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chapter 16
Moving and Positioning Patients
| Question | Answer |
|---|---|
| During a complete bed bath, which action helps promote circulation and venous return? a. Washing from proximal to distal b. Washing from distal to proximal c. Using cold water to stimulate the skin d. Massaging bony prominences to improve blood flow | b. Washing from distal to proximal. |
| Which of the following is an evidence-based finding related to bathing methods? a. Soap-and-water baths are more effective than disposable wipes. b. Disposable wipes are less costly and may maintain more stable vital signs. c. Patients who use wipes | b. Disposable wipes are less costly and may maintain more stable vital signs. |
| Why did the FDA ban the antibacterial ingredient triclosan in 2017? a. It was found to be ineffective in killing germs. b. It caused skin irritation in most patients. c. It was found to be toxic and potentially harmful to humans. d. It reduced the e | c. It was found to be toxic and potentially harmful to humans. |
| What is one major nursing benefit of assisting a patient with bathing? a. It allows the nurse to assess the patient’s skin condition and circulation. b. It reduces the nurse’s workload by delegating care to aides. c. It limits close contact, preventi | a. It allows the nurse to assess the patient’s skin condition and circulation. |
| Which patient would not be an appropriate candidate for a back massage? a. A patient with anxiety b. A patient recovering from a hip fracture c. A patient who is restless after surgery d. A patient with difficulty sleeping | b. A patient recovering from a hip fracture. |
| When providing oral care to an unconscious patient, which action is most important to prevent aspiration? a. Use a large amount of fluid for thorough rinsing b. Place the patient in a side-lying position c. Brush teeth with a firm toothbrush d. Avoi | b. Place the patient in a side-lying position |
| A patient is receiving anticoagulant therapy (blood thinners). Which action by the nurse is appropriate when assisting with shaving? a. Use a straight razor for a close shave. b. Avoid shaving the patient entirely. c. Use an electric razor to prevent | c. Use an electric razor to prevent cuts. |
| Which of the following best describes the purpose of routine scheduled care (early a.m., a.m., p.m., h.s.)? a. To ensure patients bathe only once a day b. To help patients maintain hygiene and comfort through consistent care c. To replace individuali | b. To help patients maintain hygiene and comfort through consistent care |
| What is the main advantage of using commercially prepared bathing wipes instead of a traditional basin and washcloth? a. They reduce cross-contamination and infection risk b. They clean the skin more thoroughly c. They smell better and improve comfor | a. They reduce cross-contamination and infection risk |
| During a bed bath, why should the nurse wash from distal to proximal on the extremities? a. To make the process faster and easier b. To stimulate venous return and improve circulation c. To prevent chilling of the patient d. To minimize soap residue | b. To stimulate venous return and improve circulation |
| What should the nurse do if the patient becomes fatigued or short of breath while performing an assisted bath? a. Encourage the patient to finish independently b. Stop the bath completely and try again later c. Allow the patient to rest, then finish | c. Allow the patient to rest, then finish the bath for them |
| Which of the following statements about bathing and culture is true? a. All patients should bathe daily for infection prevention. b. It’s acceptable to ignore cultural beliefs if hygiene is a concern. c. Some cultures bathe weekly or find body odor a | c. Some cultures bathe weekly or find body odor acceptable. |
| Why is it important to cover the patient with a bath blanket during a bed bath? a. To keep the nurse’s scrubs clean b. To prevent contamination of supplies c. To preserve the patient’s warmth and modesty d. To absorb extra water during the bath | c. To preserve the patient’s warmth and modesty |
| seborrhea | Thick, oily scales on the scalp may be due to this/ an overproduction of sebum |
| tinea capitus (ringworm) | a fungal infection that can affect any part of the body and can be spread from one person to another. |
| lesions | or open areas ( happens in scalp) |
| intubation | involves passing a tube through the mouth to the trachea; |
| Which type of bed is made when the patient will be returning on a stretcher and the top linens need to be out of the way? a. Open bed b. Surgical bed c. Closed bed d. Occupied bed | b. Surgical bed |
| Under which circumstances should jewelry be removed from a body piercing? a. Only when the patient requests it b. For surgery, intubation, diagnostic testing (like MRI), or catheterization c. When the piercing is healed d. Only if the jewelry is mad | b. For surgery, intubation, diagnostic testing (like MRI), or catheterization |
| ocular prosthesis | is custom made to fit the socket and is hand painted with great detail to match the existing eye. |
| enucleated | completely removed, leaving only the socket. |
