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103 Cards in this Set
- Front
- Back
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What position is less of a concern for foot drop?
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lateral position because gravity does not pull down the feet
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Point at which the mass of an object is centered. The ______ __ ________ for a standing person is the center of the pelvis and about halfway between the umbilicus and the pubic bone.
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Center of gravity
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What is it called when bed ridden patients can begin to lose muscle tone/mass in a very short time especially if frail?
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disuse syndrome
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Where does the base of support achieve balance?
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Center of gravity
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What position should you distribute weight equally on both feet to provide a broad base of support?
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Standing
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What position are the buttocks and upper thighs the base of support?
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Sitting
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Bend the knees slightly to avoid straining the joints and maintain the hips at an even level in what position
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standing
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The knees are bent with the posterior of the knee free from the edge of the chair to avoid interfering with distal circulation in what position?
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Sitting
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What position looks the same as a standing position except the person is horizontal?
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Lying Down
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What position do you hold your chest up and slightly forward, extend the waist to give internal organs more space and maintain good alignment of the spine?
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Standing
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Name four ways your can use good body mechanics?
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• Use the longest and strongest muscles of the arms and legs
• When lifting a heavy load, center it over the feet • Hold objects close to the body • Bend the knees |
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Name a way you can promote functional mobility in your clients and what it is.
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• an inactive client's position is changed to relieve pressure on bony areas of the body
• alignment that maintains the potential for movement and ambulation |
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Name four ways you can use good body mechanics?
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• Push pull or roll objects whenever possible rather than lifting them -roll toward you
• Use body weight as a lever to assist with pushing or pulling an object • Keep feet apart for a broad base of support • Bend the knees and keep the back straight when lifting an object |
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What are some important tips for positioning clients?
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• change the inactive client's position every 2 hours
• get the help of another caregiver • raise the bed to elbow height • remove pillows and positioning devices • unfasten drainage tubes from bed linen |
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What is the position called when a person is lying on their back?
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Supine
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What are two primary concerns associated with the supine position?
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• prolonged pressure especially at the end of the spine that leads to skin breakdown
• gravity combined with pressure on the toes from bed linen, creates a potential for foot drop |
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What is the permanent dysfunctional position caused by shortening of the calf muscles and lengthening of the opposing muscles on the anterior leg?
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foot drop
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What is the position called when a person is lying on their side?
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lateral position
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What is the position called when a person lies on their abdomen?
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prone position
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What is the position called that is semi-prone, lying on their left side with the right knee drawn up toward the chest?
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Sims' Position
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What is the position that is semi-sitting and makes it easier for the client to eat, talk, and look around?
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Fowler's Position
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There are three variations of the Fowler's position?
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low Fowler's Position
mid Fowler's Position high Fowler's Position |
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Why is Fowler's Position helpful?
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Its helpful for clients with dyspnea because it causes the abdominal organs to drop away from the diaphragm
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What are some positioning devices that nurses can use?
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Adjustable Bed, Mattress, Bed Board, Pillows, Roller or Draw Sheet
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What is the Trendelenburg position?
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head of bed is slightly lower than feet keeping the client from sliding down toward the foot of the bed
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What are some other positioning devices nurses use?
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Trochanter Rolls
Hand Rolls Foot Boards Boot and foot splints |
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What is a Trochanter roll used for?
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It is a sheet rolled around a towel on each side of the patient's hip area - it prevents the legs from turning outward
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What is the Trochanter?
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bony protrusions at the head of the femur
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What is it called when the fingers muscles are permanently shortened and resist stretching?
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contractures
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What is a hand roll used for?
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They are rolled up wash cloths or balls that preserves the client's ability to grasp and pick up objects. They keep the thumb out and the fingers in a neutral position instead of contracted.
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What devices prevent foot drop by keeping the feet in a functional position?
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Foot boards, boots and splints
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If a client is short what is used so they don't get foot drop?
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foot splints
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What is the triangular piece of metal hung by a chain over the head of the bed that helps maintain independence?
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Trapeze
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What are some protective devices nurses use to help their clients?
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Side Rails, Mattress Overlays, Cradle, Specialty Beds
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Why are side rails valuable other than for safety?
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they aid clients in changing their position
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Describe the Anatomic position
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Frontal and back views with arms at the sides and palms forward.
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What is it called when parts of an object are in proper relationship to one another?
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Alignment
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What is the position of the body, or the way in which it is held called?
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Posture
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Why is good posture important?
