocking size.
3. Slide stocking up over patient’s calf until sock is completely extended.
4. Turn elastic stocking inside out, keeping hand inside holding heel. Take other hand and pull stocking inside out until reaching the heel.
5. Slide remaining portion of stocking over patient’s foot, covering toes. Be sure foot fits into toe and heel of stocking.
2. Use tape measure to measure patient’s leg for proper stocking size.
4. Turn elastic stocking inside out, keeping hand inside holding heel. Take other hand and pull stocking inside out until reaching the heel.
1. Place patient’s toes into foot of stocking up to the heel; keep smooth.
5. Slide remaining portion of stocking over patient’s foot, covering toes. Be sure foot fits into toe and heel of stocking.
3. Slide stocking up over patient’s calf until sock is completely extended.
41
An older-adult patient is admitted following a hip fracture and surgical repair. Before ambulating the patient postoperatively on the evening of surgery, which of the following would be most important to assess? (Select all that apply.)
1. Patient’s usual dietary intake
2. Time and date of the patient’s last bowel movement
3. Preadmission activity tolerance
4. Baseline heart rate
5. Patient’s home living situation
3. Preadmission activity tolerance
4. Baseline heart rate
42
A nurse is helping a patient perform active assisted range of motion in the right elbow. Which statement describes the correct technique?
1. Support elbow by holding distal part of extremity.
2. Grasp joint with fingers to provide support.
3. Have patient move joint independently.
4. Move the joint past the point of resistance.
5. Perform the exercise a few times only, and gradually build up to more.
1. Support elbow by holding distal part of extremity.
43
A middle-aged adult patient has limited mobility following a total knee arthroplasty. During assessment, the nurse notes that the patient is having difficulty breathing while lying supine. Which assessment data support a pulmonary issue related to immobility? (Select all that apply.)
1. Oxygen saturation of 89%
2. Irregular radial pulse
3. Diminished breath sounds bilateral bases on auscultation
4. BP: 132/84
5. Pain reported at 3 on scale of 0 to 10 following medication
6. Respiratory rate of 26
1. Oxygen saturation of 89%
3. Diminished breath sounds bilateral bases on auscultation
6. Respiratory rate of 26
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