TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 18: Exercise, Mobility, & Immobilization Devices Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse delegates helping the older patient ambulate with a walker without wheels to
nursing assistive personnel (NAP). Which instructions does the nurse provide to the NAP? a. Show the patient how to slide the walker a few steps ahead. b. Check the patient for non-skid shoes before using the walker. c. Be sure that the patient places all weight on the front of the walker. d. Ensure that the patient is wearing soft slipper socks while walking. ANS: B
The nurse instructs the NAP to check the patient for supportive, non-skid shoes to prevent injury to the patient’s feet and provide sure footing while using the walker. The patient should be instructed to lift the walker and set it into place to advance. Sliding is not safe because it does not provide a stable foundation and is more likely to lead to patient falls. The patient should not place all weight on the front of the walker because this will cause the walker to tip. The patient should be instructed to place weight in the center of the walker for stability. Soft slipper socks do not provide adequate support for the ambulating patient and are more likely to lead to falls. DIF: Cognitive Level: Understanding TOP: Nursing Process: Planning
OBJ: NCLEX: Physiological Integrity
2. The nurse instructs the patient, who has right-sided weakness, to use the cane during
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ambulation and assesses the patient’s use of the cane. Which assessment would the nurse address before the patient ambulates with the cane? a. The cane makes a tapping sound each time the patient touches it to the floor. b. The patient holds the cane in the unaffected hand for support. c. The patient holds the cane 10–15 cm (4–6 inches) to the side of the left foot. d. The patient ambulated 4 times with the cane in physical therapy. ANS: A
The cane should have a rubber tip on the end and should be silent when the rubber tip contacts the floor, indicating that the rubber is intact; if the cane clicks each time it hits the floor, the rubber cannot effectively maintain the patient’s stability. Using the cane on the unaffected side is proper technique for ambulating with a cane. Holding the cane 10–15 cm (4–6 inches) to the side of the unaffected foot is appropriate. The patient’s history of cane use is valuable information for subsequent instruction and gives the nurse a basis for comparison. DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment
OBJ: NCLEX: Physiological Integrity
3. A patient is being moved into a dangling position before ambulating. To decrease the chance
of orthostatic hypotension, what activity can the patient do? a. Sit on the side of the bed for a minute before standing up. b. Take several deep breaths while moving into the dangling position. c. Push up into the dangling position on the side of the bed. d. Stretch all of the muscles in the body.
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