Podcast
Questions and Answers
Which assistive technique should the nurse prioritize in the plan of care for a bedbound client?
Which assistive technique should the nurse prioritize in the plan of care for a bedbound client?
What intervention should the nurse implement to promote ventilation in a client with chronic obstructive pulmonary disease?
What intervention should the nurse implement to promote ventilation in a client with chronic obstructive pulmonary disease?
Which assessment findings would cause the nurse to choose a different assistive device instead of a power stand-assist machine?
Which assessment findings would cause the nurse to choose a different assistive device instead of a power stand-assist machine?
What is the correct documentation for a client with impaired muscle coordination?
What is the correct documentation for a client with impaired muscle coordination?
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What knowledge about the bones should the nurse apply when working with a client who has a fractured wrist?
What knowledge about the bones should the nurse apply when working with a client who has a fractured wrist?
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What finding should the nurse document as a normal age-related change in an older adult client?
What finding should the nurse document as a normal age-related change in an older adult client?
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What action should the nurse instruct a client with a history of lung disease before beginning an exercise program?
What action should the nurse instruct a client with a history of lung disease before beginning an exercise program?
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What are hand rolls used for in client care?
What are hand rolls used for in client care?
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Which action by the UAP would cause the nurse to intervene when assisting an inactive client with positioning?
Which action by the UAP would cause the nurse to intervene when assisting an inactive client with positioning?
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What is one of the most common injuries associated with exercise in a healthy person?
What is one of the most common injuries associated with exercise in a healthy person?
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Which assessment priority is needed for an adolescent client?
Which assessment priority is needed for an adolescent client?
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What teaching point would be appropriate for promoting exercise in an older adult client?
What teaching point would be appropriate for promoting exercise in an older adult client?
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Which statement correctly describes good posture when lying down?
Which statement correctly describes good posture when lying down?
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In which position should the nurse place a client to prevent sliding toward the foot of the bed?
In which position should the nurse place a client to prevent sliding toward the foot of the bed?
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Where should the nurse position the stretcher when transferring a client from a bed?
Where should the nurse position the stretcher when transferring a client from a bed?
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When logrolling a client, the nurse should use supportive devices in turning the client in order to:
When logrolling a client, the nurse should use supportive devices in turning the client in order to:
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When turning a client in bed, what muscle groups would the nurse use to pull the client to the opposite side of the bed?
When turning a client in bed, what muscle groups would the nurse use to pull the client to the opposite side of the bed?
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After successfully turning the client to the side, where would the nurse place an additional pillow?
After successfully turning the client to the side, where would the nurse place an additional pillow?
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What is a recommended guideline when assisting a client from the bed into a wheelchair?
What is a recommended guideline when assisting a client from the bed into a wheelchair?
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For what adverse condition is the nurse assessing the client when they show signs of dizziness upon standing?
For what adverse condition is the nurse assessing the client when they show signs of dizziness upon standing?
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For which condition would the nurse consider a bedridden client to be at risk?
For which condition would the nurse consider a bedridden client to be at risk?
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Into which position will the nurse place the client who reports shortness of breath while lying prone?
Into which position will the nurse place the client who reports shortness of breath while lying prone?
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In an assessment for proper body alignment of a standing client, which finding is normal?
In an assessment for proper body alignment of a standing client, which finding is normal?
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What should the nurse do upon entering a hospital room and observing a UAP making the bed while a client is in therapy?
What should the nurse do upon entering a hospital room and observing a UAP making the bed while a client is in therapy?
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How should the nurse best prevent or minimize damage from a client who begins to fall?
How should the nurse best prevent or minimize damage from a client who begins to fall?
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In what position would the nurse place the client to begin the procedure of turning in bed?
In what position would the nurse place the client to begin the procedure of turning in bed?
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What is the best explanation for why a client does not bump into a bedside table while ambulating in the room?
What is the best explanation for why a client does not bump into a bedside table while ambulating in the room?
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Which nursing action is appropriate when transferring a client from a bed to a wheelchair?
Which nursing action is appropriate when transferring a client from a bed to a wheelchair?
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Which client would be a likely candidate for using a gait belt?
Which client would be a likely candidate for using a gait belt?
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What can be expected developmentally from a 2-year-old child over the next few years?
What can be expected developmentally from a 2-year-old child over the next few years?