| scleral cover shell | a thick contact lens that fits flush against the implanted globe or blind globe. |
| What is the main reason for performing a back massage during patient care? a) To improve flexibility b) To relax the patient and stimulate circulation c) To reduce body odor d) To apply lotion more effectively | b) To relax the patient and stimulate circulation |
| Which of the following is a proper technique when performing a back massage? a) Use fingertips to rub the skin quickly b) Massage muscles using the flat side of your fingers and thumbs c) Apply lotion only on top of the skin without massaging d) Avo | b) Massage muscles using the flat side of your fingers and thumbs |
| Open bed: | made with the top linens fanfolded to the foot of the bed so that the patient can easily slip into the bed and pull them up. |
| Surgical bed: | top linens fanfolded to the side of the bed (the side away from the door). |
| Closed bed: | only used when the patient is discharged. The room is terminally cleaned and the bed is made with fresh linens. The top linens are spread to the head of the bed to keep the bed clean. This will be converted to an open bed when staff are alerted to a pati |
| UNOCCUPIED BED. | when the patient is out of the bed while the linens are changed. The patient may be sitting up in the chair or may have left the patient unit for therapy or diagnostic tests. |
| OCCUPIED BED. | the linens are changed while the patient remains in the bed. |
| draw sheet | or turn sheet are applied to the bed up to where the patient is lying. / narrower than a flat sheet and has two narrow hems on each end. |
| A flat sheet | has a wide hem at the top and a narrow hem at the bottom. |
| mitered corner | slanted corner/ purpose of this type of corner is to anchor the linens more firmly than if they were only tucked at the foot of the mattress. |
| Why is it important to cuff the top sheet over the blanket when making a bed? a) To make the bed look neat and tidy b) To prevent rough fabric edges from irritating the patient’s face and neck c) To make it easier to tuck the sheets under the mattres | b) To prevent rough fabric edges from irritating the patient’s face and neck |
| The heat of a shower or bath can cause/ widening of blood vessels | vasodilation |
| Reverse Trendelenburg’s | Used to elevate the patient’s head without bending at the waist for patients who have returned from procedures requiring that the legs be kept straight at the groin, such as a cardiac catheterization. |
| Trendelenburg’s | Used for patients who have very low blood pressure (shock) to return blood to the brain and vital organs. Keeping the head of the bed flat with the feet elevated is the preferred bed position for patients with breathing difficulty or head injury. |
| Semi-Fowler’s | Used for patients on continuous tube feedings to prevent aspiration and for comfort when patient does not wish to be completely flat. |
| Fowler’s | Knees slightly elevated to prevent sliding down; used when patients want to sit up to watch TV or converse with visitors. |
| Flat | Used for resting or sleeping and after certain procedures such as lumbar punctures and back surgery. |
| When making an occupied bed, why should you lift the top linens above the patient’s toes instead of tucking them tightly under the foot of the mattress? a) To keep the bed looking tidy b) To allow room for the natural foot position and prevent footdro | b) To allow room for the natural foot position and prevent footdrop or pressure injuries |
| Why might a disposable pad be placed between clean and soiled linens when making an occupied bed? a) To add extra comfort for the patient b) To prevent contamination of clean linens c) To make it easier to tuck the sheets d) To keep the mattress war | b) To prevent contamination of clean linens |
| What are the three types of patient care? a) Independent care, dependent care, and shared care b) Self-care, assisted care, and total care c) Personal care, medical care, and collaborative care d) Individual care, group care, and managed care | b) Self-care, assisted care, and total care |
| Which type of care applies when the patient can perform all activities of daily living (ADLs) without help? a) Assisted care b) Self-care c) Partial care d) Total care | b) Self-care |
| Which type of care involves the nurse helping the patient with only a few activities, such as bathing or dressing? a) Assisted care b) Total care c) Partial care d) Supportive care | a) Assisted care |
| Which type of care applies when the nurse must perform all activities of daily living (ADLs) for the patient? a) Self-care b) Partial care c) Total care d) Assisted care | c) Total care |
| The heat of a shower or bath can cause/ widening of blood vessels | vasodilation |
| When making an occupied bed, why should you lift the top linens above the patient’s toes instead of tucking them tightly under the foot of the mattress? a) To keep the bed looking tidy b) To allow room for the natural foot position and prevent footdro | b) To allow room for the natural foot position and prevent footdrop or pressure injuries |
| Why might a disposable pad be placed between clean and soiled linens when making an occupied bed? a) To add extra comfort for the patient b) To prevent contamination of clean linens c) To make it easier to tuck the sheets d) To keep the mattress war | b) To prevent contamination of clean linens |
