Chapter 10: Exercise and Ambulation Nursing School Test Banks

MULTIPLE CHOICE

1. The patient has been admitted for hypertension. His blood pressure is normally in the 160/90 range. He has been on bed rest for the past few days, and the doctor has started him on a new blood pressure medication. The nurse is assisting the patient to move from the bed to the chair for breakfast, but when the patient tries to sit up on the side of the bed, he complains of being dizzy and nauseous. The nurse lays the patient down and takes his vital signs. His pulse is 124. His blood pressure is 130/80. This blood pressure is indicative of what?

a.

A normal blood pressure for this patient

b.

Orthostatic hypotension

c.

Orthostatic hypertension

d.

Effective baroreceptor function

ANS: B

Orthostatic hypotension is a drop in blood pressure that occurs when the patient changes from a horizontal to a vertical position. It traditionally is defined as a drop in systolic or diastolic blood pressure of 20 or 10 mm Hg, respectively. Those at higher risk are immobilized patients, those undergoing prolonged bed rest, the older adult patient, those receiving antihypertensive medications, and those with chronic illness, such as diabetes mellitus or cardiovascular disease. Signs and symptoms of orthostatic hypotension include dizziness, light-headedness, nausea, tachycardia, pallor, and even fainting. Orthostatic hypertension would be an increase in blood pressure. Physiological changes associated with aging and prolonged bed rest may reduce the effectiveness of the baroreceptors. In these patients, moving to the dangling position may cause a gravity-induced drop in blood pressure; thus, it is recommended to raise the head of the bed and allow a few minutes before dangling.

DIF: Cognitive Level: Analysis REF: Text reference: p. 236

OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation.

TOP: Orthostatic Hypotension KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. The patient is an elderly gentleman who has been on bed rest for the past several days. When getting the patient up, the nurse should:

a.

tell the patient not to move his legs when dangling.

b.

tell the patient to hold his breath while dangling.

c.

raise the head of the bed and allow a few minutes before dangling.

d.

have the patient stand without dangling.

ANS: C

Physiological changes associated with aging and prolonged bed rest may influence the effectiveness of the baroreceptors. For these patients, moving to the dangling position may cause a gravity-induced drop in blood pressure; thus, it is recommended to raise the head of the bed and allow a few minutes before dangling. Interventions to minimize orthostatic hypotension include movement of the legs and feet in the dangling position to promote venous return via intermittent contraction and relaxation of the skeletal leg muscles, and asking the patient to take several deep breaths before and during dangling. Dangling a patient before standing is an intermediate step that allows assessment of the individual before changing positions to maintain safety and prevent injury to the patient.

DIF: Cognitive Level: Application REF: Text reference: p. 236

OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation.

TOP: Dangling KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. An appropriate technique for the nurse to use when performing range of motion (ROM) exercises is to:

a.

repeat each action five times during the exercise.

b.

perform the exercises quickly and firmly.

c.

support the proximal portion of the extremity being exercised.

d.

continue the exercise slightly beyond the point of resistance.

ANS: A

Each movement should be repeated five times during an exercise period. Be sure that ROM exercises are performed slowly and gently. When performing active-assisted or passive ROM exercises, support the joint by holding the distal portion of the extremity, or by using a cupped hand to support the joint. Discontinue exercise if the patient complains of discomfort, or if you note resistance or muscle spasm.

DIF: Cognitive Level: Application REF: Text reference: p. 223

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Range of Motion KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. A patient is admitted to the medical unit following a cerebrovascular accident (CVA). Evidence of left-sided hemiparesis is noted, and the nurse will be following up on ROM and other exercises performed in physical therapy. The nurse should correctly teach the patient and family members which of the following principles of ROM exercises?

a.

Flex the joint to the point of discomfort.

b.

Medicate the patient after the ROM exercise session.

c.

Move the joints quickly.

d.

Provide support for distal joints.

ANS: D

When performing active-assisted or passive ROM exercises, support the joint by holding the distal portion of the extremity, or by using a cupped hand to support the joint. The joint should be flexed to the point of resistance, not to the point of discomfort. Assess the patients level of comfort (on a scale of 0 to 10, with 10 being the worst pain) before performing exercises. Before beginning ROM exercises, determine whether the patient would benefit from pain medication. Joints should be moved slowly through the ROM. Quick movement could cause injury.

