Question 1

The nurse is helping a patient with hemiparesis take a few steps. A gait belt has been applied. The patient is using a cane. Where should the nurse stand in relation to the patient?

Accepted Answer

On the patient's weak side.
Rationale: The patient’s weak side would need support if the patient begins to fall.

Question 2

The nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse determine how far to walk?

Accepted Answer

Ask the patient how far she would like to go.
Rationale: Setting mutual goals increases the likelihood of success in achieving the goal of ambulation.

Question 3

The nurse has applied a gait belt to a postoperative patient to facilitate ambulation. Within a few feet of the bed, the patient begins to complain of dizziness and leans heavily on the nurse. What would be the nurse's initial response?

Accepted Answer

Slowly lower the patient to the floor.
Rationale: safest action would be for the nurse to slowly lower the patient to the floor. The patient is already leaning heavily on the nurse.

Question 4

The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to nursing assistive personnel (NAP). Which statement made by NAP requires the nurse to follow up?

Accepted Answer

I will use the under-axillae technique to help him up to a standing position.
Rationale: Using the under-axillae technique is not a safe lifting technique, so this statement requires the nurse to follow up.

Question 5

The nurse is ambulating a patient with a gait belt when he says he feels sick to his stomach. What would the nurse do?

Accepted Answer

Return the patient to the bed or chair (whichever is closer).
Rationale: Returning the patient to the bed or chair allows patient to rest, and the nausea may subside.

Question 6

When preparing to apply elastic stockings, why does the nurse assess for skin discoloration?

Accepted Answer

To identify the potential risk for deep vein thrombosis (DVT).
Rationale: The nurse assesses for skin discoloration because it is one possible indicator of deep vein thrombosis (DVT).

Question 7

Which condition is not associated with venous stasis, part of Virchow's triad?

Accepted Answer

Anxiety.
Rationale: Pregnancy, obesity, and immobility can all cause pooling of blood in the lower extremities. Anxiety is not associated with blood stasis( blood is not flowing or circulating as optimally as it could to all parts of the body)

Question 8

Why does the nurse remove the patient's elastic stockings at least once per shift?

Accepted Answer

To check the skin for irritation or breakdown.

Question 9

Why might the nurse choose not to apply a pair of prescribed elastic stockings to a patient's legs?

Accepted Answer

The patient's skin is irritated.
Rationale: Compression stockings should not be applied if the skin of the legs is irritated.

Question 10

The nurse discovers that the NAP has been using moisturizer on the patient's legs before applying the stockings. What is the best action by the nurse?

Accepted Answer

Instruct NAP to use a small amount of cornstarch or powder.
Rationale: cornstarch/powder will decrease friction, making stockings easier to apply. moisturizer applied to legs may not cause skin breakdown, but will make them harder to apply.

Question 11

Which of the following techniques is used to assess muscle strength in a patient?

Accepted Answer

Apply an opposing force or resistance
Rationale: Muscle strength is tested for symmetry and grade. Strength should be bilaterally symmetric with full motion against resistance.

Question 12

What is an increased thoracic curvature, common in older adults, called?

Accepted Answer

Kyphosis
Rationale: Kyphosis is an increased thoracic curvature commonly found in older adults.

Question 13

Neck flexion and extension should be:

Accepted Answer

45 Degrees

Question 14

Which of the following findings in a musculoskeletal assessment would be considered abnormal?

Accepted Answer

Nodules and Bogginess

Question 15

What does a goniometer measure?

Accepted Answer

Angles of extension and flexion

Question 16

When preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first?

Accepted Answer

Assess the patient's physiological capacity to transfer.
Rationale: Assessing patient's physiological capacity to transfer determines the patient's ability to tolerate and assist with the transfer and whether special adaptive techniques are necessary.

Question 17

Which instruction would the nurse give a patient who is able to assist with transfer from a bed to a wheelchair using a transfer belt?

