ATI ambulation

Which of your four patients should you manage first?
. The patient with quadriplegia who had sacral redness when last turned 2 hours ago
Patients who have quadriplegia are at an increased risk for skin breakdown, especially over the bony prominences and in the sacral area, due to impaired mobility, infrequent repositioning, and skin exposure to such irritants as rough linen, urine, and stool. Any of these conditions may result in tissue damage from impaired circulation or skin breakdown. Since the patient has quadriplegia, he may also be unable to report the first signs of skin breakdown because of impaired or absent sensation. It was reported to you that the patient had sacral redness when last turned 2 hours ago so not only is the patient due to be turned again now, but your immediate nursing assessment of the sacral area is your highest priority at this time.

Three point gait
correct procedure is to advance the crutches while bringing the affected leg forward. The patient then advances the unaffected leg.

When teaching the patient how to ambulate with a walker, you say,
“When properly fitted, the upper bar of your walker should be slightly below your waist.”

The height of a properly fitted walker should be just below the level of the patient’s waist. The patient should stand in the center of the walker and grasp the handgrips on either side, with her elbows bent approximately 30 degrees.

Prior to morning therapy, the patient requires several nursing interventions. Which nursing action do you and the nursing assistant perform first?
Morning hygiene care and assessment
Patients who need total care also require a thorough nursing assessment. Not only are they at increased risk for skin breakdown due to impaired mobility, but they are also at increased risk for other complications of immobility, including respiratory failure, impaired circulation, and sluggish digestion. It can be helpful to use the nursing process when deciding the order of nursing actions, Assessment is first, and it guides your subsequent actions. Also, performing the morning assessment while providing hygiene care is an efficient use of your nursing time.

You determine that the nursing assistant understands range-of-motion (ROM) exercises when she initiates
passive ROM
Passive ROM exercises are performed without the patient’s assistance to prevent joint contracture. These are most appropriate for a patient who is totally dependent and unable to follow instructions.

Which action is appropriate when getting a patient out of bed via a mechanical/hydraulic lift?
Place the sling under the patient’s center of gravity and greatest portion of body weight.
The sling (or hammock) is supplied with the lift. Hammocks that provide neck support are best for patients who are flaccid or have poor muscle tone. This helps ensure the patient’s safety.

Which action is appropriate when transferring the patient to the gurney using a slide board and three team members?
Have one person hold the slide board steady while the other two pull the patient onto the gurney.
Using this method, the slide board remains stationary as two team members pull the draw sheet and move the patient. This slippery surface reduces friction and makes it easier for the staff to pull the patient onto the gurney.

Which of the following should be your therapeutic response to this patient?
“It sounds like you are concerned that getting out of bed will be painful.”
When responding therapeutically to patients’ questions, always remember that you must use communication skills and avoid communication blocks. In general, therapeutic responses are open-ended, patient-centered, and focused on the patient’s feelings. This response meets all of these criteria. By acknowledging that you have heard the patient’s message, this response encourages further communication.

Which of the following nursing actions will help improve your patient’s tolerance of getting out of bed?
-Have your patient dangle her legs at the side of the bed first for a few minutes before getting out of bed.
Dangling allows the patient’s circulation to equilibrate and helps prevent episodes of dizziness due to orthostatic hypotension and, therefore, injuries from falling.
-Administer the prescribed oral pain medication to your patient about 20 minutes before she gets out of bed.
Oral pain medication typically has a time of onset of about 20 minutes, so the patient will have the benefit of pain relief while moving – the most difficult and painful aspect of getting up
-Teaching and demonstrating the techniques to be used enhance the patient’s understanding, reduce anxiety, and encourage her to cooperate with the procedure.

To assist the patient in transferring from the bed to the chair, you
flex your hips and knees while lowering patient to the chair.
Flexing the hips and knees while lifting weight reflects good body mechanics as this prevents injury due to poor body alignment. Flexion of the knees and hips lowers your center of gravity in relation to the object you are raising or lifting.

Which data may help to explain the patient’s extreme fatigue?
Hemoglobin and hematocrit
These values are a reflection of the patient’s capacity to carry oxygen in the blood. This patient’s results are below the normal range, possibly as a result of blood loss during surgery. A hemoglobin and a hematocrit below normal indicate anemia, which causes the manifestations of extreme fatigue, pallor, and weakness.

Which instruction is appropriate regarding ambulation with a cane?
Placing the cane on the side opposite the involved leg provides added support for the weak (and painful) affected side.

A nurse is caring for a hospitalized patient who is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse the patient has full range of motion of the shoulder?
Flexing the shoulder by raising the arm from a side position to a 180° angle.

This demonstrates full range of motion of the shoulder. The patient’s fingers would be pointing directly upward.

A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a patient from the bed to a chair. The nurse should intervene if the AP
leaves the bed in the lowest position throughout the procedure.

The bed should be raised to its highest position in order to prevent injury to nursing staff and to properly position the lift under the patient’s bed.

A nurse in the emergency department is caring for a patient who has a knee injury. The patient will be discharged and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include when discharging this patient?
Hold the crutches on the unaffected side when preparing to sit in a chair.

The crutches should be held on the unaffected side when preparing to sit in a chair.

A nurse stands facing a patient to demonstrate active range-of-motion exercises. Which of the following should the nurse do when demonstrating hyperextension of the hip?
move leg behind body

A nurse is about to transfer to a chair a patient who has a weak left leg. Which of the following actions by the nurse demonstrates correct transfer technique?
Aligning the nurse’s knees with the patient’s knees just before the transfer
is a correct strategy that helps the nurse safely stabilize the patient while moving to a standing position.

A nurse is performing a physical assessment on a patient and instructs the patient to stand with his feet together and arms at his sides. The purpose of positioning the patient in this manner is to test which of the following?
Balance
This maneuver, the Romberg test, assesses balance. The nurse watches for swaying and stands near the patient to protect him from falling.

As a nurse ambulates an unsteady patient, the patient becomes light-headed and begins to fall. Which of the following interventions by the nurse is appropriate in this situation?
extend one leg and allow the patient to slide down it
As the patient gets close to the floor, the nurse bends both legs, continuing to support the patient.

A nurse is performing a physical assessment on a patient and instructs the patient to stand with his feet and arms at his sides. The purpose of positioning the patient in this manner is to test what? Balance. -This maneuver, …

Supine Position The client is lying on thei rback, w/ knees straight & arms are at the sides. This position is used for exams of the anterior body surfaces, breast exams & xrays. Prone Position The client is lying on …

What nursing diagnoses might relate to a patient who requires assessment of the peripheral neurovascular system? Acute Pain Ineffective Peripheral Tissue Perfusion What are some actual nursing diagnosis that would be appropriate for patients within the Area of Care, Neurological …

Principles of Body Mechanics – rules that allow you to move your body without causing injury – stand in proper body alignment – use a wide base of support – squat to lift heavy objects from the floor – keep …

logrolling a patient principles based checklist lock the bed lowers the head of the bed and place patient supine WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write my sample ensure that …

Musculoskeletal system 1. Assessing the musculoskeletal system entails examination of the muscles, bones, and joints. remember that the CNS system coordinates muscle and bone function, therefore the nurse must understand how the two systems interrelate. Musculoskeletal System 1. Usually, the …

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