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 OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning 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.

2. The nurse instructs the patient, who has right-sided weakness, to use the cane during ambulation and assesses the patient’s use of the cane. Which assessment would the nurse address before the patient ambulates with the cane?

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 OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment 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.

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?

ANS: A

Sitting on the side of the bed stabilizes the redistribution of the blood during the position change. Deep breathing helps lung expansion but does not affect the change in the blood distribution during position changes. Pushing up from the side of the bed helps the patient transition to standing, but it doesn’t prevent orthostatic hypotension. There are many muscles throughout the body that cannot be stretched voluntarily.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Interview the patient’s visitors. b. Discuss ambulation goals. c. Review the patient progress notes. d. Measure the distances ambulated.

4. The nurse is preparing to increase the amount of ambulation that the patient is able to tolerate. Which is the best method for the nurse to assess a patient’s ability to ambulate?

ANS: B

Mutual goal setting between the nurse and the patient is a beginning point. Watching the patient ambulate is essential but working with the patient is beneficial. Even if the patient’s visitors are health care professionals, the nurse must assess the patient before taking action. Reviewing progress notes provides valuable baseline data for comparison to the nurse’s assessment; however, the nurse assesses the patient to determine the nurse’s future care. Measuring the distance covered by the patient is valuable information and is one part of the data the nurse gathers for the nursing assessment.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Prevent the left leg from touching the floor at all times. b. Rest the left leg gently on the floor to stand with crutches. c. Distribute weight equally to each leg while crutch walking. d. Step with the left leg first to ascend the stairway with crutches.

5. The health care provider prescribes partial weight bearing of the left leg for the postoperative patient. Which instruction does the nurse include in patient teaching?

ANS: B

The nurse instructs the patient to rest the left leg on the floor without applying any weight to it when standing with the crutches to avoid full weight bearing on the affected leg. Equal distribution of weight is weight-bearing activity, and this is contraindicated for the patient. The patient steps with the unaffected leg first to provide a stable method for ascending stairs.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Complete the exercises in a bottom-up approach. b. Repeat each movement 8 times during the exercise period. c. Always use gloves if there are skin lesions. d. Complete the exercises in a head-to-toe sequence.

6. The nurse is planning to perform range-of-motion exercises on a patient who has had a stroke and has mobility issues. Which of the following principles does the nurse follow?

ANS: D

Complete exercises in head-to-toe sequence. Repeat each movement 5 times during the exercise period. Inform the patient how these exercises are performed and how they can be incorporated into activities of daily living (ADLs). Use gloves if wound drainage or skin lesions are present; however, this is not specific to providing range of motion.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Use a firm grip to grasp the cane with the right hand. b. Place the cane about 30.5 cm (12 inches) in front of the right leg. c. Distribute weight evenly between the cane and the left leg. d. Move the right leg forward first, the cane next, and left leg last.

7. The nurse teaches a patient who is alert and oriented to use a cane for left leg weakness. Which does the nurse include in patient teaching?

ANS: A

The nurse instructs the patient to hold the cane on the unaffected, or right, side to broaden the patient’s base of support because using the unaffected side offers more support. The cane should be placed 15–25 cm (6–10 inches) in front of the unaffected leg. The patient is instructed to distribute the body weight between both legs, to begin walking by moving the affected leg first to be even with the cane, and then to move the unaffected leg forward past the cane. This method provides support for the affected leg with the cane and realigns the patient’s center of gravity.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Hip b. Shoulder c. Ankle d. Wrist

8. The nurse instructs the patient how to incorporate range-of-motion exercises into activities of daily living (ADLs). With which of the patient’s joints can the nurse perform the most movements for the ADLs?

ANS: A

The hip can be moved into flexion, extension, internal rotation, external rotation, abduction, and adduction while performing ADLs. The shoulder can be moved into flexion, extension, and abduction. The ankle can dorsiflex and plantar flex. The wrist can be moved into flexion, extension, abduction, and adduction.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Determine the patients’ current pain level. b. Assist stable patients with their range-of-motion exercises. c. Force the joint motion gently a slight bit with each session. d. Place socks on patients before exercising the lower extremities.

