Chapter 11 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

Chapter 11 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

• The nurse is caring for a client requiring mobility The physician orders Lofstrand 1) crutches, and the client asks what the crutch looks like. Which of the following would be the best

description?

1. A crutch that rests just under the axilla with a hand bar
2. A crutch that has a cuff for the upper arm
3. A crutch that extends to the forearm and has a metal cuff around the forearm to stabilize the

wrist

1. A crutch with a rubber tip to prevent slippage on a floor surface

Answer: C

Explanation: A)       Option 3 describes a Lofstrand crutch. Option 1 describes an axillary crutch, option 2 describes a platform crutch, and option 4 describes the tip found on all crutch

types.

Cognitive Level: Knowledge

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. Option 3 describes a Lofstrand Option 1 describes an axillary crutch, option 2 describes a platform crutch, and option 4 describes the tip found on all crutch

types.

Cognitive Level: Knowledge

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. Option 3 describes a Lofstrand Option 1 describes an axillary crutch, option 2 describes a platform crutch, and option 4 describes the tip found on all crutch

types.

Cognitive Level: Knowledge

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. Option 3 describes a Lofstrand Option 1 describes an axillary crutch, option 2 describes a platform crutch, and option 4 describes the tip found on all crutch

types.

Cognitive Level: Knowledge

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

Objective: Learning Outcome 11-1: Define the key terms used in the skills of mobilization.

 

• The nurse is caring for a client who had a cerebrovascular accident (CVA) and is paralyzed on the 2) right side of the The nurse documents this as:

1. A) B) Paraplegia.
2. C) D) Essential paralysis.

Answer: C

Explanation: A)      Paralysis on the left or right half of the body is hemiplegia. Paraplegia is paralysis of two extremities, while quadriplegia is paralysis of four extremities. Infantile paralysis is a form of spinal paralysis, and is also known as acute poliomyelitis. Cognitive Level: Knowledge

Client Need: Physiological Integrity

Nursing Process: Implementation

1. Paralysis on the left or right half of the body is Paraplegia is paralysis of two extremities, while quadriplegia is paralysis of four extremities. Infantile paralysis is a form of spinal paralysis, and is also known as acute poliomyelitis. Cognitive Level: Knowledge

Client Need: Physiological Integrity

Nursing Process: Implementation

1. Paralysis on the left or right half of the body is Paraplegia is paralysis of two extremities, while quadriplegia is paralysis of four extremities. Infantile paralysis is a form of spinal paralysis, and is also known as acute poliomyelitis. Cognitive Level: Knowledge

Client Need: Physiological Integrity

Nursing Process: Implementation

1. Paralysis on the left or right half of the body is Paraplegia is paralysis of two extremities, while quadriplegia is paralysis of four extremities. Infantile paralysis is a form of spinal paralysis, and is also known as acute poliomyelitis. Cognitive Level: Knowledge

Client Need: Physiological Integrity

Nursing Process: Implementation

Objective: Learning Outcome 11-1: Define the key terms used in the skills of mobilization.

 

• The client is recovering from a fractured left femur, and has just had the cast The nurse 3) assists the client to ambulate by:

1. Standing on the client’s left
2. Standing on the client’s right
3. Standing behind the client and holding the client’s
4. Standing in front of the client and having the client lean on the nurse’s

Answer: A

Explanation: A)      When assisting with ambulation, the nurse stands on the client’s weak side, on the left, in order to act as a support when the client moves the strong leg forward. Standing behind or in front of the client would be dangerous, and standing on the strong side would not be as effective.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. When assisting with ambulation, the nurse stands on the client’s weak side, on the left, in order to act as a support when the client moves the strong leg Standing behind or in front of the client would be dangerous, and standing on the strong side would not be as effective.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. When assisting with ambulation, the nurse stands on the client’s weak side, on the left, in order to act as a support when the client moves the strong leg Standing behind or in front of the client would be dangerous, and standing on the strong side would not be as effective.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

1. When assisting with ambulation, the nurse stands on the client’s weak side, on the left, in order to act as a support when the client moves the strong leg Standing behind or in front of the client would be dangerous, and standing on the strong side would not be as effective.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Implementation

Objective: Learning Outcome 11-2: Describe appropriate safety measures to use when assisting clients to ambulate.

