Nsg 106: Test 2 study guide complete
guide A+ graded
Mobility: observations - answers -balance,gait,any difficulties bearing weight
-use of assistive devices
-ability to sit, stand, and walk
-idications of pain
Mobility (subjective data) - answers -lifestyle, ADLs, sports,nutrition
-pain and how they typically relieve it
-factors that increase/decrease mobility
physical examination - answers -inspect and palpate bones,muscles, joints for
tenderness,deformities, and pain
-assess ROM
-assess skin condition
-neurovascular assessment
(Pain, pulses,pallor,paresthesia, paralysis)
How often should a mobility assessment be performed before moving a patient? -
answers Every 24 hours
Level 1 Maximum assist - answers Patient cannot bear weight,assist staff with moving,
or maintain a seated position
Level 1 is assigned if the patient cannot: - answers -shake hands with the nurse
-move from a semi-reclining position to sitting on the edge of bed for two minutes
Level 2 moderate assist - answers Patient cannot sit on the edge of the bed with feet
on floor and then extend the leg, flex the ankle, and point toes bilaterally
Level 3 Minimal Assist - answers Patient can bear weight and may have an assistive
device
, Level 3 is assigned if patient: - answers -cannot rise from seater position and maintain
standing position for 5s
-patient uses an assistive device
Level 4 No assist - answers Patient can stand, march in place, and walk without help
Level 4 is assigned if patient can: - answers -march in place
-step forward
-step backward
Timed Up and Go Test (TUG) - answers Tool used to evaluate mobility and fall risk in
older adults
-patient stands up from their seat,walks 10ft, turns, walks back to the chair and sits
down.
-if takes longer than 12 seconds then patient is at risk of falling
acute pain - answers Lasts seconds to less than 6 months
FLACC pain scale is used for: - answers Neonates/infants
Wong-Baker FACES scale is used for: - answers Young patients
Numeric pain scale - answers Most commonly used
0 is no pain and 10 is excruciating pain
sarcopenia - answers Loss of lean muscle mass caused by immobility and/or aging
atelectasis - answers partial or complete collapse of the lung
pneumonia - answers Infection that occurs from shallow breathing, thick mucus, and
the decreased ability to cough
Mobility risk factors - answers - aging: primary risk factor
-genetics
-obesity
-maternal nutrition before birth
-diet (calcium and vitamin D, protein)
Prone - answers Face down
Lateral - answers Side lying
Trendelenburg - answers HOB down, feet up.
Orthopneic/ High Fowlers - answers HOB is at 90* or patient is sitting on edge of bed
with with head on bedside table
guide A+ graded
Mobility: observations - answers -balance,gait,any difficulties bearing weight
-use of assistive devices
-ability to sit, stand, and walk
-idications of pain
Mobility (subjective data) - answers -lifestyle, ADLs, sports,nutrition
-pain and how they typically relieve it
-factors that increase/decrease mobility
physical examination - answers -inspect and palpate bones,muscles, joints for
tenderness,deformities, and pain
-assess ROM
-assess skin condition
-neurovascular assessment
(Pain, pulses,pallor,paresthesia, paralysis)
How often should a mobility assessment be performed before moving a patient? -
answers Every 24 hours
Level 1 Maximum assist - answers Patient cannot bear weight,assist staff with moving,
or maintain a seated position
Level 1 is assigned if the patient cannot: - answers -shake hands with the nurse
-move from a semi-reclining position to sitting on the edge of bed for two minutes
Level 2 moderate assist - answers Patient cannot sit on the edge of the bed with feet
on floor and then extend the leg, flex the ankle, and point toes bilaterally
Level 3 Minimal Assist - answers Patient can bear weight and may have an assistive
device
, Level 3 is assigned if patient: - answers -cannot rise from seater position and maintain
standing position for 5s
-patient uses an assistive device
Level 4 No assist - answers Patient can stand, march in place, and walk without help
Level 4 is assigned if patient can: - answers -march in place
-step forward
-step backward
Timed Up and Go Test (TUG) - answers Tool used to evaluate mobility and fall risk in
older adults
-patient stands up from their seat,walks 10ft, turns, walks back to the chair and sits
down.
-if takes longer than 12 seconds then patient is at risk of falling
acute pain - answers Lasts seconds to less than 6 months
FLACC pain scale is used for: - answers Neonates/infants
Wong-Baker FACES scale is used for: - answers Young patients
Numeric pain scale - answers Most commonly used
0 is no pain and 10 is excruciating pain
sarcopenia - answers Loss of lean muscle mass caused by immobility and/or aging
atelectasis - answers partial or complete collapse of the lung
pneumonia - answers Infection that occurs from shallow breathing, thick mucus, and
the decreased ability to cough
Mobility risk factors - answers - aging: primary risk factor
-genetics
-obesity
-maternal nutrition before birth
-diet (calcium and vitamin D, protein)
Prone - answers Face down
Lateral - answers Side lying
Trendelenburg - answers HOB down, feet up.
Orthopneic/ High Fowlers - answers HOB is at 90* or patient is sitting on edge of bed
with with head on bedside table