9. Nursing assistive personnel (NAP) are working with patients performing range-of-motion exercises. Which activity can the nurse delegate to NAP?

ANS: B

The nurse can delegate range-of-motion exercises to NAP because training and education have been provided to allow them to perform the task safely. The nurse determines the patient’s pain level because it requires nursing assessment and nursing judgment. The joint motion should never be forced when performing range-of-motion exercises. Placing socks on patients before exercising the lower extremities has no purpose and is not done with range-of-motion exercises.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Ask the health care provider to order a wheelchair for the patient. b. Plan an adequate rest period before and after ambulating. c. Sit the patient on the bed for 15 minutes before ambulating. d. Increase the amount of range-of-motion exercises done daily.

10. A patient’s pulse has gone from 78 at rest to 98 after ambulating. What nursing action is indicated at this time?

ANS: B

The patient’s pulse rate has elevated over 20% of the baseline, which indicates a poor response to the level of activity. Rest needs to be provided immediately before and after the period of ambulation, or the amount of ambulation should be decreased until the patient adjusts to the activity. The patient would not be ambulating if riding in a wheelchair and would not build up tolerance to activity. Dangling helps decrease orthostatic hypotension but not activity intolerance. Range-of-motion exercises help with joint movement, not activity tolerance.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Get the nearest chair and put it behind the patient. b. Ease the patient to the side to protect his or her head. c. Straighten your leg and help the patient slide to the floor. d. Hold onto the gait belt and pull the patient close to you.

11. The nurse teaches the patient’s caregiver how to respond if the patient begins to fall while ambulating. Which instruction does the nurse provide to minimize potential injury to the patient and the caregiver?

ANS: C

If the patient complains of dizziness or begins to fall, instruct the caregiver to extend a leg under him or her and allow him or her to slide down the leg and gently reach the floor. This is the best method of preventing injury to the patient and caregiver because the caregiver engages strong muscles to act as an angle between the patient and the floor, slowing the speed of the patient’s descent. If the caregiver has to release the patient to get the chair, the patient is left unstable and is likely to suffer a fall or injury. The caregiver risks personal injury trying to direct the patient’s fall unless strong muscles such as the legs are used. The nurse uses back muscles to hold the gait belt with a patient fall and risks a serious back injury from twisting and reaching in the process.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Document that the patient is using the crutches properly. b. Encourage the patient to minimize the weight on the axilla. c. Ensure the patient’s crutches fit him or her properly. d. Increase the layer of padding to the top of the crutches.

12. The patient ambulates with two crutches, and the nurse notes that the patient’s weight is resting on the axilla. Which intervention is best?

ANS: C

Using crutches correctly the patient will place most of his or her weight on the hands, not the axilla. Placing weight on the axilla can cause nerve damage. While encouraging the patient to minimize the weight on the axilla is fine, the nurse must first assess the fit of the crutches. If they are too short, excess pressure will be placed in the axilla. The patient is not using the crutches appropriately so the nurse does not document that. More padding encourages more weight on the axilla.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Moves the right crutch first, left crutch second, and right leg last. b. Begins in the tripod position and bears all weight on the left leg. c. Slips three fingerbreadths between the crutch padding and the patient’s axilla. d. Flexes elbows at approximately 20 degrees while walking with crutches.

13. The patient is postoperative day 1 after surgery on the right knee and is to begin to walking with crutches using the three-point gait. Which action by the patient indicates the nurse needs to review the teaching?

ANS: A

N

The three-point gait requires the patient to advance both crutches at the same time with the affected leg while the unaffected leg bears the body weight. This technique allows the patient to avoid weight bearing on the affected leg by using a stable base of support. Moving the right crutch and then the left crutch is not the correct coordination for a three-point gait. The other options are correct for using a three-point gait.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Use the handrail on the right side. b. Shift the weight to the left leg to begin. c. Keep crutches very close to the hips. d. Place the left leg on the stair below first.