| What are the three types of patient care? a) Independent care, dependent care, and shared care b) Self-care, assisted care, and total care c) Personal care, medical care, and collaborative care d) Individual care, group care, and managed care | b) Self-care, assisted care, and total care |
| Which type of care applies when the patient can perform all activities of daily living (ADLs) without help? a) Assisted care b) Self-care c) Partial care d) Total care | b) Self-care |
| Which type of care involves the nurse helping the patient with only a few activities, such as bathing or dressing? a) Assisted care b) Total care c) Partial care d) Supportive care | a) Assisted care |
| Which type of care applies when the nurse must perform all activities of daily living (ADLs) for the patient? a) Self-care b) Partial care c) Total care d) Assisted care | c) Total care |
| What could happen if a patient develops footdrop due to improper linen placement? a) The patient may find walking difficult or impossible b) The patient’s circulation will improve c) The patient will be able to flex the foot normally d) The patient | a) The patient may find walking difficult or impossible |
| Hygiene | used to describe keeping oneself clean and well groomed |
| .When each of us prepares for the day, the activities involved—such as bathing, washing and styling hair, brushing and flossing teeth, dressing, and shaving—are referred to as | activities of daily living (ADLs). |
| maceration | redness, cracking/ softened skin caused by continuous exposure to moisture. This often occurs in skin crevices such as under the breasts and scrotum, in the axilla and groin areas, between the toes, and between the buttocks. |
| excoriation, | scrapes on the skin, that may be the result of scratching or that may occur during care |
| venous return | distal to proximal to improve blood return from the extremities back to the heart |
| mottling | a purplish blotching of the skin when circulation slows greatly |
| Which nursing intervention helps conserve a patient’s energy during a tub bath or shower? a) Instructing the patient to stand for the entire shower. b) Placing a bench or chair in the shower or tub for the patient to sit on. c) Asking the patient to | b) Placing a bench or chair in the shower or tub for the patient to sit on. |
| an article about the dangers of immobility was published in the British Medical Journal. | 1947 |
| The American Journal of Nursing published the often-cited article, “The Hazards of Immobility,” detailing the effects of immobility on each body system. | 1967 |
| When a patient is unable to move about, they can suffer from this/which means that muscle decreases in size, tone, and strength as a result of disuse. | muscle atrophy |
| contractures | shortening and tightening of the muscles because of disuse. This is why your muscles feel weak when you have been ill and have remained in bed for several days. |
| Osteoporosis | a condition that occurs because of loss of bone minerals; it leads to an increased risk of skeletal fractures |
| bone demineralization can begin as early as? | 2 to 3 days from the onset of immobility. |
| The most basic nursing measure to prevent musculoskeletal complications is to? | maintain proper body alignment, which means to keep the head, trunk, and hips positioned in a straight line. |
| supine position | all variations of side-lying positions, and even while sitting. |
| dorsiflexion | When lying in the supine position, the patient’s ankles should be flexed approximately 90 degrees so that the toes point toward the ceiling. |
| footdrop | If the toes are allowed to fall toward the foot of the bed, the proper dorsiflexion of the ankle is lost and permanent plantar flexion of the foot develops |
| How often should a patient who cannot move independently be repositioned in bed? A. Every 4 hours B. Every 3 hours C. Every 2 hours D. Only when they request | C. Every 2 hours |
| Which complication is most likely if an immobile patient is not turned regularly? A. Hypotension B. Pressure injuries (decubitus ulcers) C. Improved circulation D. Hyperactivity | Pressure injuries (decubitus ulcers) |
| How can immobility contribute to the formation of kidney stones? A. By decreasing urine output B. By causing hypercalcemia from bone demineralization C. By increasing peristalsis D. By improving renal filtration | B. By causing hypercalcemia from bone demineralization |
| One common nursing measure that is used to combat the physiological effects of immobility/ a series of activities designed to move each joint through all of its natural actions. | the use of range-of-motion (ROM) exercises |
| trochanter roll | is a rolled towel or cylindrical device placed snugly against the lateral aspect of the patient’s thigh to prevent the leg from rotating outward. |
| Active ROM exercises | performed by the patient without physical nursing assistance. |
| Passive ROM exercises | are done with the nurse performing the exercising of the patient’s joints while providing proper support to the patient’s extremity. |
