ATI SM 3.0 Mobility exam with 100% correct answers

A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include? A. "Lean on the crutches to support your body weight when standing." B. "Fully extend your arms when holding onto the hand grips." C. "Hold the crutches on your unaffected side when preparing to sit in a chair." D. "Hold the crutches 9 inches in front of and to the side of each foot." C. "Hold the crutches on your unaffected side when preparing to sit in a chair." Rationale: The crutches should be held on the unaffected side when preparing to sit in a chair. Incorrect rationale: - crutches should be fitted so the client's arms are flexed ~ 30° at elbows when holding onto hand grips. - crutches should be held 6 inches in front of & to side of each foot to assist w/ balance A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip? A. Move their leg behind their body. B. Move their leg forward and up. C. Move their leg medially toward their other leg. D. Turn their foot and leg away from their other leg. A. Move their leg behind their body. Rationale: This movement demonstrates hyperextension of the hip. B. flexion C. adduction D. external rotation A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take? A. Place the stockings on the client after the client ambulates to the restroom. B. Ensure the client's toes are visible after placing the stockings on the client. C. After applying the stockings, place two fingers between the client's leg and stocking to check the fit. D. Measure the client's calf circumference and leg length from heel to knee. D. Measure the client's calf circumference and leg length from heel to knee. Rationale: To ensure proper fit, the nurse should measure the widest part of the client's calf as well as the length of client's leg from heel to knee. Antiembolic stockings that are too large will not apply the pressure needed to prevent DVT. Antiembolic stockings that are too small could impair circulation in the client's legs. A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take? A. Wrap both arms around the client's arms and shoulders. B. Move both feet together when the client begins to fall. C. Protect the client's extremities while lowering them to the floor. D. Extend one leg and allow the client to slide down the leg to the floor. D. Extend one leg and allow the client to slide down the leg to the floor. Rationale: This action helps prevent injury to the client. As the client gets close to the floor, the nurse should bend both legs to continue supporting the client. A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique? A. Positioning the chair slightly behind the nurse so that the seat faces the client's bed B. Placing the client's left leg in front of the right leg just prior to the transfer C. Aligning the nurse's knees with the client's knees just before the transfer D. Grasping the client under the axillae to assist them to their feet C. Aligning the nurse's knees with the client's knees just before the transfer. Rationale: This is a correct strategy that helps the nurse safely stabilize the client while moving to a standing position. A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder? A. Adducting the arm so that it lies next to the client's side B. Flexing the shoulder by raising the arm from a side position to a 180° angle C. Abducting the arm to a 90° angle from the side of the body D. Circumducting the shoulder in a 180° half circle B. Flexing the shoulder by raising the arm from a side position to a 180° angle Rationale: This demonstrates full ROM of shoulder. The client's fingers should be pointing directly upward. circumduct = 360* circle A nurse is observing an assistive personnel (AP) who is using a mechanical lift w/ a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene? A. Places a removable cover over the sling B. Leaves the bed in the lowest position throughout the procedure C. Locks the hydraulic valve before attaching the sling to the lift D. Raises the head of the bed to a sitting position just before transfer B. Leaves the bed in the lowest position throughout the procedure Rationale: The bed should be raised to a comfortable working position in order to prevent injury to nursing staff and to properly position the lift under the client's bed.