Accepted Answer

Please push down onto the mattress with both hands and stand when I count to three.
Rationale: Telling the patient to push against the mattress is the best instruction - teaches the patient how to help achieve a standing position during the transfer.

Question 18

A patient lying supine in bed is being transferred to a wheelchair using a transfer belt. Which action would the nurse perform just before moving the patient to the side of the bed?

Accepted Answer

Raise the head of the bed 30 degrees.

Question 19

The nurse is preparing to transfer a patient with left-sided weakness from the bed to a wheelchair using a transfer belt. Which position would the nurse instruct the patient to assume?

Accepted Answer

Place your stronger leg forward and your weaker leg toward the back.
Rationale: This allows the stronger leg to support most of the patient's body weight.

Question 20

A patient has been transferred to a wheelchair with a transfer belt. What is one action the nurse would take to position the patient safely in the chair?

Accepted Answer

Lower the foot rests, and place the patient's feet on them.
Rationale: Doing so supports the patient's feet and keeps them from dragging and creating a falling hazard when the chair is moved.

Question 21

When preparing for safe patient transfer using a hydraulic lift, the nurse performs which action first?

Accepted Answer

Assesses the patient for weakness, dizziness, or postural hypotension.
Rationale: Assessing the patient for weakness, dizziness, or postural hypotension will help ensure the patient’s safety.

Question 22

Which position is used when applying the sling to transfer a patient from the bed to a chair with a hydraulic lift?

Accepted Answer

Supine.

Question 23

Which action would decrease a patient's pain before a transfer with a hydraulic lift?

Accepted Answer

Administer a prescribed analgesic 30 to 60 minutes before the transfer.
Rationale: allowing time for the medication to take effect before the patient is moved. The remaining actions do not pertain to pain prevention.

Question 24

What does the nurse do after attaching the hooks to the holes in the sling on a hydraulic lift?

Accepted Answer

Have the patient cross the arms over the chest.

Question 25

When using a hydraulic lift to transfer a patient from the bed to a chair, when does the nurse turn off the check valve?

Accepted Answer

As soon as the patient has been placed in the chair

Question 26

Which patient is most at risk of developing permanently impaired mobility?

Accepted Answer

A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease)
diabetes, a serious chronic condition, and old age puts her at high risk of mobility impairment.

Question 27

The nurse is performing passive shoulder and elbow exercises for a patient. Why does the nurse cup one hand around the patient's elbow and support the forearm and wrist during the ROM exercises?

Accepted Answer

To ensure stability while exercising the joint.
Rationale: The nurse supports the distal portion of the extremity in order to ensure joint stability.

Question 28

The nurse notes that a patient's left elbow is resistant to extension and flexion while performing range of motion exercises. What is the appropriate nursing action?

Accepted Answer

Perform range of motion to the left elbow until resistance is met.
Rationale: stop the range of motion exercises because resistance is met.

Question 29

Which of the following are basic guidelines when assisting a patient with passive range of motion?

Accepted Answer

Each joint is exercised to the point of resistance but not pain.
Rationale: Joints should be exercised slowly, smoothly, and rhythmically to the point of resistance, but pain should not be felt by the patient.

Question 30

Why would the nurse ask a physical therapist to perform passive ROM exercises for a patient with lower extremity injuries sustained in a motor vehicle crash?

Accepted Answer

The patient has orthopedic trauma.
Rationale: Specialized expertise is usually required to perform passive ROM exercises for a patient with orthopedic trauma or spinal cord injury.

Question 31

When preparing to move a patient in bed, what will the nurse do first?

Accepted Answer

Assess the patient's ability to help with moving.
Rationale: Assessing the patient's ability to help is the first thing the nurse must do, since the answer determines how much help is needed with the move.

Question 32

When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety?

Accepted Answer

Flex the hips and knees.
Rationale: Flexing the hips and knees is the safest posture for both caregivers to assume when moving a patient in bed.