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Which activities would help to prevent falls for a 90-year-old client with a hemiplegic gait?
Which activities would help to prevent falls for a 90-year-old client with a hemiplegic gait?
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What is the priority nursing diagnosis for a client with incontinence left in a supine position for more than a week?
What is the priority nursing diagnosis for a client with incontinence left in a supine position for more than a week?
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What risk factor associated with flying should the nurse emphasize for a client who flies often?
What risk factor associated with flying should the nurse emphasize for a client who flies often?
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Which method is most appropriate to assist a 76-year-old client with an unsteady gait during transfer?
Which method is most appropriate to assist a 76-year-old client with an unsteady gait during transfer?
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In what position will the nurse place the client to facilitate a rectal examination?
In what position will the nurse place the client to facilitate a rectal examination?
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A nurse is supervising a client who wants to transfer from the bed to a stretcher without assistance. What is the best response?
A nurse is supervising a client who wants to transfer from the bed to a stretcher without assistance. What is the best response?
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How should the nurse stand when helping the client sit up on the side of the bed during a transfer?
How should the nurse stand when helping the client sit up on the side of the bed during a transfer?
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What position should the nurse take when assisting a client from the bed into a wheelchair?
What position should the nurse take when assisting a client from the bed into a wheelchair?
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What is the primary purpose for using proper body mechanics?
What is the primary purpose for using proper body mechanics?
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Which client would the nurse be most concerned about regarding physical activity?
Which client would the nurse be most concerned about regarding physical activity?
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What motions should the nurse make to move an object using proper body mechanics?
What motions should the nurse make to move an object using proper body mechanics?
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Which guideline promotes safe use of a cane for a client with unilateral weakness?
Which guideline promotes safe use of a cane for a client with unilateral weakness?
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What should the nurse advise a client using crutches?
What should the nurse advise a client using crutches?
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What should a nurse do when a client reports dizziness during transfer from bed to wheelchair?
What should a nurse do when a client reports dizziness during transfer from bed to wheelchair?
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Which action should the nurse take after turning a client on bed rest to the left side?
Which action should the nurse take after turning a client on bed rest to the left side?
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Which developmental concern would the nurse have for a pediatric client?
Which developmental concern would the nurse have for a pediatric client?
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What statement is most beneficial when assisting a client with dementia in getting dressed?
What statement is most beneficial when assisting a client with dementia in getting dressed?
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In which position should a client with hemorrhoids be placed for a rectal examination?
In which position should a client with hemorrhoids be placed for a rectal examination?
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What information should a nurse provide to unlicensed assistive personnel (UAP) regarding meals for a partially blind older adult client?
What information should a nurse provide to unlicensed assistive personnel (UAP) regarding meals for a partially blind older adult client?
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What does a client who walks with knees slightly flexed and body leaning demonstrate?
What does a client who walks with knees slightly flexed and body leaning demonstrate?
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Which mobility aid is most appropriate for a client who has poor balance?
Which mobility aid is most appropriate for a client who has poor balance?
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Which activities can help prevent falls for a 90-year-old client with a hemiplegic gait? Select all that apply.
Which activities can help prevent falls for a 90-year-old client with a hemiplegic gait? Select all that apply.
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What is the nursing response for the purpose of trochanter rolls?
What is the nursing response for the purpose of trochanter rolls?
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How should graduated compression stockings be applied?
How should graduated compression stockings be applied?
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Which strategies does the nurse use to maintain proper body mechanics? Select all that apply.
Which strategies does the nurse use to maintain proper body mechanics? Select all that apply.
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In which position(s) should a nurse place a client at high risk for aspiration?
In which position(s) should a nurse place a client at high risk for aspiration?
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What intervention is appropriate for a 74-year-old client with kyphosis reporting cervical vertebra discomfort?
What intervention is appropriate for a 74-year-old client with kyphosis reporting cervical vertebra discomfort?
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What type of exercise is represented by swimming laps and walking miles?
What type of exercise is represented by swimming laps and walking miles?
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Study Notes
Logrolling Technique
- Logrolling is used for clients with back or spinal injuries to maintain spinal alignment and prevent injury.
- Supporting devices help keep the natural alignment of the client's body and minimize discomfort.
Client Turning in Bed
- When turning a client, the nurse utilizes leg muscles while keeping the gluteal and abdominal muscles engaged to avoid back strain.
