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You are caring for a newly admitted patient who will soon need to be taken to the radiology department for a CT scan. The patient has a Body Mass Index (BMI) of 52. Which of the following strategies to transport the patient is most appropriate?
a)Obtain a mechanical lateral transfer device to move the patient onto a stretcher.
b)Position a friction-reducing sheet under the patient before attempting the transfer.
c)Enlist the aid of two other staff members and pull the patient across the bed and onto a stretcher.
d)Transport the patient to the radiology department in the hospital bed.
a. Obtain a mechanical lateral transfer device to move the patient onto a stretcher. (The combined weight of the bed and patient will be difficult to move safely. Additionally, this strategy does not address the need to transfer the patient onto and off of equipment in the radiology department.)
A nurse is providing care for a patient who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the patient?
a)The patient's cognitive status
b)The patient's age
c)The patient's body weight
d)The patient's ability to assist
d. The patient's ability to assist (The nurse assesses several parameters when choosing whether to use a mechanized assistive device for a patient transfer. The most important consideration, however, is the patient's ability to safely assist with his or her transfer.)
The nurse adjusts a patient's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action?
Move the patient to edge of the bed opposite the side that patient will be turning. (When turning a patient in bed, the nurse would use a friction-reducing sheet to pull the patient to the edge of the bed that is opposite the side the patient will be turning. Consult a Safe Patient Handling Algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual patient.)
An 80-year-old patient experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the patient?
High-Fowler's (A high-Fowler's position optimizes cardiac function and respiratory function in addition to being the best position for eating. The patient's risk of aspiration would be extreme in a supine position. Low-Fowler's and semi-Fowler's are synonymous, and this position does not aid swallowing as much as a high-Fowler's position.)
When moving a pt. up in bed, the RN asks the pt to fold the arms across the chest and lift the head with the chin on the chest. What is the rationale for placing the pt in this position?
To prevent hyperextension of the neck
The nurse is preparing to move a pt up in bed with the assistance of another nurse. In what position would the nurse place the pt., if tolerated?
To compensate for the shift in the center of the gravity, an older adult will
flex the knees for support
impaired muscle strength/weakness
the absence of strength secondary to nervous impairment
weakness of one half of the body
paralysis of one half of the body (with this gait, the leg that's paralyzed may be dragged/swung around to propel it forward)
paralysis of the legs
paralysis of the arms and legs
Bone tumor may cause pain but the demineralization of the bone will cause hip fracture.
slow blood flow in the veins/poor blood circulation (leads to venous thrombosis, which is a blood clot--thrombus--that forms in the vein/blood vessel, and that's common in people who are immobile)
incomplete expansion or collapse of lung tissue (may occur when areas of lung tissue are not used over time, and often occurs in immobile pts)
type of pneumonia that results from inactivity and immobility. causing secretions to pool up and leading to respiratory congestion.
a consolidation and immobilization of a joint. (contractures result from atrophy of muscles, with subsequent inability to fx, and from a decrease in the muscle's strength, coordination, and endurance. A joint can be permanently fixed when ankylosed.)
kidney stones (from excessive excretion of calcium)
breakdown of body's protein stores to provide energy to meet the body's energy requirements (if unchecked, this process results in muscle wasting and a negative nitrogen balance)
negative nitrogen balance
diseases characterized by a larger breakdown of protein than that which is manufactured leads to a negative nitrogen balance (e.g., anorexia nervosa and certain cancers) that results in muscle wasting and decreased physical energy for movement and work.
decreased tone, results from disuse/neurologic impairments
increased tone that interferes with movement, is caused by neurologic impairments
increased muscle mass resulting from exercise/training
muscle mass that is decreased through disuse/neurologic impairment
When is ROM exercises contraindicated?
In pts who are nonresponsive because they're unable to sense/report pain during passive ROM exercises.
Use of crutches
prevent pressure on axillae, keep elbows close to sides, prevent crutches from getting closer than inches to feet. To rise from chair: slide forward to the edge of the chair, extend the injured leg to prevent any weight bearing, place crutches on unaffected side, lean forward, and push off using crutches. To climb stairs: advance unaffected leg past crutches, then place weight on unaffected leg, advance affected leg and then crutches to the step, and continue with this order until top of the stairs is reached. To descend stairs: move crutches and affected leg first, followed by the unaffected leg.