Question 33

A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers?

Accepted Answer

At least three.
Rationale: Since a friction-reducing device will be used and the client weighs 200 lbs., a minimum of three to four people are needed to move this patient safely.

Question 34

In which position will the nurse place the patient to move him or her up in bed?

Accepted Answer

Supine with the head of the bed flat.
Rationale: Placing the patient in the supine position with the head of the bed flat is the recommended position to use to move a patient up in bed.

Question 35

A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient?

Accepted Answer

Roll the patient from side to side, and place the device under the drawsheet.

Question

Question

Question

BSN 205

Nursing concepts

Question	Answer
The nurse is helping a patient with hemiparesis take a few steps. A gait belt has been applied. The patient is using a cane. Where should the nurse stand in relation to the patient?	On the patient's weak side. Rationale: The patient’s weak side would need support if the patient begins to fall.
The nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse determine how far to walk?	Ask the patient how far she would like to go. Rationale: Setting mutual goals increases the likelihood of success in achieving the goal of ambulation.
The nurse has applied a gait belt to a postoperative patient to facilitate ambulation. Within a few feet of the bed, the patient begins to complain of dizziness and leans heavily on the nurse. What would be the nurse's initial response?	Slowly lower the patient to the floor. Rationale: safest action would be for the nurse to slowly lower the patient to the floor. The patient is already leaning heavily on the nurse.
The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to nursing assistive personnel (NAP). Which statement made by NAP requires the nurse to follow up?	I will use the under-axillae technique to help him up to a standing position. Rationale: Using the under-axillae technique is not a safe lifting technique, so this statement requires the nurse to follow up.
The nurse is ambulating a patient with a gait belt when he says he feels sick to his stomach. What would the nurse do?	Return the patient to the bed or chair (whichever is closer). Rationale: Returning the patient to the bed or chair allows patient to rest, and the nausea may subside.
When preparing to apply elastic stockings, why does the nurse assess for skin discoloration?	To identify the potential risk for deep vein thrombosis (DVT). Rationale: The nurse assesses for skin discoloration because it is one possible indicator of deep vein thrombosis (DVT).
Which condition is not associated with venous stasis, part of Virchow's triad?	Anxiety. Rationale: Pregnancy, obesity, and immobility can all cause pooling of blood in the lower extremities. Anxiety is not associated with blood stasis( blood is not flowing or circulating as optimally as it could to all parts of the body)
Why does the nurse remove the patient's elastic stockings at least once per shift?	To check the skin for irritation or breakdown.
Why might the nurse choose not to apply a pair of prescribed elastic stockings to a patient's legs?	The patient's skin is irritated. Rationale: Compression stockings should not be applied if the skin of the legs is irritated.
The nurse discovers that the NAP has been using moisturizer on the patient's legs before applying the stockings. What is the best action by the nurse?	Instruct NAP to use a small amount of cornstarch or powder. Rationale: cornstarch/powder will decrease friction, making stockings easier to apply. moisturizer applied to legs may not cause skin breakdown, but will make them harder to apply.
Which of the following techniques is used to assess muscle strength in a patient?	Apply an opposing force or resistance Rationale: Muscle strength is tested for symmetry and grade. Strength should be bilaterally symmetric with full motion against resistance.
What is an increased thoracic curvature, common in older adults, called?	Kyphosis Rationale: Kyphosis is an increased thoracic curvature commonly found in older adults.
Neck flexion and extension should be:	45 Degrees
Which of the following findings in a musculoskeletal assessment would be considered abnormal?	Nodules and Bogginess
What does a goniometer measure?	Angles of extension and flexion
When preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first?	Assess the patient's physiological capacity to transfer. Rationale: Assessing patient's physiological capacity to transfer determines the patient's ability to tolerate and assist with the transfer and whether special adaptive techniques are necessary.