DIF: Cognitive Level: Application REF: Text reference: p. 222

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Range of Motion KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. A nurse should be concerned when observing a patient performing isometric exercises if the patient is:

a.

holding his or her breath while exerting.

b.

performing the exercises four times per day.

c.

tightening each muscle group for 8 seconds, then relaxing.

d.

repeating each exercise 8 to 10 times for each muscle group.

ANS: A

Patients doing isometric exercises should be taught to exhale while exerting effort. Many persons hold their breath (Valsalva maneuver), which increases intrathoracic pressure, causing a decrease in venous return to the heart. Each exercise prescription is individualized according to the patients needs and limitations. Gradual buildup of exercise repetitions improves both muscle strength and endurance. Hold the muscles tightly contracted for 5 to 15 seconds, and then relax completely for several seconds.

DIF: Cognitive Level: Application REF: Text reference: p. 228

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Isometric Exercises KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

6. A nurse encourages a patient to prevent venous stasis by:

a.

crossing the legs when sitting in a chair.

b.

wearing thigh-length nylon stockings or garters.

c.

elevating the legs on pillows while in bed.

d.

increasing early ambulation.

ANS: D

Prevention is the best method to reduce the risk for deep vein thrombosis (DVT) secondary to immobility. Early ambulation remains the most effective preventive measure. Discourage patients from activities that promote venous stasis (e.g., crossing legs, wearing garters, elevating legs on pillows).

DIF: Cognitive Level: Comprehension REF: Text reference: p. 234

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Venous Stasis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. Antiembolic stockings (TEDs) are ordered for the patient on bed rest after surgery. The nurse explains to the patient that the primary purpose for the elastic stockings is to:

a.

keep the skin warm and dry.

b.

prevent abnormal joint flexion.

c.

apply external pressure.

d.

prevent bleeding.

ANS: C

The primary purpose of TEDs is to maintain external pressure on the muscles of the lower extremities and thus promote venous return. The primary purpose of TEDs is not to keep the skin warm and dry, prevent abnormal joint flexion, or prevent bleeding. They are used to prevent clot formation due to venous stasis.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 234

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Antiembolic Stockings KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. When assessing the patient for risk for DVT, the nurse should consider which of the following an indicator of increased risk?

a.

A positive Homans sign

b.

Pallor to the distal area

c.

Edema noted in the extremity

d.

Fever or dehydration

ANS: D

Indicators in Virchows triad include clotting disorders, fever, and dehydration. Additionally, a swollen extremity, pain, and warm cyanotic skin, indicate an elevated risk. Less than 20% of patients exhibit a positive Homans sign. Edema of the extremity may or may not occur.

DIF: Cognitive Level: Application REF: Text reference: p. 234

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: DVT KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

9. An appropriate procedure for the nurse to use when applying an elastic stocking is to:

a.

remove the stockings every 24 hours.

b.

keep the tops of the stockings rolled down slightly.

c.

turn the stocking inside out to apply from the toes up.

d.

wash stockings daily and dry in a dryer.

ANS: C

Turn elastic stocking inside out by placing one hand into the sock, holding the toe of the sock with the other hand, and pulling. This allows easier application of the stocking. Elastic stockings should be removed and reapplied at least twice a day. Instruct the patient not to roll the socks partially down. Rolling the socks partially down has a constricting effect and can impede venous return. Instruct the patient to launder elastic stockings every 2 days with mild detergent and lay flat to dry.

DIF: Cognitive Level: Application REF: Text reference: pp. 234-235

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Applying Elastic Stockings KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10. When using an SCD, the nurse should:

a.

apply powder to the patients skin if redness and itching are present.

b.

leave a two-finger space between the patients leg and the compression stocking.

c.

keep the patient connected to the compression device when transferring into and out of bed.

d.

remove the elastic stockings before putting on the sequential pneumatic compression stockings.

ANS: B

Check the fit of SCD sleeves by placing two fingers between the patients leg and the sleeve. Observe for signs, symptoms, and conditions that might contraindicate the use of elastic stockings or SCD: Elastic stockings and SCD sleeves may aggravate a skin condition or cause it to spread. Remove SCD sleeves when transferring the patient into and out of bed to prevent injury. If the patient is wearing elastic stockings, eliminate any wrinkles and folds before applying SCD sleeves. Wrinkles lead to increased pressure and alter circulation.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 235

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Applying SCD Sleeves KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11. The patient is a paraplegic who possesses good arm and hand strength. When the following devices are compared, which would be most appropriate for this patient?

a.

Axillary crutch

b.

Platform crutch

c.

Lofstrand crutch

d.