Assisting a pt with turning in bed
You should stand opposite the pt's center with your feet about shoulder width apart and with one foot ahead of the other. Tighten your gluteal and abdominal muscles and flex your knees. Use your leg muscles to do the pulling. Use the friction reducing sheet to move the pt. to his/her side.
When teaching range-of-motion exercises to a caregiver, a nurse moves
the arm of the patient laterally to an upright position above the head,
and then returns it to the original position. What term is used to
describe this body movement?
Abduction (Abduction is lateral movement of a body part away from the midline of the body.)
A nurse is assisting in the transfer of a patient, who has casts on both legs, to a stretcher. Which of the following devices would be the best choice for this patient?
Transfer chair (Chairs that can convert into stretchers are available. These are useful with patients who have no weight-bearing capacity, cannot follow directions, and/or cannot cooperate. The back of the chair bends back and the leg supports elevate to form a stretcher configuration, eliminating the need for lifting the patient. Powered-stand assist and repositioning devices require the patient to have weight-bearing capacity in one leg. Gait belts are used to assist patients to ambulate safely.)
When is a gait belt contraindicated?
Gait belt should not be used on pts with abdominal or thoracic incisions. (For example, a pt. who had a colon resection 2 days ago.)
Clients with fractures, back surgeries, or joint replacements should be instructed to
Use the overhead trapeze (Overhead trapezes may provide handholds for orthopedic clients.)
When turning a patient in bed, what positioning instructions would the
nurse give the patient before using the friction-reducing sheet to turn
Cross the arms across the chest AND cross the legs. And if the pt. can, they should grab the hand rail for assistance in the move.
available in various sizes, can be used to immobilize an extremity and support body alignment. provide support. position a sandbag to avoid creating pressure on a bony prominence.
Lateral deviation/curvature of the thoracic spine
increased convexity in the curvature of the thoracic spine
forward curvature of the lumbar spine
While performing passive range-of-motion exercises on the lower
extremities of a patient with a spinal cord injury, the nurse assesses
permanent flexion of the muscles. What term will the nurse use to
document this finding related to the muscles?
Contractures (Contractures are permanent contraction of a muscle. Tonus is the term used to describe the state of slight contraction, the usual state of skeletal muscles. Atrophy is the decrease in muscle size from immobility. Ankylosis is a consolidation and immobilization of a joint.)
permanent contraction of a muscle
A nurse is providing post-operative care for a client who is immobilized
due to rod fixation. The nurse would place the client in which
Semi-Fowler's (Semi-Fowler's position is a commonly used position for an immobile client. Dorsal recumbent position, Trendelenburg's position, and reverse Trendelenburg's position are not recommended positions for immobile clients.)
A nurse is teaching a patient how to walk with a cane. Which of the following is an accurate guideline for using this device?
When taking a step forward, the heel of the foot should be slightly beyond the tip of the cane. (When stepping forward, the heel should be slightly beyond the tip of the cane. The patient should hold the cane on the opposite side of the foot with the deficit and evenly distribute weight between the feet and the cane. The patient should step first with the weaker leg.)
Steps in ambulation with a cane
- 1. pt stands with weight evenly distributed between the feet and the cane
- 2. cane is held on the pt's stronger side and is advanced 4 to 12 inches
- 3. supporting weight on the stronger leg and the cane, the pt advances the weaker foot forward, parallel w/the cane
- 4. supporting weight on the weaker leg and the cane, the pt next advances the stronger leg forward ahead of the cane (heel slightly beyond the tip of the cane)
- 5. the weaker leg is moved forward until even with the stronger leg, and the cane is once again advanced as in step 2
- Teach pts to position their cane within easy reach when they sit down so that they can rise easily.
For which one of the following patients would a pneumatic compression device (PCD) be indicated?
a) A postoperative patient with arterial occlusive disease
b) A postoperative patient suspected of having deep vein thrombosis (DVT)
c) A patient with severe edema following a hip replacement
d) A postoperative patient with a knee replacement who has a history of cancer
A postoperative patient with a knee replacement who has a history of cancer (PCDs are contraindicated in patients with suspected or existing DVT. They should not be used for patients with arterial occlusive disease, severe edema, cellulitis, phlebitis, a skin graft, or an infection of the extremity.)
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