| Bedrest results in a 50% reduction of blood flow to the legs and contributes to/ or pooling of blood in the veins of the lower legs. | venous stasis |
| deep vein thrombosis (DVT | which is a clot that develops in the deep veins of the legs. |
| embolus | Any stationary clot or clot fragment may dislodge and enter the circulation/ a traveling blood clot |
| When it occurs in the lungs, it is referred to as a | a pulmonary embolus (PE) |
| What is shearing, and what can result from it? A. Friction of skin against bed sheets; can cause pressure injuries B. Pulling muscles during exercise; can cause strains C. Breaking of bones under pressure; can cause fractures D. Stretching of ligament | A. Friction of skin against bed sheets; can cause pressure injuries |
| How can altered skin integrity be prevented in immobile patients? A. Reposition every 2 hours, provide adequate nutrition, use support surfaces B. Keep patient in bed at all times, avoid touching the skin C. Limit fluids to prevent sweating D. Only cl | A. Reposition every 2 hours, provide adequate nutrition, use support surfaces |
| Orthostatic hypotension, also known as postural hypotension | is a decrease in blood pressure that occurs when a patient changes from a reclining or flat position to an upright position, such as sitting or standing. |
| A patient who is immobile develops a blood clot in the leg that dislodges and travels through the bloodstream. If the clot lodges in the lungs, heart, or brain, which of the following conditions can result? Why is this situation considered highly preventa | A. Pulmonary embolus (PE), myocardial infarction (MI), cerebrovascular accident (CVA); preventable with proper patient mobility and blood flow interventions |
| One common nursing measure that is used to combat the physiological effects of immobility/ a series of activities designed to move each joint through all of its natural actions. | the use of range-of-motion (ROM) exercises |
| trochanter roll | is a rolled towel or cylindrical device placed snugly against the lateral aspect of the patient’s thigh to prevent the leg from rotating outward. |
| Active ROM exercises | performed by the patient without physical nursing assistance. |
| Passive ROM exercises | are done with the nurse performing the exercising of the patient’s joints while providing proper support to the patient’s extremity. |
| Bedrest results in a 50% reduction of blood flow to the legs and contributes to/ or pooling of blood in the veins of the lower legs. | venous stasis |
| deep vein thrombosis (DVT | which is a clot that develops in the deep veins of the legs. |
| embolus | Any stationary clot or clot fragment may dislodge and enter the circulation/ a traveling blood clot |
| When it occurs in the lungs, it is referred to as a | a pulmonary embolus (PE) |
| What is shearing, and what can result from it? A. Friction of skin against bed sheets; can cause pressure injuries B. Pulling muscles during exercise; can cause strains C. Breaking of bones under pressure; can cause fractures D. Stretching of ligament | A. Friction of skin against bed sheets; can cause pressure injuries |
| How can altered skin integrity be prevented in immobile patients? A. Reposition every 2 hours, provide adequate nutrition, use support surfaces B. Keep patient in bed at all times, avoid touching the skin C. Limit fluids to prevent sweating D. Only cl | A. Reposition every 2 hours, provide adequate nutrition, use support surfaces |
| Orthostatic hypotension, also known as postural hypotension | is a decrease in blood pressure that occurs when a patient changes from a reclining or flat position to an upright position, such as sitting or standing. |
| A patient who is immobile develops a blood clot in the leg that dislodges and travels through the bloodstream. If the clot lodges in the lungs, heart, or brain, which of the following conditions can result? Why is this situation considered highly preventa | A. Pulmonary embolus (PE), myocardial infarction (MI), cerebrovascular accident (CVA); preventable with proper patient mobility and blood flow interventions |
| One common nursing measure that is used to combat the physiological effects of immobility/ a series of activities designed to move each joint through all of its natural actions. | the use of range-of-motion (ROM) exercises |
| trochanter roll | is a rolled towel or cylindrical device placed snugly against the lateral aspect of the patient’s thigh to prevent the leg from rotating outward. |
| Active ROM exercises | performed by the patient without physical nursing assistance. |
| Passive ROM exercises | are done with the nurse performing the exercising of the patient’s joints while providing proper support to the patient’s extremity. |
| Bedrest results in a 50% reduction of blood flow to the legs and contributes to/ or pooling of blood in the veins of the lower legs. | venous stasis |
| deep vein thrombosis (DVT | which is a clot that develops in the deep veins of the legs. |
| embolus | Any stationary clot or clot fragment may dislodge and enter the circulation/ a traveling blood clot |
| When it occurs in the lungs, it is referred to as a | a pulmonary embolus (PE) |