Standard crook cane

ANS: C

The Lofstrand crutch has a handgrip and a metal band that fits around the patients forearm. Both the metal band and the handgrip are adjusted to fit the patients height. This type of crutch is useful for patients with a permanent disability such as paraplegia. The axillary crutch frequently is used by patients of all ages on a short-term basis. The platform crutch is used by patients who are unable to bear weight on their wrists. It has a horizontal trough on which patients can rest their forearms and wrists and a vertical handle for the patient to grip. The standard crook cane provides the least support and is used by patients who require only minimal assistance to walk.

DIF: Cognitive Level: Analysis REF: Text reference: p. 237

OBJ: Develop teaching plans for selected patients for safety precautions to use at home while using an ambulation aid, applying and monitoring effects of elastic stockings and SCDs, using the CPM, and performing ROM and isometric exercises. TOP: Crutches

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

12. An appropriate way for the nurse to measure a patient for crutches is to:

a.

have a flexion of 45 degrees at both of the patients elbows.

b.

have a space of two to three fingers between the top of the crutch and the axilla.

c.

place the crutch tips 1 foot to each side of the patients feet, and observe the positioning of the crutches.

d.

place the crutch tips 1 foot to the front of the patients feet, and observe the positioning of the crutches.

ANS: B

Following correct crutch adjustment, two to three fingers should fit between the top of the crutch and the axilla. Following correct crutch adjustment, elbows should be flexed 15 to 30 degrees. Elbow flexion is verified with a goniometer. Position the crutches with the crutch tips at 6 inches (15 cm) to the side and 6 inches in front of the patients feet, and the crutch pads 2 inches (5 cm) below the axilla.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 239-240

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Crutches KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

13. The patient has been using crutches for the past 2 weeks. When she comes for her follow-up examination, she complains of tingling and numbness in her hands and upper torso. Possible causes of these symptoms are:

a.

the patients elbows are flexed 15 to 30 degrees when using the crutches.

b.

crutch pad is approximately 2 inches below the patients axilla.

c.

patient holds the cane 4 to 6 inches to the side of her foot.

d.

handgrip does not allow for elbow flexion.

ANS: D

Instruct the patient to report any tingling or numbness in the upper torso, which may mean that the crutches are being used incorrectly, or that they are the wrong size. If the handgrip is too low, radial nerve damage can occur even if overall crutch length is correct, because the extra length between the handgrip and the axillary bar can force the bar up into the axilla as the patient stretches down to reach the handgrip. After correct crutch adjustment, two to three fingers must fit between the top of the crutch and the axilla. Adequate space prevents crutch palsy. Proper fit is when the crutch pad is approximately 2 inches or two to three finger widths under the axilla, with the crutch tips positioned 6 inches (15 cm) lateral to the patients heel.

DIF: Cognitive Level: Analysis REF: Text reference: p. 239

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Crutches KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

14. The patient has a leg injury and is being fitted for a cane. The patient should be taught to:

a.

hold the cane on the uninvolved side.

b.

hold the cane on the weaker side.

c.

extend the cane 15 inches from the foot when used.

d.

maintain approximately 60 degrees of elbow flexion.

ANS: A

The patient holds the cane on the uninvolved side, 4 to 6 inches (10 to 15 cm) to the side of the foot. This offers the most support when the cane is placed on the stronger side of the body. The cane and the weaker leg work together with each step. The cane extends from the greater trochanter to the floor while the cane is held 6 inches (15 cm) from the foot. Allow approximately 15 to 30 degrees of elbow flexion. As weight is taken on by the hand and the affected leg is lifted off the floor, complete extension of the elbow is necessary.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 245

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Cane Measurement KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

15. While ambulating, the patient becomes light-headed and starts to fall. What should the nurse do first?

a.

Call for help.

b.

Try to reach for a chair.

c.

Ease the patient down to the floor.

d.

Push the patient back toward the bed.

ANS: C

If the patient begins to fall, gently ease the patient to the floor by holding firmly onto the gait belt; stand with the feet apart to provide a broad base of support, extend the leg, and let the patient gently slide to the floor. As the patient slides, the nurse bends the knees to lower the body. The nurse can cause more damage to self and patient by trying to catch the patient.

The nurse certainly will call for help, but this is not the first priority. The nurse must ensure the patients safety before getting help by easing him to the floor.

DIF: Cognitive Level: Application REF: Text reference: p. 240

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Patient Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16. When the four gaits listed below are compared, which is the most stable of the crutch gaits?

a.

