1. The nnnurse nnis nnpreparing nnto nnlift nna nnpatient. nnWhich nnaction nnwill nnthe nnnurse
nntake
first?
a. Position nna nndrawsheet nnunder nnthe nnpatient.
b. Assess nnweight nnand nndetermine nnassistance nnneeds.
c. Delegate nnthe nntask nnto nna nnnursing nnassistive nnpersonnel.
d. Attempt nnto nnmanually nnlift nnthe nnpatient nnalone nnbefore nnasking nnfor
nn assistance.
ANS: nnB
When nnlifting, nnassess nnthe nnweight nnyou nnwill nnlift, nnand nndetermine nnthe
nnassistance nnyou nnwill nnneed. nnThe nnnurse nnhas nnto nnassess nnbefore
nnpositioning nna nndrawsheet nnor nndelegating nnthe nntask. nnManual nnlifting nnis
nnthe nnlast nnresort, nnand nnit nnis nnused nnwhen nnthe nntask nnat nnhand nndoes nnnot
nninvolve nnlifting nnmost nnor nnall nnof nnthe nnpatient’s nnweight; nnmost nnfacilities
nnhave nna nnno-lift nnpolicy.
2. The nnnurse nnis nncaring nnfor nnan nnolder-adult nnpatient nnwho nnhas nnbeen
diagnosed nnwith nna nnstroke. nnWhich nnintervention nnwill nnthe nnnurse
nn
nn add nnto nnthe nncare nnplan?
Encourage nnthe nnpatient nnto nnperform nnas nnmany nnself-care nnactivities nnas
a. possible.
b. Provide nna nncomplete nnbed nnbath nnto nnpromote nnpatient nncomfort.
,c. Coordinate nnwith nnoccupational nntherapy nnfor nngait nntraining.
d. Place nnthe nnpatient nnon nnbed nnrest nnto nnprevent nnfatigue.
ANS: nnA
Nurses nnshould nnencourage nnthe nnolder-adult nnpatient nnto nnperform nnas
nnmany nnself-care nnactivities nnas nnpossible, nnthereby nnmaintaining nnthe
nnhighest nnlevel nnof nnmobility.
Sometimes nnnurses nninadvertently nncontribute nnto nna nnpatient’s nnimmobility
nnby nnproviding nnunnecessary nnhelp nnwith nnactivities nnsuch nnas nnbathing
nnand nntransferring. nnPlacing nnthe nnpatient nnon nnbed nnrest nnwithout
133
nnsufficient nnambulation nnleads nnto nnloss nnof nnmobility nnand nnfunctional
nndecline, nnresulting nnin nnweakness, nnfatigue, nnand nnincreased nnrisk nnfor
nnfalls. nnAfter nna nnstroke nnor nnbrain nnattack, nna nnpatient nnlikely nnreceives
nngait
, training nnfrom nna nnphysical nntherapist; nnspeech nnrehabilitation nnfrom nna
nnspeech nntherapist; nnand nnhelp nnfrom nnan nnoccupational nntherapist nnfor
nnADLs nnsuch nnas nndressing, nnbathing nnand nntoileting, nnor nnhousehold
nnchores.
3. The nnnurse nnis nnobserving nnthe nnway nna nnpatient nnwalks. nnWhich nnaspect
nnis nnthe nnnurse nnassessing?
a. Activity nntolerance
b. Body nnalignment
c. Range nnof nnmotion
d. Gait
ANS: nnD
Gait nndescribes nna nnparticular nnmanner nnor nnstyle nnof nnwalking. nnActivity
nntolerance nnis nnthe nntype nnand nnamount nnof nnexercise nnor nnwork nnthat nna
nnperson nnis nnable nnto nnperform.
Body nnalignment nnrefers nnto nnthe nnposition nnof nnthe nnjoints, nntendons,
nnligaments, nnand nnmuscles nnwhile nnstanding, nnsitting, nnand nnlying. nnRange
nnof nnmotion nnis nnthe nnmaximum nnamount nnof nnmovement nnavailable nnat nna
nnjoint nnin nnone nnof nnthe nnthree nnplanes nnof nnthe nnbody: nnsagittal, nnfrontal, nnor
nntransverse.
4. A nnnurse nnis nnassessing nnthe nnbody nnalignment nnof nna nnstanding
patient. nnWhich nnfinding nnwill nnthe nnnurse nnreport nnas nnnormal?
nn
When nnobserved nnlaterally, nnthe nnspinal nncurves nnalign nnin nna nnreversed nn“S”
a. pattern.
When nnobserved nnposteriorly, nnthe nnhips nnand nnshoulders nnform nnan nn“S”
b. pattern.
c. The nnarms nnshould nnbe nncrossed nnover nnthe nnchest nnor nnin nnthe nnlap.
d. The nnfeet nnshould nnbe nnclose nntogether nnwith nntoes nnpointed nnout.
ANS: nnA
When nnthe nnpatient nnis nnobserved nnlaterally, nnthe nnhead nnis nnerect nnand nnthe
nnspinal nncurves nnare nnaligned nnin nna nnreversed nn“S” nnpattern. nnWhen
nnobserved nnposteriorly, nnthe nnshoulders nnand nnhips nnare nnstraight nnand
nnparallel. nnThe nnarms nnhang nncomfortably nnat nnthe nnsides. nnThe nnfeet nnare
nnslightly nnapart nnto nnachieve nna nnbase nnof nnsupport, nnand nnthe nntoes nnare
nnpointed nnforward.
5. The nnnurse nnis nnevaluating nnthe nnbody nnalignment nnof nna nnpatient nnin nnthe
nnsitting 133