A nurse is evaluating a client who has a broken leg and is using crutches. Which of the
following actions by the client demonstrates proper use of the crutches?
A. The hand grips of the crutches are at the level of the client’s umbilicus.
B. The client’s elbows are bent 45° when holding the crutches.
C. The client places their weight on their axilla when using the crutches.
D. The client has the crutches resting 5 cm (2 in) below their axilla.
D. The client has the crutches resting 5 cm (2 in) below their axilla.
The nurse should identify that the client is using the crutches properly when they rest
the crutches 5 cm (2 in) below their axilla.
A nurse is assisting with preparing a presentation about muscle function for a group of
newly licensed nurses. Which of the following information should the nurse plan to
include?
A. Muscles store calcium and magnesium.
B. Muscles produce red blood cells and platelets.
C. Muscles assist with thermoregulation in the body.
D. Muscles provide protection of internal organs.
C. Muscles assist with thermoregulation in the body.
Contracting muscles generate heat that assists in maintaining body temperature.
Shivering is an example of the muscles working to produce heat.
A nurse is assisting with completing the Mobility Assessment Tool (MAT) for a client and
determines that the client is at Level 1 Mobility. The nurse should identify that the client
is unable to perform which of the following tasks?
A. Walk in place.
B. Stand in place for 5 seconds.
C. Sit on the edge of the bed for 1 min.
D. Step forward and backward.
C. Sit on the edge of the bed for 1 min.
,The nurse should identify that the client who is at Level 1 Mobility of the MAT requires
maximum assistance. The client should be able to sit on the edge of the bed for 2 min
and extend their arms across their chest to shake hands with the nurse before
advancing to the next level. If the client is unable to complete both tasks, they remain at
Level 1 Mobility of the MAT.
A nurse in a long-term care facility is caring for an older adult client and notes their
muscles have become smaller and weaker. Which of the following should the nurse
suspect the client is experiencing?
A. Sarcopenia
B. Disuse osteoporosis
C. Atrophy
D. Joint contracture
C. Atrophy
The nurse should suspect the client is experiencing atrophy of their muscles. Atrophy
occurs when the muscles of the body become smaller and weaker. This can occur with
prolonged immobility or disuse of a limb.
A nurse is reinforcing teaching with a newly hired assistive personnel (AP) about
working with clients who require assistance with ADLs. Which of the following activities
should the nurse include as an ADL?
A. Toileting
B. Writing
C. Ambulating
D. Talking
A. Toileting
The nurse should include that toileting is an ADL that the AP can assist the client to
perform. Other ADLs include dressing, bathing, and feeding.
, A nurse is caring for a client who requires total assistance with mobility. When using the
Mobility Assessment Tool (MAT), which of the following pieces of equipment should the
nurse use to transfer the client?
A. Gait belt
B. Mechanical lift
C. Cane
D. Sit-to-stand lift
B. Mechanical lift
The nurse should identify that, according to the MAT, a client who requires total
assistance requires the use of a mechanical lift or slide board, along with assistance
from one to two personnel, to transfer the client.
A nurse is caring for a client who had a stroke and reports difficulty with proprioception.
The nurse should plan to collect data from the client for which of the following?
A. Restricted movement due to abnormal fixation of a joint
B. A drop in blood pressure that occurs with a change in position
C. Altered gait with dragging of the toes while ambulating
D. Diminished awareness of body position and balance
D. Diminished awareness of body position and balance
Proprioception, or kinesthesia, is a sense of self-awareness and body position. It is the
result of feedback from nerve sensory receptors that alert the brain to fine-tune muscle
movement in order to regulate balance, coordination, and movement.
A nurse is caring for a client who has pneumonia. In which of the following positions
should the nurse place the client to promote postural drainage?
A. Lateral
B. Supine
C. Prone
D. Fowler’s
C. Prone
following actions by the client demonstrates proper use of the crutches?
A. The hand grips of the crutches are at the level of the client’s umbilicus.
B. The client’s elbows are bent 45° when holding the crutches.
C. The client places their weight on their axilla when using the crutches.
D. The client has the crutches resting 5 cm (2 in) below their axilla.
D. The client has the crutches resting 5 cm (2 in) below their axilla.
The nurse should identify that the client is using the crutches properly when they rest
the crutches 5 cm (2 in) below their axilla.
A nurse is assisting with preparing a presentation about muscle function for a group of
newly licensed nurses. Which of the following information should the nurse plan to
include?
A. Muscles store calcium and magnesium.
B. Muscles produce red blood cells and platelets.
C. Muscles assist with thermoregulation in the body.
D. Muscles provide protection of internal organs.
C. Muscles assist with thermoregulation in the body.
Contracting muscles generate heat that assists in maintaining body temperature.
Shivering is an example of the muscles working to produce heat.
A nurse is assisting with completing the Mobility Assessment Tool (MAT) for a client and
determines that the client is at Level 1 Mobility. The nurse should identify that the client
is unable to perform which of the following tasks?
A. Walk in place.
B. Stand in place for 5 seconds.
C. Sit on the edge of the bed for 1 min.
D. Step forward and backward.
C. Sit on the edge of the bed for 1 min.
,The nurse should identify that the client who is at Level 1 Mobility of the MAT requires
maximum assistance. The client should be able to sit on the edge of the bed for 2 min
and extend their arms across their chest to shake hands with the nurse before
advancing to the next level. If the client is unable to complete both tasks, they remain at
Level 1 Mobility of the MAT.
A nurse in a long-term care facility is caring for an older adult client and notes their
muscles have become smaller and weaker. Which of the following should the nurse
suspect the client is experiencing?
A. Sarcopenia
B. Disuse osteoporosis
C. Atrophy
D. Joint contracture
C. Atrophy
The nurse should suspect the client is experiencing atrophy of their muscles. Atrophy
occurs when the muscles of the body become smaller and weaker. This can occur with
prolonged immobility or disuse of a limb.
A nurse is reinforcing teaching with a newly hired assistive personnel (AP) about
working with clients who require assistance with ADLs. Which of the following activities
should the nurse include as an ADL?
A. Toileting
B. Writing
C. Ambulating
D. Talking
A. Toileting
The nurse should include that toileting is an ADL that the AP can assist the client to
perform. Other ADLs include dressing, bathing, and feeding.
, A nurse is caring for a client who requires total assistance with mobility. When using the
Mobility Assessment Tool (MAT), which of the following pieces of equipment should the
nurse use to transfer the client?
A. Gait belt
B. Mechanical lift
C. Cane
D. Sit-to-stand lift
B. Mechanical lift
The nurse should identify that, according to the MAT, a client who requires total
assistance requires the use of a mechanical lift or slide board, along with assistance
from one to two personnel, to transfer the client.
A nurse is caring for a client who had a stroke and reports difficulty with proprioception.
The nurse should plan to collect data from the client for which of the following?
A. Restricted movement due to abnormal fixation of a joint
B. A drop in blood pressure that occurs with a change in position
C. Altered gait with dragging of the toes while ambulating
D. Diminished awareness of body position and balance
D. Diminished awareness of body position and balance
Proprioception, or kinesthesia, is a sense of self-awareness and body position. It is the
result of feedback from nerve sensory receptors that alert the brain to fine-tune muscle
movement in order to regulate balance, coordination, and movement.
A nurse is caring for a client who has pneumonia. In which of the following positions
should the nurse place the client to promote postural drainage?
A. Lateral
B. Supine
C. Prone
D. Fowler’s
C. Prone
