SOLUTIONS SCORED A+
✔✔Which of the following patients is at greatest risk for experiencing a fall? - ✔✔A
confused patient with a history of a previous fall.
✔✔A nursing instructor asks what may cause orthostatic hypotension. The nursing
student correctly replies: (Select all that apply.) - ✔✔-Prolonged bed rest.
-Hypovolemia.
-Antihypertensives.
✔✔The nurse is getting a patient with right-sided weakness up in a chair. On what side
of the bed should the nurse place the chair? - ✔✔On the patient's left side.
✔✔The nurse is planning tasks for the day. Which of the following patients would
require repositioning at this time? (Select all that apply.) - ✔✔-A patient in correct body
alignment who was turned 2 hours ago.
-A comfortable patient with paraplegia who has been sitting in a chair for 30 minutes.
✔✔Which of the following patients should be allowed to lie back down? - ✔✔A patient
who complains of feeling dizzy and slightly nauseous when sitting on the bedside.
✔✔Which of the following techniques is used to assess muscle strength in a patient? -
✔✔. APPLY AN OPPOSING FORCE OR RESISTANCE
✔✔What is an increased thoracic curvature, common in older adults, called? -
✔✔Kyphosis
✔✔Neck flexion and extension should be - ✔✔45 degrees
✔✔Which of the following findings in a musculoskeletal assessment would be
considered abnormal?
A. Nodules
B. Bogginess
C. Symmetry
D. BOTH A AND B - ✔✔A. Nodules
B. Bogginess
✔✔What does a goniometer measure? - ✔✔Angles of extension and flexion
✔✔The nurse is helping a patient with hemiparesis take a few steps. A gait belt has
been applied. The patient is using a cane. Where should the nurse stand in relation to
the patient? - ✔✔On the patient's weak side
,✔✔The nurse is preparing to initiate ambulation with a patient who is recovering from a
stroke. What information will help the nurse determine how far to walk? - ✔✔Ask the
patient how far she would like to go.
✔✔The nurse has applied a gait belt to a postoperative patient to facilitate ambulation.
Within a few feet of the bed, the patient begins to complain of dizziness and leans
heavily on the nurse. What would be the nurse's initial response? - ✔✔Slowly lower the
patient to the floor.
✔✔The nurse is preparing to delegate the ambulation of a patient with the use of a gait
belt to nursing assistive personnel (NAP). Which statement made by NAP requires the
nurse to follow up? - ✔✔"I will use the under-axillae technique to help him up to a
standing position."
✔✔The nurse is ambulating a patient with a gait belt when he says he feels sick to his
stomach. What would the nurse do? - ✔✔Return the patient to the bed or chair
(whichever is closer).
✔✔When preparing to move a patient in bed, what will the nurse do first? - ✔✔Assess
the patient's ability to help with moving.
✔✔When preparing to move a patient in bed with the help of an assistant, which
posture will both caregivers use to ensure their own safety? - ✔✔Flex the hips and
knees
✔✔A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-
reducing device. The nurse will prepare for this move by assembling how many
caregivers? - ✔✔At least three
✔✔In which position will the nurse place the patient to move him or her up in bed? -
✔✔Supine with the head of the bed flat
✔✔A patient will be moved up in bed with the use of a friction-reducing device. How will
the nurse place this device under the patient? - ✔✔Roll the patient from side to side,
and place the device under the drawsheet.
✔✔Which patient is most at risk of developing permanently impaired mobility? - ✔✔A
72-year-old woman hospitalized for anemia associated with diabetic nephropathy
(kidney disease)
, ✔✔The nurse notes that a patient's left elbow is resistant to extension and flexion while
performing range of motion exercises. What is the appropriate nursing action? -
✔✔Perform range of motion to the left elbow until resistance is met.
✔✔The nurse is performing passive shoulder and elbow exercises for a patient who is
recovering from surgery to remove a soft-tissue tumor in her upper arm. Why does the
nurse cup one hand around the patient's elbow and support the forearm and wrist
during the ROM exercises? - ✔✔To ensure stability while exercising the joint
✔✔Which of the following are basic guidelines when assisting a patient with passive
range of motion? - ✔✔Each joint is exercised to the point of resistance but not pain.
✔✔Why would the nurse ask a physical therapist to perform passive ROM exercises for
a patient with lower extremity injuries sustained in a motor vehicle crash? - ✔✔The
patient has orthopedic trauma.
✔✔When preparing to safely transfer a patient from a bed to a wheelchair using a
transfer belt, the nurse would do what first? - ✔✔Assess the patient's physiological
capacity to transfer.
✔✔Which instruction would the nurse give a patient who is able to assist with transfer
from a bed to a wheelchair using a transfer belt? - ✔✔"Please push down onto the
mattress with both hands and stand when I count to three."
✔✔A patient lying supine in bed is being transferred to a wheelchair using a transfer
belt. Which action would the nurse perform just before moving the patient to the side of
the bed? - ✔✔Raise the head of the bed 30 degrees.
✔✔The nurse is preparing to transfer a patient with left-sided weakness from the bed to
a wheelchair using a transfer belt. Which position would the nurse instruct the patient to
assume? - ✔✔Place your stronger leg forward and your weaker leg toward the back.
✔✔A patient has been transferred to a wheelchair with a transfer belt. What is one
action the nurse would take to position the patient safely in the chair? - ✔✔Lower the
foot rests, and place the patient's feet on them.
✔✔What does the nurse do after attaching the hooks to the holes in the sling on a
hydraulic lift?
A. Lower the head of the bed.
B. Remove the patient's eyeglasses.
C. Have the patient cross the arms over the chest.
D. Elevate the head of the bed. - ✔✔D. Elevate the head of the bed.