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Full Clinical Nursing Skills and Techniques 8Th Edition Perry Test Bank Online PDF All Chapter
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Chapter 10: Exercise and Ambulation
MULTIPLE CHOICE
1. The patient has been admitted for hypertension. His blood pressure is normally in the 160/90
range. He has been on bed rest for the past few days, and the doctor has started him on a new
blood pressure medication. The nurse is assisting the patient to move from the bed to the chair
for breakfast, but when the patient tries to sit up on the side of the bed, he complains of being
dizzy and nauseous. The nurse lays the patient down and takes his vital signs. His pulse is
124. His blood pressure is 130/80. This blood pressure is indicative of what?
a. A normal blood pressure for this patient
b. Orthostatic hypotension
c. Orthostatic hypertension
d. Effective baroreceptor function
ANS: B
Orthostatic hypotension is a drop in blood pressure that occurs when the patient changes from
a horizontal to a vertical position. It traditionally is defined as a drop in systolic or diastolic
blood pressure of 20 or 10 mm Hg, respectively. Those at higher risk are immobilized
patients, those undergoing prolonged bed rest, the older adult patient, those receiving
antihypertensive medications, and those with chronic illness, such as diabetes mellitus or
cardiovascular disease. Signs and symptoms of orthostatic hypotension include dizziness,
light-headedness, nausea, tachycardia, pallor, and even fainting. Orthostatic hypertension
would be an increase in blood pressure. Physiological changes associated with aging and
prolonged bed rest may reduce the effectiveness of the baroreceptors. In these patients,
moving to the dangling position may cause a gravity-induced drop in blood pressure; thus, it
is recommended to raise the head of the bed and allow a few minutes before dangling.
2. The patient is an elderly gentleman who has been on bed rest for the past several days. When
getting the patient up, the nurse should:
a. tell the patient not to move his legs when dangling.
b. tell the patient to hold his breath while dangling.
c. raise the head of the bed and allow a few minutes before dangling.
d. have the patient stand without dangling.
ANS: C
Physiological changes associated with aging and prolonged bed rest may influence the
effectiveness of the baroreceptors. For these patients, moving to the dangling position may
cause a gravity-induced drop in blood pressure; thus, it is recommended to raise the head of
the bed and allow a few minutes before dangling. Interventions to minimize orthostatic
hypotension include movement of the legs and feet in the dangling position to promote venous
return via intermittent contraction and relaxation of the skeletal leg muscles, and asking the
patient to take several deep breaths before and during dangling. Dangling a patient before
standing is an intermediate step that allows assessment of the individual before changing
positions to maintain safety and prevent injury to the patient.
DIF: Cognitive Level: Application REF: Text reference: p. 236
OBJ: Discuss indications for assisting with ambulation or using devices to assist with ambulation.
TOP: Dangling KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3. An appropriate technique for the nurse to use when performing range of motion (ROM)
exercises is to:
a. repeat each action five times during the exercise.
b. perform the exercises quickly and firmly.
c. support the proximal portion of the extremity being exercised.
d. continue the exercise slightly beyond the point of resistance.
ANS: A
Each movement should be repeated five times during an exercise period. Be sure that ROM
exercises are performed slowly and gently. When performing active-assisted or passive ROM
exercises, support the joint by holding the distal portion of the extremity, or by using a cupped
hand to support the joint. Discontinue exercise if the patient complains of discomfort, or if
you note resistance or muscle spasm.
7. Antiembolic stockings (TEDs) are ordered for the patient on bed rest after surgery. The nurse
explains to the patient that the primary purpose for the elastic stockings is to:
a. keep the skin warm and dry.
b. prevent abnormal joint flexion.
c. apply external pressure.
d. prevent bleeding.
ANS: C
The primary purpose of TEDs is to maintain external pressure on the muscles of the lower
extremities and thus promote venous return. The primary purpose of TEDs is not to keep the
skin warm and dry, prevent abnormal joint flexion, or prevent bleeding. They are used to
prevent clot formation due to venous stasis.