Which instruction would the nurse give a patient who is able to assist with transfer from a bed to a wheelchair using a transfer belt?	Please push down onto the mattress with both hands and stand when I count to three. Rationale: Telling the patient to push against the mattress is the best instruction - teaches the patient how to help achieve a standing position during the transfer.
A patient lying supine in bed is being transferred to a wheelchair using a transfer belt. Which action would the nurse perform just before moving the patient to the side of the bed?	Raise the head of the bed 30 degrees.
The nurse is preparing to transfer a patient with left-sided weakness from the bed to a wheelchair using a transfer belt. Which position would the nurse instruct the patient to assume?	Place your stronger leg forward and your weaker leg toward the back. Rationale: This allows the stronger leg to support most of the patient's body weight.
A patient has been transferred to a wheelchair with a transfer belt. What is one action the nurse would take to position the patient safely in the chair?	Lower the foot rests, and place the patient's feet on them. Rationale: Doing so supports the patient's feet and keeps them from dragging and creating a falling hazard when the chair is moved.
When preparing for safe patient transfer using a hydraulic lift, the nurse performs which action first?	Assesses the patient for weakness, dizziness, or postural hypotension. Rationale: Assessing the patient for weakness, dizziness, or postural hypotension will help ensure the patient’s safety.
Which position is used when applying the sling to transfer a patient from the bed to a chair with a hydraulic lift?	Supine.
Which action would decrease a patient's pain before a transfer with a hydraulic lift?	Administer a prescribed analgesic 30 to 60 minutes before the transfer. Rationale: allowing time for the medication to take effect before the patient is moved. The remaining actions do not pertain to pain prevention.
What does the nurse do after attaching the hooks to the holes in the sling on a hydraulic lift?	Have the patient cross the arms over the chest.
When using a hydraulic lift to transfer a patient from the bed to a chair, when does the nurse turn off the check valve?	As soon as the patient has been placed in the chair
Which patient is most at risk of developing permanently impaired mobility?	A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease) diabetes, a serious chronic condition, and old age puts her at high risk of mobility impairment.
The nurse is performing passive shoulder and elbow exercises for a patient. Why does the nurse cup one hand around the patient's elbow and support the forearm and wrist during the ROM exercises?	To ensure stability while exercising the joint. Rationale: The nurse supports the distal portion of the extremity in order to ensure joint stability.
The nurse notes that a patient's left elbow is resistant to extension and flexion while performing range of motion exercises. What is the appropriate nursing action?	Perform range of motion to the left elbow until resistance is met. Rationale: stop the range of motion exercises because resistance is met.
Which of the following are basic guidelines when assisting a patient with passive range of motion?	Each joint is exercised to the point of resistance but not pain. Rationale: Joints should be exercised slowly, smoothly, and rhythmically to the point of resistance, but pain should not be felt by the patient.
Why would the nurse ask a physical therapist to perform passive ROM exercises for a patient with lower extremity injuries sustained in a motor vehicle crash?	The patient has orthopedic trauma. Rationale: Specialized expertise is usually required to perform passive ROM exercises for a patient with orthopedic trauma or spinal cord injury.
When preparing to move a patient in bed, what will the nurse do first?	Assess the patient's ability to help with moving. Rationale: Assessing the patient's ability to help is the first thing the nurse must do, since the answer determines how much help is needed with the move.
When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety?	Flex the hips and knees. Rationale: Flexing the hips and knees is the safest posture for both caregivers to assume when moving a patient in bed.
A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers?	At least three. Rationale: Since a friction-reducing device will be used and the client weighs 200 lbs., a minimum of three to four people are needed to move this patient safely.
In which position will the nurse place the patient to move him or her up in bed?	Supine with the head of the bed flat. Rationale: Placing the patient in the supine position with the head of the bed flat is the recommended position to use to move a patient up in bed.
A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient?	Roll the patient from side to side, and place the device under the drawsheet.

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