NURS 106 MIDTERM QUESTIONS WITH VERIFIED
ANSWERS
What does PQRSTU stand for - Answers - Provokes
Quality
Radiation
Severity
Timing
Understanding (pt.'s)
What does PERRLA stand for? - Answers - pupils equal, round, reactive to light and
accommodation
What does CWMS stand for - Answers - Color, warmth, movement, sensation
What does ABCIOPS stand for - Answers - airway, breathing, circulation, intake, output,
pain, safety
What are the three principles of body mechanics - Answers - Maintain body balance
Increase Stability
Maintain body alignment
What are wedge pillows used for - Answers - maintaining legs in abduction after hip
replacement surgery
What are two reasons to use prone position - Answers - acute respiratory distress
syndrome, acute lung injury
What criteria must a patient meet to use the sabina lift (sit-to-stand) - Answers - weight
bearing on at least one leg
have upper body tone
able to sit unassisted
able to grip with at least one hand
able to follow instructions
cooperative
max 440lbs
In what two circumstance should a pt/'s arms be outside of the sling - Answers - when
using a sit-to-stand lift
or using the hygiene sling with a ceiling lift
In what circumstance would a ceiling lift be used - Answers - for pt.'s who are unable to
weight bear, unable to follow instructions, or have poor body tone
, Prior to restraint use what things must have been done - Answers - Tried alternative and
documented outcomes
Client consent or alternate must be obtained
Physician must order it
Care plan in place
What are the only circumstances for restraint use - Answers - Increased risk of injury to
self or others
Prevent interruption of therapy
Prevent confused or combative pt. from removing life-supporting equipment
What are some complications of restraint use - Answers - - increased disorientation,
agitation, fear, humiliation.
- loss of self-esteem
- contractures, nerve damage, circulatory impairment, asphyxiation
- increased risk of injury from falls
- pressure ulcers, skin breakdown
- constipation
- pneumonia
- urinary and fecal incontinence
- urinary retention
* all complications of being immobile
What must be done while a restraint is in use - Answers - - ensure you can fit 2 fingers
between the pt. and restraint
- proper placement, skin integrity, pulses, temp, skin color, and sensation of restrained
body part should be assessed at least every hour or according to agencies policy
- regular assessment of pt.'s need for continued use of the restraint with the intent of
discontinuing the restraint at the earliest time possible
What is a mitten restrain used for - Answers - to prevent itching, removing dressings,
removing IV or other invasive equipment. allows greater movement than a wrist restraint
What is an elbow restrain (freedom arm splint) used for - Answers - prevents flexion of
the elbow, commonly used in children/infants to keep an IV line in place
What is a mummy restraint used for - Answers - maintains short term restraint of torso
and extremities in small children, used for exams or treatments involving the head or
neck
What is a pelvic soft belt used for - Answers - helps for anatomical positioning in chair, if
used for this reasoning it is not a restraint
What is a belt restraint (segufix/pinel) used for - Answers - restrains centre of gravity
and prevents the pt. from rolling off the stretcher or sitting up
ANSWERS
What does PQRSTU stand for - Answers - Provokes
Quality
Radiation
Severity
Timing
Understanding (pt.'s)
What does PERRLA stand for? - Answers - pupils equal, round, reactive to light and
accommodation
What does CWMS stand for - Answers - Color, warmth, movement, sensation
What does ABCIOPS stand for - Answers - airway, breathing, circulation, intake, output,
pain, safety
What are the three principles of body mechanics - Answers - Maintain body balance
Increase Stability
Maintain body alignment
What are wedge pillows used for - Answers - maintaining legs in abduction after hip
replacement surgery
What are two reasons to use prone position - Answers - acute respiratory distress
syndrome, acute lung injury
What criteria must a patient meet to use the sabina lift (sit-to-stand) - Answers - weight
bearing on at least one leg
have upper body tone
able to sit unassisted
able to grip with at least one hand
able to follow instructions
cooperative
max 440lbs
In what two circumstance should a pt/'s arms be outside of the sling - Answers - when
using a sit-to-stand lift
or using the hygiene sling with a ceiling lift
In what circumstance would a ceiling lift be used - Answers - for pt.'s who are unable to
weight bear, unable to follow instructions, or have poor body tone
, Prior to restraint use what things must have been done - Answers - Tried alternative and
documented outcomes
Client consent or alternate must be obtained
Physician must order it
Care plan in place
What are the only circumstances for restraint use - Answers - Increased risk of injury to
self or others
Prevent interruption of therapy
Prevent confused or combative pt. from removing life-supporting equipment
What are some complications of restraint use - Answers - - increased disorientation,
agitation, fear, humiliation.
- loss of self-esteem
- contractures, nerve damage, circulatory impairment, asphyxiation
- increased risk of injury from falls
- pressure ulcers, skin breakdown
- constipation
- pneumonia
- urinary and fecal incontinence
- urinary retention
* all complications of being immobile
What must be done while a restraint is in use - Answers - - ensure you can fit 2 fingers
between the pt. and restraint
- proper placement, skin integrity, pulses, temp, skin color, and sensation of restrained
body part should be assessed at least every hour or according to agencies policy
- regular assessment of pt.'s need for continued use of the restraint with the intent of
discontinuing the restraint at the earliest time possible
What is a mitten restrain used for - Answers - to prevent itching, removing dressings,
removing IV or other invasive equipment. allows greater movement than a wrist restraint
What is an elbow restrain (freedom arm splint) used for - Answers - prevents flexion of
the elbow, commonly used in children/infants to keep an IV line in place
What is a mummy restraint used for - Answers - maintains short term restraint of torso
and extremities in small children, used for exams or treatments involving the head or
neck
What is a pelvic soft belt used for - Answers - helps for anatomical positioning in chair, if
used for this reasoning it is not a restraint
What is a belt restraint (segufix/pinel) used for - Answers - restrains centre of gravity
and prevents the pt. from rolling off the stretcher or sitting up
