Nokea
In a nonerect patient, what is a potential consequence of immobility?
- A. Improved blood flow to the kidneys
- B. Urinary stasis favoring bacterial growth
- C. Bone mineralization
- D. Acidic urine
Correct Answer: B
Rationale: In a nonerect patient, the kidneys and ureters are level, limiting or delaying urinary drainage from the kidney pelvis to ureter and bladder. The resulting urinary stasis favors the growth of bacteria that can promote urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to bone demineralization, resulting in increased urinary calcium levels and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.
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A nurse is teaching a patient with weak dorsiflexion how to prevent foot drop. Which instruction should the nurse include?
- A. Maintain the supine position with supination on the feet.
- B. Ask the family to bring in high-top sneakers to maintain foot dorsiflexion.
- C. Encourage hyperextension of the feet with adapdive devices or splints.
- D. Use pillows to keep the feet in the abducted position.
Correct Answer: B
Rationale: To prevent foot drop, the nurse should support the feet in dorsiflexion using a footboard and/or high-top sneakers for further support. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions do not prevent foot drop.
A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: 'Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self.' Based on this data, which score would the patient receive on the Katz index?
- A. 2
- B. 4
- C. 5
- D. 6
Correct Answer: B
Rationale: The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding. The patient is independent in bathing (1 point), toileting (1 point), continence (1 point), and feeding (1 point), but requires help with dressing and transferring, so no points are awarded for those activities. Thus, the total score is 4.
A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient tells the AP not to place the patient in which position?
- A. Side-lying
- B. Fowler's
- C. Sims'
- D. Prone
Correct Answer: D
Rationale: While placing the patient in the prone position for 30 minutes two or three times daily helps prevent knee and hip flexion contractures, it is contraindicated in patients who have spinal problems. The pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine.
A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient?
- A. Lean on the crutches using the axillae to bear body weight.
- B. Keep elbows close to the sides of the body.
- C. When rising, extend the uninjured leg to prevent weight bearing.
- D. To climb stairs, place weight on affected leg first.
Correct Answer: B
Rationale: The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg when rising to prevent weight bearing, and advance the unaffected leg first when climbing stairs.
A nurse is getting a patient with right hemiparesis out of bed to the chair. What will the nurse say to the patient?
- A. Stand on the weaker leg and pivot toward the chair.
- B. I will call the lift team to carry you to the chair.
- C. The chair is by your non-affected leg for smoother movement.
- D. Avoid putting your hospital socks on, as that will restrict your feet moving.
Correct Answer: C
Rationale: When transferring a patient, the chair is placed on the unaffected or stronger side, rather than the weaker or affected side. Lifting and carrying a patient unless absolutely necessary poses an unnecessary risk for injury to patient and staff. Patients should wear proper shoes, sturdy slippers, or hospital-issued socks with grips to prevent sliding and/or falling.