| What is shearing, and what can result from it? A. Friction of skin against bed sheets; can cause pressure injuries B. Pulling muscles during exercise; can cause strains C. Breaking of bones under pressure; can cause fractures D. Stretching of ligament | A. Friction of skin against bed sheets; can cause pressure injuries |
| How can altered skin integrity be prevented in immobile patients? A. Reposition every 2 hours, provide adequate nutrition, use support surfaces B. Keep patient in bed at all times, avoid touching the skin C. Limit fluids to prevent sweating D. Only cl | A. Reposition every 2 hours, provide adequate nutrition, use support surfaces |
| Orthostatic hypotension, also known as postural hypotension | is a decrease in blood pressure that occurs when a patient changes from a reclining or flat position to an upright position, such as sitting or standing. |
| A patient who is immobile develops a blood clot in the leg that dislodges and travels through the bloodstream. If the clot lodges in the lungs, heart, or brain, which of the following conditions can result? Why is this situation considered highly preventa | A. Pulmonary embolus (PE), myocardial infarction (MI), cerebrovascular accident (CVA); preventable with proper patient mobility and blood flow interventions |
| One common nursing measure that is used to combat the physiological effects of immobility/ a series of activities designed to move each joint through all of its natural actions. | the use of range-of-motion (ROM) exercises |
| trochanter roll | is a rolled towel or cylindrical device placed snugly against the lateral aspect of the patient’s thigh to prevent the leg from rotating outward. |
| Active ROM exercises | performed by the patient without physical nursing assistance. |
| Passive ROM exercises | are done with the nurse performing the exercising of the patient’s joints while providing proper support to the patient’s extremity. |
| Bedrest results in a 50% reduction of blood flow to the legs and contributes to/ or pooling of blood in the veins of the lower legs. | venous stasis |
| deep vein thrombosis (DVT | which is a clot that develops in the deep veins of the legs. |
| embolus | Any stationary clot or clot fragment may dislodge and enter the circulation/ a traveling blood clot |
| When it occurs in the lungs, it is referred to as a | a pulmonary embolus (PE) |
| What is shearing, and what can result from it? A. Friction of skin against bed sheets; can cause pressure injuries B. Pulling muscles during exercise; can cause strains C. Breaking of bones under pressure; can cause fractures D. Stretching of ligament | A. Friction of skin against bed sheets; can cause pressure injuries |
| How can altered skin integrity be prevented in immobile patients? A. Reposition every 2 hours, provide adequate nutrition, use support surfaces B. Keep patient in bed at all times, avoid touching the skin C. Limit fluids to prevent sweating D. Only cl | A. Reposition every 2 hours, provide adequate nutrition, use support surfaces |
| Orthostatic hypotension, also known as postural hypotension | is a decrease in blood pressure that occurs when a patient changes from a reclining or flat position to an upright position, such as sitting or standing. |
| A patient who is immobile develops a blood clot in the leg that dislodges and travels through the bloodstream. If the clot lodges in the lungs, heart, or brain, which of the following conditions can result? Why is this situation considered highly preventa | A. Pulmonary embolus (PE), myocardial infarction (MI), cerebrovascular accident (CVA); preventable with proper patient mobility and blood flow interventions |
| If the blood pressure falls too far, the patient may experience/ or fainting | syncope |
| antiembolism stockings | which are close-fitting elastic stockings that usually cover the whole leg |
| sequential compression devices (SCDs) | air-filled sleeves that are wrapped around the patient’s lower legs and connected to a pump that inflates and deflates each area of the sleeve in a sequence designed to move blood in the legs toward the heart. |
| Atelectasis | collapse of lung tissue affecting part or all of a lung, can occur because of the inability of the lung to fully expand |
| hypoxemia | When the alveoli collapse, oxygen and carbon dioxide exchange is impaired, resulting in lowered oxygen in the blood |
| a pressure injury, also called skin breakdown or a decubitus ulcer. | When a patient is immobile and consistent pressure is applied to the same area of the body, the blood flow to that area is reduced or is stopped entirely. When this occurs, the skin and underlying tissue die |
| compression neuropathy | In addition, if the patient is not turned and positioned appropriately, nerves may be compressed between the bones and the firm surface of the bed, resulting in impaired nerve function called |
| The most common site for compression neuropathy in the lower extremities of the immobile patient is the? | peroneal nerve at the fibular head. |
| When you are placing a patient’s extremity in the position of function | avoid direct pressure over bony prominences, compromised tissue, or pressure injuries |
| position of function | placing the extremities in alignment to maintain the potential for their use and movement |
Created by:
kelly s