 

• The nurse is assisting the client to ambulate in the hall when the client suddenly says she feels very 4) The nurse’s priority action is to:

1. Quickly escort the client back to the room and into
2. Call for help to escort the client back to the
3. Assist the client to sit on the nearest chair with her head between her legs, and go to find

assistance.

1. Assist the client to a horizontal position on the floor if no chair is

Answer: D

Explanation: A)      The client should be either seated in a chair, if available, or assisted to a horizontal position on the floor, and the nurse must stay with the client. Attempting to escort the client back to the room could result in injury if the client loses consciousness. Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. The client should be either seated in a chair, if available, or assisted to a horizontal position on the floor, and the nurse must stay with the Attempting to escort the client back to the room could result in injury if the client loses consciousness. Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. The client should be either seated in a chair, if available, or assisted to a horizontal position on the floor, and the nurse must stay with the Attempting to escort the client back to the room could result in injury if the client loses consciousness. Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. The client should be either seated in a chair, if available, or assisted to a horizontal position on the floor, and the nurse must stay with the Attempting to escort the client back to the room could result in injury if the client loses consciousness. Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

Objective: Learning Outcome 11-2: Describe appropriate safety measures to use when assisting clients to

ambulate.

• The nurse is planning to delegate ambulation of the client to the unlicensed assistive personnel 5) (UAP). In order to provide proper instructions to the UAP, the nurse:

1. Will ambulate the client first and then have the UAP ambulate the
2. Quizzes the UAP to assure he understands how to ambulate the
3. Assesses the client’s
4. Observes the client as she

Answer: C

Explanation: A)      The nurse must first assess the client’s ability to ambulate so proper instructions can be provided to the UAP. Ambulating the client first would tire the client, and there would be no need to delegate to the UAP. Quizzing the UAP would not be productive. If the nurse is uncertain about the UAP’s abilities, the nurse would assist in ambulating the client and would evaluate the UAP’s performance. Observing the client as she ambulates would not allow the nurse to provide

thorough instructions to the UAP before ambulating the client.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Planning

1. The nurse must first assess the client’s ability to ambulate so proper instructions can be provided to the Ambulating the client first would tire the client, and there would be no need to delegate to the UAP. Quizzing the UAP would not be productive. If the nurse is uncertain about the UAP’s abilities, the nurse would assist in ambulating the client and would evaluate the UAP’s performance. Observing the client as she ambulates would not allow the nurse to provide thorough instructions to the UAP before ambulating the client.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Planning

1. The nurse must first assess the client’s ability to ambulate so proper instructions can be provided to the Ambulating the client first would tire the client, and there would be no need to delegate to the UAP. Quizzing the UAP would not be productive. If the nurse is uncertain about the UAP’s abilities, the nurse would assist in ambulating the client and would evaluate the UAP’s performance. Observing the client as she ambulates would not allow the nurse to provide thorough instructions to the UAP before ambulating the client.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Planning

1. The nurse must first assess the client’s ability to ambulate so proper instructions can be provided to the Ambulating the client first would tire the client, and there would be no need to delegate to the UAP. Quizzing the UAP would not be productive. If the nurse is uncertain about the UAP’s abilities, the nurse would assist in ambulating the client and would evaluate the UAP’s performance. Observing the client as she ambulates would not allow the nurse to provide thorough instructions to the UAP before ambulating the client.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Planning

Objective: Learning Outcome 11-3: Recognize when it is appropriate to delegate client ambulation assistance to unlicensed assistive personnel.