- An additional pillow should be placed under the client's back for support after turning them to the side.
Bed to Wheelchair Transfer
- Raise the head of the bed to a sitting position before transferring the client to ensure comfort and safety.
- Always lock the wheelchair brakes and position the chair close to the bed.
Assessing for Dizziness
- Orthostatic hypotension is assessed by observing the client for dizziness or balance issues upon standing.
- A blood pressure drop occurs when transitioning from a lying or sitting to a standing position.
Risks for Bedridden Clients
- Bedridden clients are at increased risk for renal calculi due to urinary stasis and potential infections.
- Immobility also affects respiratory function, metabolic rate, and increases overall health risks.
Positioning for Shortness of Breath
- Fowler's position aids in alleviating dyspnea as it allows abdominal organs to drop away from the diaphragm.
Body Alignment in Standing Clients
- Normal body alignment involves weight distribution on soles and heels, with the chest held moderately upward and abdominal muscles engaged.
Guiding UAP Behavior
- Health care personnel should not place linens on the floor and should use proper body mechanics to avoid injury.
Fall Prevention Techniques
- Strategies to prevent falls in elderly, at-risk clients include decluttering environments, installing nightlights, and relocating bedrooms to lower floors.
Nursing Diagnosis Prioritization
- The top priority for a client with incontinence and prolonged supine positioning is risk for impaired skin integrity due to potential skin breakdown.
Risks of Prolonged Sitting
- Long-term sitting during flights increases the risk for thrombus formation, necessitating discussion of stretching and mobility strategies.
Appropriate Transfer Aids
- A transfer belt is optimal for clients with balance issues who can assist during transfers, supporting their weight safely.
Rectal Examination Position
- Sims' position, semi-prone, is best for facilitating rectal examination, unlike other positions which limit visibility.
Supervision During Independent Transfers
- Nurses should supervise clients who wish to transfer independently to ensure safety without intervention when clients can assist themselves.
Body Mechanics in Nursing
- Proper body mechanics are critical to prevent injury to both clients and nurses during movement tasks.
Client Activity Concerns
- Assessing physical activity levels should raise concern for sedentary clients such as middle-aged computer programmers, as their lifestyle may contribute to health issues.### Body Mechanics and Transfer Techniques
- Nurses maintain proper body mechanics by balancing the head over shoulders, leaning forward, and engaging stomach muscles during object movement.
- The internal girdle and a long midriff stabilize the pelvis and protect abdominal organs while lifting, pulling, or reaching.
- When lifting, directly pick up objects instead of sliding or pushing to minimize energy expenditure against gravity.
Safe Cane Usage
- For clients with unilateral weakness, hold the cane in the hand opposite the affected leg for better stability.
- When stepping forward, the stronger leg should move ahead of the cane, with the heel beyond the cane's tip to promote balance.
Crutch Utilization
- Crutches should be properly fitted so elbows remain slightly bent, with weight supported primarily by the hands rather than armpits.
- Clients should rest if feeling fatigued while using crutches and should not rely on unlicensed personnel for supervision during ambulation.
Safe Patient Transfers
- When a client reports dizziness during a transfer, the nurse should lower the client back into bed using a gait belt to prevent falls; standing may exacerbate dizziness.
Preventing Skin Integrity Issues
- After turning a bedridden client, the nurse should reposition the shoulder blade forward to alleviate pressure on bony prominences and reduce the risk of skin breakdown.
Developmental Milestones in Children
- A 24-month-old child who cannot walk unassisted raises concern, as walking is typically achieved by 15 months. Other developmental milestones are contextually appropriate for their respective ages.
Dressing Support for Dementia Clients
- Short, clear instructions aid clients with dementia; for example, saying, "Put your arm in this sleeve," simplifies the dressing process compared to more complex commands.
Rectal Examination Position
- The Sims' position is best for rectal examinations, allowing proper access compared to supine or prone positions.
Assisting Clients with Visual Impairments
- During meals, position clients upright, provide verbal cues for food placement, cut food into small pieces, and ensure food temperature is safe to prevent aspiration.
Common Gait Patterns in Older Adults
- Older adults may walk with slightly flexed knees and a leaning posture due to changes in balance and center of gravity, which is considered a normal adaptation.
Mobility Aids for Balance
- A quad cane provides a stable base of support for clients with poor balance, while single-ended canes and crutches suit different mobility needs.
