Chapter 16: Exercise & Mobility

Chapter 16: Exercise & Mobility

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse delegates helping the older patient ambulate with a walker without wheels to nursing assistive personnel (NAP). Which instructions should the nurse provide to the NAP?

a.	Show the patient how to slide the walker a few steps ahead.
b.	Check the patient for non-skid shoes before using the walker.
c.	Be sure that the patient places all weight on the front of the walker.
d.	Ensure that the patient is wearing soft slipper socks while walking.

 

 

ANS:  B

The nurse instructs the NAP to check the patient for supportive, non-skid shoes to prevent injury to the patient’s feet and provide sure footing while using the walker. The patient should be instructed to lift the walker and set it into place to advance. Sliding is not safe because it does not provide a stable foundation and is more likely to lead to patient falls. The patient should not place all weight on the front of the walker because this will cause the walker to tip. The patient should be instructed to place weight in the center of the walker for stability. Soft slipper socks do not provide adequate support for the ambulating patient and are more likely to lead to falls.

 

DIF:    Cognitive Level: Apply                   REF:   Page 438| Page 444

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Planning

 

2. The nurse instructs the patient, who has right-sided weakness, to use the cane during ambulation and assesses the patient’s use of the cane. Which assessment should the nurse address before the patient ambulates with the cane?

a.	The cane makes a tapping sound each time the patient touches it to the floor.
b.	The patient holds the cane in the unaffected hand for support.
c.	The patient holds the cane 10 to 15 cm (4 to 6 inches) to the side of the left foot.
d.	The patient ambulated 4 times with the cane in physical therapy.

 

 

ANS:  A

The cane should have a rubber tip on the end and should be silent when the rubber tip contacts the floor, indicating that the rubber is intact; if the cane clicks each time it hits the floor, the rubber cannot effectively maintain the patient’s stability. Using the cane on the unaffected side is proper technique for ambulating with a cane. Holding the cane 10 to 15 cm (4 to 6 inches) to the side of the unaffected foot is appropriate. The patient’s history of cane use is valuable information for subsequent instruction and gives the nurse a basis for comparison.

 

DIF:    Cognitive Level: Apply                   REF:   Page 438

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment

 

3. A patient is being moved into a dangling position before ambulating. To decrease the chance of orthostatic hypotension, what activity can the patient do?

a.	Sit on the side of the bed for a minute before standing up.
b.	Take several deep breaths while moving into the dangling position.
c.	Push up from the bed into the dangling position on the side of the bed.
d.	Stretch all of the muscles in the body.

 

 

ANS:  A

Sitting on the side of the bed stabilizes the redistribution of the blood during the position change. Deep breathing helps lung expansion but does not affect the change in the blood distribution during position changes. Pushing up from the side of the bed helps the patient transition to standing, but it doesn’t prevent orthostatic hypotension. There are many muscles throughout the body that cannot be stretched voluntarily.

 

DIF:    Cognitive Level: Apply                   REF:   Page 434

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Planning

 

4. The nurse is preparing to increase the amount of ambulation that the patient is able to tolerate, to prepare for discharge. Which is the best method for the nurse to assess a patient’s ability to ambulate?

a.	Interview the patient’s visitors.
b.	Talk with the patient about the distance to ambulate.
c.	Review the patient progress notes.
d.	Measure the distances ambulated.

 

 

ANS:  B

Mutual goal setting between the nurse and the patient is a beginning point. Watching the patient ambulate is essential, but working with the patient is beneficial. Even if the patient’s visitors are healthcare professionals, the nurse must assess the patient before taking action. Reviewing progress notes provides valuable baseline data for comparison to the nurse’s assessment; however, the nurse assesses the patient to determine the nurse’s future care. Measuring the distance covered by the patient is valuable information and is one part of the data the nurse gathers for the nursing assessment.

 

DIF:    Cognitive Level: Analyze                REF:   Page 433

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Evaluation