8. When assessing the patient for risk for DVT, the nurse should consider which of the following
an indicator of increased risk?
a. A positive Homans’ sign
b. Pallor to the distal area
c. Edema noted in the extremity
d. Fever or dehydration
ANS: D
Indicators in Virchow’s triad include clotting disorders, fever, and dehydration. Additionally,
a swollen extremity, pain, and warm cyanotic skin, indicate an elevated risk. Less than 20% of
patients exhibit a positive Homans’ sign. Edema of the extremity may or may not occur.
9. An appropriate procedure for the nurse to use when applying an elastic stocking is to:
a. remove the stockings every 24 hours.
b. keep the tops of the stockings rolled down slightly.
c. turn the stocking inside out to apply from the toes up.
d. wash stockings daily and dry in a dryer.
ANS: C
Turn elastic stocking inside out by placing one hand into the sock, holding the toe of the sock
with the other hand, and pulling. This allows easier application of the stocking. Elastic
stockings should be removed and reapplied at least twice a day. Instruct the patient not to roll
the socks partially down. Rolling the socks partially down has a constricting effect and can
impede venous return. Instruct the patient to launder elastic stockings every 2 days with mild
detergent and lay flat to dry.
11. The patient is a paraplegic who possesses good arm and hand strength. When the following
devices are compared, which would be most appropriate for this patient?
a. Axillary crutch
b. Platform crutch
c. Lofstrand crutch
d. Standard crook cane
ANS: C
The Lofstrand crutch has a handgrip and a metal band that fits around the patient’s forearm.
Both the metal band and the handgrip are adjusted to fit the patient’s height. This type of
crutch is useful for patients with a permanent disability such as paraplegia. The axillary crutch
frequently is used by patients of all ages on a short-term basis. The platform crutch is used by
patients who are unable to bear weight on their wrists. It has a horizontal trough on which
patients can rest their forearms and wrists and a vertical handle for the patient to grip. The
standard crook cane provides the least support and is used by patients who require only
minimal assistance to walk.
12. An appropriate way for the nurse to measure a patient for crutches is to:
a. have a flexion of 45 degrees at both of the patient’s elbows.
b. have a space of two to three fingers between the top of the crutch and the axilla.
c. place the crutch tips 1 foot to each side of the patient’s feet, and observe the
positioning of the crutches.
d. place the crutch tips 1 foot to the front of the patient’s feet, and observe the
positioning of the crutches.
ANS: B
Following correct crutch adjustment, two to three fingers should fit between the top of the
crutch and the axilla. Following correct crutch adjustment, elbows should be flexed 15 to 30
degrees. Elbow flexion is verified with a goniometer. Position the crutches with the crutch tips
at 6 inches (15 cm) to the side and 6 inches in front of the patient’s feet, and the crutch pads 2
inches (5 cm) below the axilla.
13. The patient has been using crutches for the past 2 weeks. When she comes for her follow-up
examination, she complains of tingling and numbness in her hands and upper torso. Possible
causes of these symptoms are:
a. the patient’s elbows are flexed 15 to 30 degrees when using the crutches.
b. crutch pad is approximately 2 inches below the patient’s axilla.
c. patient holds the cane 4 to 6 inches to the side of her foot.
d. handgrip does not allow for elbow flexion.
ANS: D
Instruct the patient to report any tingling or numbness in the upper torso, which may mean
that the crutches are being used incorrectly, or that they are the wrong size. If the handgrip is
too low, radial nerve damage can occur even if overall crutch length is correct, because the
extra length between the handgrip and the axillary bar can force the bar up into the axilla as
the patient stretches down to reach the handgrip. After correct crutch adjustment, two to three
fingers must fit between the top of the crutch and the axilla. Adequate space prevents crutch
palsy. Proper fit is when the crutch pad is approximately 2 inches or two to three finger widths
under the axilla, with the crutch tips positioned 6 inches (15 cm) lateral to the patient’s heel.
14. The patient has a leg injury and is being fitted for a cane. The patient should be taught to:
a. hold the cane on the uninvolved side.
b. hold the cane on the weaker side.
c. extend the cane 15 inches from the foot when used.
d. maintain approximately 60 degrees of elbow flexion.