Fall Prevention Strategies
- Key measures to prevent falls in elderly clients include clearing floor clutter, installing nightlights, and moving bedrooms downstairs for easier access.
Use of Trochanter Rolls
- Trochanter rolls are utilized to prevent the outward rotation of legs during care, particularly for immobilized or post-surgery clients.
Compression Stocking Application
- Elevate the client's legs for 15 minutes before applying graduated compression stockings to optimize effectiveness and comfort.
Maintaining Proper Body Mechanics
- Effective lifting techniques include placing feet shoulder-width apart and bending at the knees rather than at the waist, avoiding strain on the back.
Positions to Prevent Aspiration
- For clients at risk of aspiration, maintaining them in Fowler, Semi-Fowler, or upright positions enhances airway patency and respiratory function.
Kyphosis Comfort Measures
- Placing a small towel under the neck can relieve pressure on cervical vertebrae for clients with kyphosis.
Types of Exercise Recognition
- Isotonic exercise includes activities like swimming and walking, characterized by muscle shortening and active movement.
Enhancing Client Independence
- A trapeze bar is effective for promoting independence and mobility in clients who are bedbound, unlike other nurse-initiated techniques.
Elevation for Ventilation
- Placing small pillows under the arms can enhance ventilation for clients with respiratory conditions, compared to other non-effective methods.
Criteria for Assistive Device Usage
- A power stand-assist machine requires the client to be cooperative, bear weight on at least one leg, and be able to follow instructions to be used safely.
Recognizing Muscle Coordination Issues
- Ataxia indicates impaired muscle coordination; differentiate it from tremors, chorea, and athetosis, each having distinct movement characteristics.
Bone Classification Knowledge
- The wrist is categorized as a short bone, contributing to movement, while other bone classifications (long, flat, irregular) serve various structural functions.### Flat Bones and Aging
- Flat bones, located in the ribs and skull, play a role in structural contour and shape.
- Typical age-related change includes a decrease in joint flexibility, important for assessment in older adults.
- Pain in the lower back, stumbling gait, and unequal pupil size may indicate underlying pathology rather than normal aging.
Exercise Considerations for Older Adults
- Clients with lung disease and arthritis should obtain a pre-exercise medical examination for safety before starting any exercise program.
- Selecting enjoyable activities promotes adherence and success in exercise, emphasizing the importance of variety over single-exercise routines.
Roles of Positioning Devices
- Hand rolls are designed to help maintain a client's ability to grasp and pick up objects, preventing contractures.
- Trochanter rolls prevent leg rotation, while side rails support independent turning for weak clients.
Safe Client Handling Techniques
- The height of the bed should be raised to elbow level of the caregiver before positioning a client to ensure proper ergonomics and safety.
- Activities should encourage good body mechanics, preventing strain during client transfers.
Common Exercise-Related Injuries
- Muscle injury is the most prevalent risk associated with exercise in healthy individuals, while major cardiac events are relatively uncommon in this demographic.
- Exercise leads to enhanced muscle mass, tone, strength, and improved respiratory function, counteracting various health risks.
Adolescent Assessment Priorities
- Scoliosis assessment is crucial during adolescence due to growth and development effects on posture.
- Awareness of kyphosis, a common issue in older adults, shifted center of gravity related to pregnancy, and increased calcium and vitamin D needs in older populations are also important in broader assessment contexts.
Promoting Exercise in Older Adults
- Emphasizing warm-up and cool-down phases in exercise routines is essential to prevent injuries and promote safety.
- Rapid increases in exercise intensity should be avoided, and clients should be advised not to continue exercising if feeling weak.
Good Posture Guidelines
- Proper lying posture mirrors good standing posture, focusing on keeping knees slightly flexed and feet at a right angle relative to the legs.
- The head and neck should remain neutral to avoid pressure.
Positioning to Prevent Sliding
- The slight Trendelenburg position can help prevent a client from sliding down in bed, ensuring safety and comfort during rest.
Safe Transfers
- Positioning the stretcher at the same height as the bed facilitates smoother transfers and reduces the risk of client injury during movement.
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Description
This quiz focuses on the logrolling technique used in nursing, especially for clients post-surgery. Test your understanding of the principles behind maintaining body alignment and preventing skin breakdown during client care.
