Nokea
Which of the following are appropriate instructions for quadricep-setting exercises?
- A. Breathe in and out smoothly during exercises
- B. Perform exercises two to three times per hour
- C. Perform exercises four to six times a day
- D. Hold breath during exercise drills
- E. Perform pushups three or four times a day
- F. Dangle for 30 to 60 minutes
- G. Use a footstool for dangling
Correct Answer: B,C,F
Rationale: Breathing in and out smoothly during quadricep-setting exercises maximizes lung inflation. The patient should perform quadricep-setting exercises two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for a few minutes is done to adjust to the upright position; dangling for 30 to 60 minutes is impractical for the nurse to supervise and may prove unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling.
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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.
When a patient is being moved or ambulated and starts to fall, the nurse should take which actions in which order?
- A. Place their feet wide apart with one foot in front
- B. Rock their pelvis out toward the side of the patient
- C. Grasp the gait belt
- D. Support the patient by pulling the patient's weight backward against their body
- E. Gently slide the patient down their body toward the floor while protecting the patient's head
- F. Remain with the patient while calling for help
Correct Answer: C,F,A,E,D,B
Rationale: When a patient is being moved or ambulated and starts to fall, the nurse places their feet wide apart with one foot in front, rocks their pelvis out toward the side of the patient, grasps the gait belt, supports the patient by pulling the patient's weight backward against their body, gently slides the patient down their body toward the floor while protecting the patient's head, and remains with the patient while calling for help.
Which position promotes maximal lung expansion during episodes of dyspnea?
- A. High-Fowler's
- B. Ambulation
- C. Distraction
- D. Holding the breath
Correct Answer: A
Rationale: High-Fowler's position promotes maximal lung expansion and is the position of choice during episodes of dyspnea. Encouraging ambulation during distress will increase dyspnea. Distracting the patient is not addressing the underlying cause of dyspnea, which is activity. Holding the breath increases demands on the heart.
A nurse is instructing a patient recovering from a stroke on proper use of a cane. What information will the nurse include in the teaching plan?
- A. Support weight on the stronger leg and cane and advance weaker foot forward.
- B. Hold the cane in the same hand of the leg with the most severe deficit.
- C. Stand with as much weight distributed on the cane as possible.
- D. Avoid using the cane to rise from a sitting position, as this is unsafe.
Correct Answer: A
Rationale: The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.
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.