Four-point gait

b.

Three-point gait

c.

Two-point gait

d.

Swing-to gait

ANS: A

Four-point gait is the most stable of crutch gaits because it provides at least three points of support at all times. The patient must be able to bear weight on both legs. Each leg is moved alternately with each opposing crutch, so that three points of support are on the floor all the time. This gait is often used when the patient has some form of paralysis, such as for spastic children with cerebral palsy. This is less stable than four-point gait because it requires the patient to bear all weight on one foot. Weight is borne on the uninvolved leg and then on both crutches. The affected leg does not touch the ground during the early phase of three-point gait. This gait may be useful for patients with a broken leg or a sprained ankle. This is less stable than four-point gait because it requires at least partial weight bearing on each foot. It is faster than four-point gait and requires better balance because only two points support the body at any one time. This is the easier of the two swinging gaits. It is less stable than four-point gait because it requires the ability to partially bear body weight on both legs. This gait is frequently used by patients whose lower extremities are paralyzed, or who wear weight-supporting braces on their legs.

DIF: Cognitive Level: Analysis REF: Text reference: pp. 241-242

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Crutch Gaits KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17. The nurse is caring for a patient who has just been treated for a broken leg. She needs to teach the patient how to use crutches. Which crutch gait is most appropriate for this patient?

a.

Four-point gait

b.

Three-point gait

c.

Two-point gait

d.

Swing-to gait

ANS: B

The three-point gait requires the patient to bear all weight on one foot. Weight is borne on the uninvolved leg and then on both crutches. The affected leg does not touch the ground during the early phase of three-point gait. It is useful for patients with a broken leg or a sprained ankle. The four-point gait is the most stable of crutch gaits because it provides at least three points of support at all times. The patient must be able to bear weight on both legs. Each leg is moved alternately with each opposing crutch, so that three points of support are on the floor all the time. The two-point is used when the patient has some form of paralysis, such as for spastic children with cerebral palsy. This gait requires at least partial weight bearing on each foot. It requires better balance because only two points support the body at one time. This is the easier of the two swinging gaits. It requires the ability to partially bear body weight on both legs. The swing-to gait is used by patients whose lower extremities are paralyzed, or who wear weight-supporting braces on their legs.

DIF: Cognitive Level: Analysis REF: Text reference: pp. 241-242

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Crutch Gaits KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

18. When teaching the use of a three-point crutch gait, the nurse should instruct the patient to move:

a.

both crutches and the affected leg first, then the stronger leg.

b.

the right crutch, left foot, left crutch, and right foot in sequence.

c.

the left crutch and right foot, then move the right crutch and left foot.

d.

both crutches, then lift and swing the legs forward as far as the crutches.

ANS: A

The proper sequence for the three-point crutch gait is: begin in tripod position, advance both crutches and the affected leg, and then move the stronger leg forward, stepping on the floor. This is the proper sequence for the four-point gait, the two-point gait, and the swing-to gait.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 241

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Crutch Gaits KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

19. A patient with left hemiparesis is using a quad cane for ambulation. Which of the following is the correct technique for the nurse to use in teaching the patient?

a.

Use the cane on the right side, with the cane moving forward first.

b.

Use the cane on the left side, with the left leg moving forward with the cane.

c.

Use the cane in either hand, with the right leg moving forward first.

d.

Use the cane in either hand, with the left leg moving beyond the forward placement of the cane.

ANS: A

To correctly use a quad cane, the patient places the cane on the side opposite the involved leg. This provides added support for the weak or impaired side. Ambulation then begins by moving the cane forward 6 to 10 inches (15 to 25 cm), keeping body weight on both legs. The weak leg is then brought forward even with the cane while the body weight is supported by the strong leg and the cane. The strong leg is then advanced past the cane. Moving a leg and the cane forward at the same time will compromise balance and increase risk of fall.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 245

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Ambulation With a Cane KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. The patient had a stroke and is currently immobile. The nurse realizes that increasing mobility is critical because immobility can result in alterations in which of the following? (Select all that apply.)

a.

Cardiovascular function

b.

Pulmonary function

c.

Skin integrity

d.

Elimination

ANS: A, B, C, D

When mobility is altered, many body systems are at risk for impairment. Impaired mobility can result in altered cardiovascular functioning, disruption of normal metabolic functioning, increased risk for pulmonary complications, the development of pressure ulcers, and urinary elimination alterations.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 221

OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation.