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• affects a person's appearance
• stamina • ability to use the musculoskeletal system efficiently |
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What is an efficient use of the musculoskeletal system?
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body mechanics
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What are disorders that result from cumulative trauma to musculoskeletal structures?
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repetitive strain injuries
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specialty field of engineering science devoted to promoting comfort, performance, and health in the workplace
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ergonomics
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What is it called when force is exerted against the surface and layers of the skin as tissues slide in opposite but parallel directions?
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shearing
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What serves as a supportive bridge between two surfaces?
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transfer board
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What serves as a combination grab bar and handrail to support the client's weight while exiting and returning to bed?
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tranfer handle
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Describe the Levels of Functional Status from 0 - 5.
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0 = Completely independent
1 = Requires use of assistive device 2 = Needs minimal help 3 = Needs assistance and/or some supervision 4 = Needs total supervision 5 = Needs total assistance or unable to assist |
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The nurse who assists with a diagnostic examination involving the lower gastrointestinal tract, such as a sigmoidoscopy, is most correct in placing the client in a
• Lithotomy position • Sims' position • Supine position • Fowler's position |
A Sims’ position is best used for procedures involving the rectum and lower gastrointestinal tract.
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Which of the following body positions is best for the nurse to use to promote drainage from an abdominal wound?
• Lithotomy position • Fowler's position • Supine position • Trendelenburg position |
A Fowler’s position promotes abdominal wound drainage via gravity.
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Before turning a postoperative client from a supine to a lateral position, which nursing instruction is most appropriate?
•“Hold your breath as you are turning.” •“Bend your far knee over the other.” • “Curl up in a ball before I help you turn.” • “Let me roll you as if you were a log.” |
To facilitate turning a client, it is helpful if the client flexes a knee prior to rolling onto his or her side.
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After a client undergoes surgery, the nurse uses a trochanter roll to prevent the hips from a position of:
• Adduction • Abduction • Flexion • Rotation |
A trochanter roll helps to prevent external rotation of the hip.
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Which of the following is most helpful for facilitating a client's independent movement?
• A bed cradle • A bed board • An overbed trapeze • Lower side rails |
A trapeze is an item that allows the client to help move and lift himself or herself.
Encouraging the client to participate actively helps to maintain muscular strength and reduces the effort the nurse must provide when moving and positioning the client. |
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What position provides good drainage from bronchioles, stretches the trunk and extremities and keeps the hips in an extended position?
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Prone Position
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What is the metal frame secured to or placed on top of the mattress over the client's lower legs called?
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cradle
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What is a benefit of an Air-Fluidized Bed?
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The pressure-relieving effects of this type of bed have been shown to speed the healing of severely impaired tissue.
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What are some disadvantages of an Air-Fluidized Bed?
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• Fluid balance may become a problem because of the accelerated evaporation caused by the warm, blowing air.
• Puncturing or tearing the mattress is also a potential problem. |
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What are some benefits of an Oscillating Support Bed?
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• continuously rocks the client from side to side in a 124-degree arc
• relieves skin pressure • helps to mobilize respiratory secretions. |
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When transferring clients what should you access first?
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Clients strength and mobility
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When transferring clients from a bed to a wheelchair, what are two important points?
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• Hold close to your center of gravity
• Keep feet a hip width apart |
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What is the padded device that is secured around the client's waist?
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transfer belt
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What is the equipment called that you use with two people to move heavy clients or those with limited ability?
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mechanical lift
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Why are elevated toilet seats with handrails helpful for older people?
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They can use their arm muscles, rather than leg muscles, to assist with sitting and rising
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Older adults may fear falling and thus limit their mobility, so what are a couple of ways to promote confidence?
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• handrails may be strategically placed
• chairs near a frequent pathway in the home or institution allow for a rest stop |
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What increases the risk for fractures in older adults?
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Bone demineralization
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What does the capacity to exercise mean?
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Fitness
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What is the most acurate fitness test?
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ECG
or Stress Electrocardiogram |
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What is a ECG
or Stress Electrocardiogram? |
It tests electrical conduction through the heart during maximal activity
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What test is worn around and continuously records heart rate and rhythm during normal activity?
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Ambulatory Electrocardiogram or Holter Monitor
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What precautions should you teach your clients when they will be wearing a holter monitor?
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client should avoid magnets
metal detectors electric blankets and high-voltage areas that may cause artifacts |
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What exercise does not stress a person to exhaustion?
