Mobility Questions

The nurse is caring for a patient who has been sitting in a chair for 5 hours. Which of the following complications is the greatest risk to the client?

• Decreased subq tissue

• Muscle atrophy

• Pressure injury

• Fecal impaction

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply).

• Hold the cane on the right side

• keep two points of support on the floor

• Place the cane in front of the feet before advancing

• After advancing the cane move the weaker leg forward

A nurse is transferring a client from a bed to a wheelchair. Which should the nurse do to quickly assess this client’s tolerance to this activity?

• 1. Obtain oxygen saturation.

• 2. Monitor for bradycardia.

• 3. Determine if the client feels dizzy.

• 4. Allow the client time to adjust to the change in position.

Answer explanation

Feeling dizzy is a subjective response to orthostatic hypotension. Obtaining feedback from the client provides a quick evaluation of the client’s tolerance of the transfer.
Blood pressure should be obtained before and after a transfer to allow a comparison to conclude that the hypotension is orthostatic hypotension.

Which nursing action is most effective in relation to the concept "Immobility can lead to ischemia in areas where bony prominences rest on a mattress?"

• 1. Encouraging the client to breathe deeply 10 times per hour

• 2. Performing range-of-motion exercises twice a day

• 3. Placing a sheepskin pad under the sacrum

• 4. Repositioning the client every 2 hours

Answer explanation

Turning a client relieves pressure on the capillary vessels of the dependent areas of the body, particularly the skin overlying bony prominences, which reestablishes blood flow to the area. When pressure on a capillary exceeds 15 to 32 mm Hg, its lumen is occluded, depriving oxygen from local body cells.

Which nursing action should be implemented when assisting a client to move from a bed to a wheelchair?

• 1. Lowering the height of the bed to 2 inches below the height of the client’s wheelchair

• 2. Applying pressure under the client’s axillae areas when assisting the client to stand

• 3. Letting the client help as much as possible when transferring to the wheelchair

• 4. Keeping the client’s feet within 6 inches of each other

Answer explanation

The bed should be higher, not lower, than the wheelchair so that gravity can facilitate the transfer.

2. Applying pressure under the client’s axillae areas when standing up should be avoided because it can injure local nerves and blood vessels.

3. Encouraging the client to be as self-sufficient as possible ensures that the transfer is conducted at the client’s pace, promotes self-esteem, and decreases the physical effort expended by the nurse.

4. Keeping the client’s feet within 6 inches of each other will provide a narrow base of support and is unsafe.

A nurse is planning to help move a client up in bed. Which of the following can the nurse implement to reduce the risk of self-strain when performing this action? Select all that apply.

• Use the force of gravity to facilitate the move.

• Keep the upper and lower body in alignment.

• Use the large muscles of the legs.

• Keep the knees slightly bent.

• Raise the bed to waist level

Answer explanation

Muscle strain is reduced when clients are moved by using gravity, not with the added effort needed to move clients against gravity.

2. Keeping the upper and lower body in alignment decreases strain on the sacrospinal muscles and intervertebral disks.

3. To exert an upward lift, the gluteal and leg muscles should be used, rather than the sacrospinal muscles of the back. The gluteal and leg muscles are larger than the sacrospinal muscles and therefore fatigue less quickly, and their use protects the intervertebral disks.

4. The muscles of the legs are most efficient when the knees and hips are slightly bent. This reduces strain on the muscles being used.

5. Positioning the bed at waist height avoids the need to reach and stretch, which may strain a caregiver’s muscles, bones, joints, tendons, or ligaments.