TOP: Complications of Immobility KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. The nurse is caring for an immobile patient. Which of the following may help reduce the hazards associated with immobility? (Select all that apply.)

a.

A high-fiber diet

b.

Frequent repositioning

c.

Muscle and joint exercises

d.

Increased fluid intake

ANS: A, B, C, D

Frequent repositioning, deep breathing and coughing exercises, muscle and joint exercises, increased fluid intake, and dietary intake of foods containing fiber are examples of measures that help to reduce the hazards of immobility.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 221

OBJ: Discuss the hazards of immobility. TOP: Prevention of Complications of Immobility

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. The nurse is applying a CPM machine to the patients leg. To do so, she must: (Select all that apply.)

a.

provide analgesia 1 hour before starting the CPM.

b.

stop the CPM when in extension and place a sheepskin on the machine.

c.

align the patients joint with the CPMs mechanical joint.

d.

secure the patients extremity tightly with Velcro straps.

ANS: B, C

Provide analgesia 20 to 30 minutes before CPM is needed. Stop the CPM when in extension. Place sheepskin on the CPM to ensure that all exposed hard surfaces are padded to prevent rubbing and chafing of the patients skin. Align the patients joint with the mechanical joint of the CPM.

DIF: Cognitive Level: Application REF: Text reference: p. 232

OBJ: Identify significant assessment data to be noted before and during the use of a machine.

TOP: CPM Machine KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. Factors that contribute to the development of DVT are: (Select all that apply.)

a.

elevated sodium (Na+) levels.

b.

hypercoagulability of the blood.

c.

venous wall damage.

d.

stasis of blood flow.

ANS: B, C, D

Three elements (commonly referred to as Virchows triad) contribute to the development of DVT: hypercoagulability of the blood, venous wall damage, and stasis of blood flow.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 234

OBJ: Understand the pathophysiology of the development of DVTs.

TOP: Deep Vein Thrombosis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

COMPLETION

1. ____________ refers to an ability to move about freely.

ANS:

Mobility

Mobility refers to an ability to move about freely.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 221

OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation.

TOP: Mobility KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. A persons inability to move about freely is known as _______________.

ANS:

immobility

Immobility refers to a persons inability to move about freely.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 221

OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation.

TOP: Immobility KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3. A drop in blood pressure that occurs when the patient changes position from a horizontal to a vertical position is known as _________________.

ANS:

orthostatic hypotension

Orthostatic hypotension is a drop in blood pressure that occurs when the patient changes position from a horizontal to a vertical position.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 236

OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation.

TOP: Orthostatic Hypotension KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

4. The patient is performing ROM exercises independently. These are known as __________ exercises.

ANS:

active ROM

ROM exercises may be active, passive, or active-assisted. They are active if the patient is able to perform the exercises independently and passive if the exercises are performed for the patient by the caregiver. The exercises are active-assisted if the patient is able to perform some of the actions independently with support and assistance from the caregiver.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 222

OBJ: Discuss indications for performing ROM and isometric exercises.

TOP: Active Range of Motion KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. Static exercises that involve tightening or tensing of muscles without moving a body part are known as ______________.

ANS:

isometric exercises

Isometric or static exercises involve tightening or tensing of muscles without moving body parts.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 227

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Isometric Exercises KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

6. _________________ increase muscle tension but do not change the length of muscle fibers.

ANS:

Isometric contractions

Isometric contractions increase muscle tension but do not change the length of muscle fibers.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 227

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Isometric Contractions KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

7. Virchows triad (hypercoagulability of blood, venous wall damage, and stasis of blood flow) has been found to contribute to ________________.

ANS:

deep vein thrombosis (DVT)

Three elements (commonly referred to as Virchows triad) contribute to the development of DVT: hypercoagulability of the blood, venous wall damage, and stasis of blood flow.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 237

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Deep Vein Thrombosis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

8. The nurse is concerned that the patient may fall while he is ambulating. To help her maintain control while the patient walks, the nurse may apply a ______________ around the patients waist.

ANS:

gait belt

A gait belt encircles a patients waist and has space for the nurse to hold while the patient walks. This gives the nurse better control and helps to prevent injury.

DIF: Cognitive Level: Application REF: Text reference: p. 240

OBJ: Demonstrate the following skills on selected patients: assisting with ambulation, assisting with ambulation with the use of an ambulation aid, assisting with ROM exercises, assisting with isometric exercises, applying a CPM, and applying elastic stockings and SCD.

TOP: Gait Belt KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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