14. The nurse is instructing a patient with a right hip replacement to descend stairs by using crutches. Which does the nurse include in patient teaching?

ANS: B

The nurse instructs the patient to begin in the tripod position and thus shift the body weight to the unaffected leg to maintain balance and a base of support. The patient uses both crutches, one on each side, to descend a stairway to provide a wide base of support and avoid hopping down each step on one foot. The crutches should be held 15 cm (6 inches) laterally to provide a wider base of support. The nurse instructs the patient to position the crutches on the stair below before shifting weight to the crutches and moving the right leg forward.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Two-point gait b. Three-point gait c. Swing-to gait d. Swing-through gait

15. The patient is currently learning how to use crutches so there is minimal weight on the affected leg. Which type of crutch-walking technique will the nurse be reinforcing?

ANS: B

The three-point gait is appropriate for patients who have partial weight bearing, can toe touch, or have weight bearing as tolerated. The two-point gait is appropriate for weight bearing as tolerated or full weight bearing. The swing-to gait is used by patients whose lower extremities are paralyzed or who wear weight-supporting braces on their legs. The swing-through gait requires the ability to bear partial weight on both feet.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Call for immediate assistance. b. Help the patient to lie on the floor. c. Help the patient to a seated position. d. Inform the patient that the dizziness will pass.

16. The nurse is measuring vital signs when the patient, who is standing, reports dizziness. What is the nurse’s priority intervention?

ANS: C

The nurse helps the patient sit after the complaint of dizziness to prevent a fall. If necessary, the nurse then calls for help. Safety is always the priority when giving care. Sitting helps restore the patient’s blood pressure to normal levels, relieving the dizziness. Assisting the patient to the floor is indicated if the patient is so dizzy as to fall. Telling the patient that the dizziness will pass is a reasonable response after the patient has been seated.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Document the findings in the patient’s chart. b. Collaborate with the provider on DVT prevention. c. Inform the provider the patient is ready for more activity. d. Consult with physical therapy for balance training.

17. The nurse has assessed a patient using the Well’s score and documented the score as an 8. What intervention by the nurse is most appropriate?

ANS: B

The Well’s score rates the patient’s risk of developing a deep vein thrombosis (DVT). A score of 2 to 0 indicates low probability. A score of 1–2 indicates moderate probability. A score of 3–8 indicates a high probability of developing a DVT, so the nurse collaborates with the provider to provide prevention measures for the patient. The nurse does document the findings, but it is more important to notify the provider. The Well’s score is not related to progressive activity or balance.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

Multiple Response

1. The nurse is explaining to a nursing student the importance of making sure the patient is wearing the ordered sequential compression devices (SCDs) when in bed. Which of the following statements indicate a good understanding of the purpose of SCDs by the student? (Select all that apply.)

a. Used to prevent DVTs.

b. Alright to walk while wearing.

c. Can be used if patient has a DVT.

d. Does not affect Virchow’s triad.

e. Prevent venous stasis.

ANS: A, D

SCDs are prescribed to help prevent DVTs. They affect Virchow’s triad by improving venous stasis. Patients should not attempt to ambulate while wearing them. They are not used when a patient has a confirmed DVT.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Associated with arterial insufficiency. b. Includes vessel wall abnormalities. c. Dehydration is a cause of hypercoagulability. d. Pregnancy can lead to venous stasis. e. Genetically mediated risk of blood clotting.

2. The student nurse is reviewing Virchow’s triad. What information does the student learn? (Select all that apply.)

ANS: B, C, D

Virchow’s triad includes venous stasis, vessel wall abnormalities, and hypercoagulability and indicates risk for deep vein thrombosis, not arterial insufficiency. Dehydration is one cause of hypercoagulability and pregnancy can lead to venous stasis. Virchow’s triad is not genetically determined.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning