Mobility
A nurse is assessing the skin of an immobilized patient. What will the nurse do?
What is use a standardized tool such as the Braden scale
Upon assessment a nurse discovers that a patient has erythema. Which actions will the nurse take? (select all that apply)
Consult a dietitian, place on pressure relieving mattress, and increase frequency of turning
Which goal is most appropriate for a patient who has had a total hip replacement?
What is The patient will walk 100 feet using a walker by the time of discharge.
A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal?
What is when observed laterally, the spinal curves align in a reversed "S" pattern
A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess?
What is impaired balance
The nurse is caring for a patient with a spinal cord injury and notices that the patient's hips tend to rotate externally when the patient is supine. Which device will the nurse use to help prevent injury secondary to this rotation?
What is a trochanter roll
A nurse is assessing body alignment. What is the nurse monitoring?
What is The relationship of one body part to another while in different positions
The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?
Dangle the patient at the bedside
A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?
The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?
What is 23
The patient is being admitted to the neurological unit with a diagnosis of stroke. When will the nurse begin discharge planning?
What is at the time of admission
A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care?
A patient with neck surgery
A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?
What is Establish goals that are measurable and realistic
The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent?
What is Back injury
Upon entering the room of a patient with a healing stage 3 pressure injury, the nurse notices an order and observes a purulent discharge, along with increased redness at the wound site. What action should the nurse give priority to?
What is completing a head-to-toe assessment, including current treatment, vital signs, and laboratory results.
Which patient will cause the nurse to select a nursing diagnosis of impaired physical mobility for a care plan?
What is A patient who is not completely immobile
A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?
Each movement is moved just to the point of resistance by the nurse
Which observation by the nurse will indicate a normal finding?
The arms hang comfortably at side, both feet are supported on the floor with ankles flexed, the edge of the seat is in contact with the popliteal space, the body weight is directly on the buttocks only
What is Both feet are supported on the floor with ankles flexed.
A patient requires repositioning every 2 hours. Which task can the nurse delegate to the assistive personnel?
What is changing the patient's position
The wound care nurse is monitor a patient with a stage 3 pressure injury whose wound presents with healthy tissue. How should the nurse document this injury in the patient's medical record?
What is Healing Stage III pressure injury
What are impaired skin integrity, Hypostatic pneumonia, and foot drop
The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend?
What is High protein, high calorie.
The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?
Raise head of bed 45 degrees, position legs flat against bed, place pillow under the patient's lower legs, turn head toward one side with large soft pillow
Place pillow under the patient's lower legs
Which behavior indicates the nurse is using a tam approach when caring for a patient who is experiencing alteration in mobility
What is Consults physical therapy for strengthening exercises in the extremities
When a comatose patient develops a stage II pressure injury, the nurse includes the nursing diagnosis of Risk for Infection to the care plan. Which is the most appropriate goal for this patient?
What is The patient will remain free of odorous or purulent drainage from the wound