Deck 11: Mobilizing the Client

Question 1

The nurse is caring for a client who has an order for Lofstrand crutches to assist with mobility.The client asks what the crutch looks like.Which description of the crutch by the nurse is the most accurate?

A)It rests just under the axilla with a hand bar.
B)It has a cuff for the upper arm.
C)It extends to the forearm and has a metal cuff around the forearm to stabilize the wrist.
D)It has a rubber tip to prevent slippage on a floor surface.

Answer 1

It extends to the forearm and has a metal cuff around the forearm to stabilize the wrist.

Question 2

The nurse is assisting the client into a wheelchair.When seating the client in the chair,which action by the nurse is the most appropriate?

A)Unlocking the wheels
B)Positioning the calf supports and lowering the footplate
C)Applying the seat belt
D)Asking the client to sit far back in the chair

Answer 2

Asking the client to sit far back in the chair

Question 3

Which method is most appropriate for the nurse to use when teaching a client to walk with a cane?

A)Holding the cane on the stronger side of the body and moving the cane forward,then moving the weak leg forward
B)Holding the cane on the weaker side and moving the weak leg forward,then following with the cane
C)Holding the cane on the stronger side,stepping forward with the weak leg,and then moving the cane forward as the stronger leg moves forward
D)Holding the cane on the weaker side,stepping forward with the weak leg,and then moving the cane forward as the stronger leg moves forward

Answer 3

Holding the cane on the stronger side of the body and moving the cane forward,then moving the weak leg forward

Question 4

The client needs to ambulate using a walker.Which activity could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

A)Documenting that the UAP cannot ambulate a client who requires assistive devices
B)Teaching the client how to use the walker
C)Evaluating the client's ability to use the walker properly
D)Ambulating using the walker once the client demonstrates adequate skill

Question 5

The nurse assists a client from the bed into a wheelchair.Which items will the nurse include when documenting this transfer in the medical record?

A)The number of assistants required for the transfer
B)The education provided to the unlicensed assistive personnel (UAP)who assisted
C)Any education provided to the client and family
D)A description of the positioning aides that were used
E)The client's tolerance of the transfer

Question 6

The nurse is caring for a client who is recovering from cerebrovascular accident (CVA)and is unable to move the right side of the body.Which term will the nurse use when documenting this client's condition?

A)Quadriplegia
B)Paraplegia
C)Hemiplegia
D)Paralysis

Question 7

The nurse assists the client to ambulate for the first time,and documents the distance,pace,and support required.What item is also appropriate for the nurse to include in the documentation for this client?

A)Activity tolerance
B)Client's sense of security
C)Use of a gait belt
D)Where the client walked

Question 8

The nurse is teaching the client how to walk with crutches.Which gait requires considerable skill,strength,and coordination?

A)Three-point gait
B)Swing-to gait
C)Swing-through gait
D)Two-point alternate gait

Question 9

The nurse is ambulating with a client who is moderately weak.Which action by the nurse is appropriate when applying support?

A)Interlocking the nurse's forearm with the client's closest forearm
B)Wrapping the arm closest to the client around the client's waist
C)Holding on to the client's waistband located on the robe
D)Holding the client under the axilla

Question 10

The nurse is planning to delegate ambulation of the client to the unlicensed assistive personnel (UAP).In order to provide proper instructions to the UAP,which action by the nurse is the most appropriate?

A)Ambulating the client first and then having the UAP ambulate the client
B)Quizzing the UAP to assure appropriate understanding of how to ambulate the client
C)Assessing the client's ability to ambulate
D)Observing the client ambulating

Question 11

The nurse is transporting the client in a wheelchair,and comes to a downward incline.Which action by the nurse will allow for safely transporting the client down the incline?

A)Applying the brakes on one of the chair's wheels
B)Pushing the wheelchair forward while pulling back on the handles
C)Positioning the nurse's body between the wheelchair and the bottom of the incline and walking backwards down the slope
D)Zigzagging sideways down the incline so the wheelchair is always pointing at a 45° angle to the slope

Question 12

The client is recovering from a fractured left femur,and has just had the cast removed.Which technique is the most appropriate for the nurse to use when assisting this client to ambulate?

A)Standing on the client's left side
B)Standing on the client's right side
C)Standing behind the client and holding the client's belt
D)Standing in front of the client and having the client lean on the nurse's shoulders

Question 13

The nurse is teaching the client who requires maximum support secondary to generalized weakness to walk with a walker.Which technique used by the nurse is the most appropriate?

A)Move the walker ahead while moving the weak leg forward,bearing weight on the strong leg.
B)Move the walker ahead while moving the strong leg forward,bearing weight on the weak leg and the arms.
C)Move the walker ahead,then move the right foot up to the walker while body weight is borne by the left leg and both arms,then move the left foot,bearing weight on the right leg and both arms.
D)Walk forward and push the walker ahead before taking the next step.

Question 14

The nurse is assisting the client to ambulate in the hall when the client suddenly complains of dizziness.Which action by the nurse is the priority?

A)Escorting the client back to the room and into bed
B)Calling for help to escort the client back to the room
C)Assisting the client to sit on the nearest chair with the head between the legs,and going to find assistance
D)Assisting the client to a horizontal position on the floor if no chair is available