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submaximal fitness test or step test which is a timed stepping activity
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What type of exercise is activity that involves movement and work and promote cardiorespiratory conditioning and increase lean
muscle mass? |
Isotonic exercise
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What is a prime example of Isotonic exercise?
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aerobics
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What type of exercise are stationary exercises generally performed against a resistive force and they improve blood circulation?
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Isometric
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What is a prime example of Isometric exercise?
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• body building
• weight lifting • simply contracting and relaxing muscle groups while sitting or standing |
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What is the activity called that is being performed by people with health risks or being treated for an existing health problem?
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Active exercise
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Where is active therapeutic exercise limited?
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It is limited to a particular part of the body that is in a weakened condition
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What therapeutic activity does the client perform with assistance or is provided when they cannot move one or more parts of the body?
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Passive exercise
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What does Passive exercise do?
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maintain muscle tone and flexible joints
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What therapeutic activities that move the joints?
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Range-of-motion (ROM) exercises
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Why are ROM exercises performed?
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• To assess joint flexibility before initiating an exercise program
• To maintain joint mobility and flexibility in inactive clients • To prevent ankylosis • To stretch joints before performing more strenuous activities • To evaluate the client's response to a therapeutic exercise program |
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What is ankylosis?
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permanent loss of joint movement
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What joint position is bending so as to decrease the angle between two adjoining bones?
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Flexion
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What joint position is straightening so as to increase the angle between two adjoining bones up to 180 degrees?
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Extension
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What joint position is increasing the angle between two adjoining bones more than 180 degrees?
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Hyperextension
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What joint position is moving away from the midline?
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Abduction
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What joint position is moving toward the midline?
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Adduction
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What joint position is turning from side to side as in an arc?
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Rotation
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What joint position is turning outward, away from the midline of the body?
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External rotation
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What joint position is turning inward, toward the midline of the body?
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Internal rotation
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What joint position is forming a circle?
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Circumduction
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What joint position is turning downward?
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Pronation
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What joint position is turning upward?
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Supination
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What joint position is bending toward the sole of the foot?
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Plantar flexion
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What joint position is bending the foot toward the dorsum or anterior side?
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Dorsiflexion
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What joint position is turning the sole of the foot toward the midline?
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Inversion
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What joint exercise is turning the sole of the foot away from the midline?
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Eversion
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When you turn the leg you circumduct what joint?
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the hip joint
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What is a CPN or continuous passive motion machine used for?
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to restore muscle and joint functions
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Why is a continuous passive motion machine preferred for the rehabilitation of clients who have experienced burns or have had knee or hip replacement surgery?
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Because the machine precisely controls the degree of joint movement and can increase it in specific increments throughout recovery
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If a client performs isometric exercises of the quadriceps muscles correctly, the nurse will observe the client
• Move the toes toward and away from the head. • Contract and relax the muscles of the thigh. • Lift the lower leg up and down from the bed. • Bend the knee and pull the lower leg upward. |
A client performs isometric exercises by (contract and relax) tensing and releasing muscles. They do not involve any appreciable movement of a joint.
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When the nursing team develops a plan of care for a client with a stroke, which area of nursing management is most important to the client's rehabilitation?
• Regulating bowel and bladder elimination • Dealing with problems of disturbed body image • Preventing contractures and joint deformities • Facilitating positive outcomes from grieving |
The long-term outcomes following a stroke often are determined by aggressive nursing efforts to maintain musculoskeletal function. Rehabilitation begins on admission with functional positioning, active and passive exercise, and early physical and occupational therapy.
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The nursing explanation that best describes the primary purpose of a continuous passive motion machine is that it is used to
• Strengthen leg muscles • Relieve foot swelling • Reduce surgical pain • Restore joint function |
The machine is used primarily to restore full ROM. Clients with joint replacement surgery are reluctant to exercise the operative joint because of pain.
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When documenting the client's progress while using a continuous passive motion machine, it is essential that the charting indicate the degree of joint flexion, the number of cycles per minute, and the
• Condition of the sutures around the incision • Time the client used the machine • Characteristics of drainage from the wound • Presence and quality of arterial pulses |
The length of time the client used the machine provides additional documentation of the client’s response to treatment.
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When a client asks of what use a stress electrocardiogram (ECG) will be, the most accurate answer the nurse can give is that it
• Shows how the client's heart performs during exercise • Determines the client's potential target heart rate • Verifies how much the client needs to improve fitness • Can predict if the client will have a heart attack soon |
A stress ECG demonstrates the extent to which the heart tolerates and responds to the additional demands placed on it during exercise.
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