ANS: A
The patient holds the cane on the uninvolved side, 4 to 6 inches (10 to 15 cm) to the side of
the foot. This offers the most support when the cane is placed on the stronger side of the body.
The cane and the weaker leg work together with each step. The cane extends from the greater
trochanter to the floor while the cane is held 6 inches (15 cm) from the foot. Allow
approximately 15 to 30 degrees of elbow flexion. As weight is taken on by the hand and the
affected leg is lifted off the floor, complete extension of the elbow is necessary.
15. While ambulating, the patient becomes light-headed and starts to fall. What should the nurse
do first?
a. Call for help.
b. Try to reach for a chair.
c. Ease the patient down to the floor.
d. Push the patient back toward the bed.
ANS: C
If the patient begins to fall, gently ease the patient to the floor by holding firmly onto the gait
belt; stand with the feet apart to provide a broad base of support, extend the leg, and let the
patient gently slide to the floor. As the patient slides, the nurse bends the knees to lower the
body. The nurse can cause more damage to self and patient by trying to catch the patient.
The nurse certainly will call for help, but this is not the first priority. The nurse must ensure
the patient’s safety before getting help by easing him to the floor.
16. When the four gaits listed below are compared, which is the most stable of the crutch gaits?
a. Four-point gait
b. Three-point gait
c. Two-point gait
d. Swing-to gait
ANS: A
Four-point gait is the most stable of crutch gaits because it provides at least three points of
support at all times. The patient must be able to bear weight on both legs. Each leg is moved
alternately with each opposing crutch, so that three points of support are on the floor all the
time. This gait is often used when the patient has some form of paralysis, such as for spastic
children with cerebral palsy. This is less stable than four-point gait because it requires the
patient to bear all weight on one foot. Weight is borne on the uninvolved leg and then on both
crutches. The affected leg does not touch the ground during the early phase of three-point gait.
This gait may be useful for patients with a broken leg or a sprained ankle. This is less stable
than four-point gait because it requires at least partial weight bearing on each foot. It is faster
than four-point gait and requires better balance because only two points support the body at
any one time. This is the easier of the two swinging gaits. It is less stable than four-point gait
because it requires the ability to partially bear body weight on both legs. This gait is
frequently used by patients whose lower extremities are paralyzed, or who wear
weight-supporting braces on their legs.
17. The nurse is caring for a patient who has just been treated for a broken leg. She needs to teach
the patient how to use crutches. Which crutch gait is most appropriate for this patient?
a. Four-point gait
b. Three-point gait
c. Two-point gait
d. Swing-to gait
ANS: B
The three-point gait requires the patient to bear all weight on one foot. Weight is borne on the
uninvolved leg and then on both crutches. The affected leg does not touch the ground during
the early phase of three-point gait. It is useful for patients with a broken leg or a sprained
ankle. The four-point gait is the most stable of crutch gaits because it provides at least three
points of support at all times. The patient must be able to bear weight on both legs. Each leg is
moved alternately with each opposing crutch, so that three points of support are on the floor
all the time. The two-point is used when the patient has some form of paralysis, such as for
spastic children with cerebral palsy. This gait requires at least partial weight bearing on each
foot. It requires better balance because only two points support the body at one time. This is
the easier of the two swinging gaits. It requires the ability to partially bear body weight on
both legs. The swing-to gait is used by patients whose lower extremities are paralyzed, or who
wear weight-supporting braces on their legs.
19. A patient with left hemiparesis is using a quad cane for ambulation. Which of the following is
the correct technique for the nurse to use in teaching the patient?
a. Use the cane on the right side, with the cane moving forward first.
b. Use the cane on the left side, with the left leg moving forward with the cane.
c. Use the cane in either hand, with the right leg moving forward first.
d. Use the cane in either hand, with the left leg moving beyond the forward
placement of the cane.
ANS: A
To correctly use a quad cane, the patient places the cane on the side opposite the involved leg.
This provides added support for the weak or impaired side. Ambulation then begins by
moving the cane forward 6 to 10 inches (15 to 25 cm), keeping body weight on both legs. The
weak leg is then brought forward even with the cane while the body weight is supported by
the strong leg and the cane. The strong leg is then advanced past the cane. Moving a leg and
the cane forward at the same time will compromise balance and increase risk of fall.
MULTIPLE RESPONSE
1. The patient had a stroke and is currently immobile. The nurse realizes that increasing mobility
is critical because immobility can result in alterations in which of the following? (Select all
that apply.)
a. Cardiovascular function
b. Pulmonary function
c. Skin integrity
d. Elimination
ANS: A, B, C, D
When mobility is altered, many body systems are at risk for impairment. Impaired mobility
can result in altered cardiovascular functioning, disruption of normal metabolic functioning,
increased risk for pulmonary complications, the development of pressure ulcers, and urinary
elimination alterations.
2. The nurse is caring for an immobile patient. Which of the following may help reduce the
hazards associated with immobility? (Select all that apply.)
a. A high-fiber diet
b. Frequent repositioning
c. Muscle and joint exercises
d. Increased fluid intake
ANS: A, B, C, D
Frequent repositioning, deep breathing and coughing exercises, muscle and joint exercises,
increased fluid intake, and dietary intake of foods containing fiber are examples of measures
that help to reduce the hazards of immobility.
3. The nurse is applying a CPM machine to the patient’s leg. To do so, she must: (Select all that
apply.)
a. provide analgesia 1 hour before starting the CPM.
b. stop the CPM when in extension and place a sheepskin on the machine.
c. align the patient’s joint with the CPM’s mechanical joint.
d. secure the patient’s extremity tightly with Velcro straps.
ANS: B, C
Provide analgesia 20 to 30 minutes before CPM is needed. Stop the CPM when in extension.
Place sheepskin on the CPM to ensure that all exposed hard surfaces are padded to prevent
rubbing and chafing of the patient’s skin. Align the patient’s joint with the mechanical joint of
the CPM.
4. Factors that contribute to the development of DVT are: (Select all that apply.)
a. elevated sodium (Na+) levels.
b. hypercoagulability of the blood.
c. venous wall damage.
d. stasis of blood flow.
ANS: B, C, D
Three elements (commonly referred to as Virchow’s triad) contribute to the development of
DVT: hypercoagulability of the blood, venous wall damage, and stasis of blood flow.
COMPLETION
ANS:
Mobility
Mobility refers to an ability to move about freely.
ANS:
immobility
Immobility refers to a person’s inability to move about freely.
3. A drop in blood pressure that occurs when the patient changes position from a horizontal to a
vertical position is known as _________________.
ANS:
orthostatic hypotension
Orthostatic hypotension is a drop in blood pressure that occurs when the patient changes
position from a horizontal to a vertical position.
4. The patient is performing ROM exercises independently. These are known as __________
exercises.
ANS:
active ROM
ROM exercises may be active, passive, or active-assisted. They are active if the patient is able
to perform the exercises independently and passive if the exercises are performed for the
patient by the caregiver. The exercises are active-assisted if the patient is able to perform
some of the actions independently with support and assistance from the caregiver.
5. Static exercises that involve tightening or tensing of muscles without moving a body part are
known as ______________.
ANS:
isometric exercises
Isometric or static exercises involve tightening or tensing of muscles without moving body
parts.
6. _________________ increase muscle tension but do not change the length of muscle fibers.
ANS:
Isometric contractions
Isometric contractions increase muscle tension but do not change the length of muscle fibers.
7. Virchow’s triad (hypercoagulability of blood, venous wall damage, and stasis of blood flow)
has been found to contribute to ________________.
ANS:
deep vein thrombosis (DVT)
Three elements (commonly referred to as Virchow’s triad) contribute to the development of
DVT: hypercoagulability of the blood, venous wall damage, and stasis of blood flow.
ANS:
gait belt
A gait belt encircles a patient’s waist and has space for the nurse to hold while the patient
walks. This gives the nurse better control and helps to prevent injury.
Language: English
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