Chapter 26: Ambulatory Aids
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. A healthy, 32-year-old man wants to start a fitness program to increase his muscle tone
and muscle strength. What advice should the nurse offer him? The United States
Department of Health and Human Services recommends:
1) That exercising even once a week is beneficial.
2) 30 minutes or more of moderate-intensity physical activity three times a week.
3) 1 hour, three times a week of moderate-intensity physical activity.
4) 150 to 300 minutes or more of moderate-intensity physical activity per week.
ANS: 4
Exercise involves physical activity and increases muscle tone and strength. The U.S.
Department of Health and Human Services recommends 150 to 300 minutes or more
of moderate- or vigorous-intensity physical activity per week.
PTS: 1 DIF: Moderate REF: V1, m 757 KEY: Nursing
process: Interventions | Client need: HPM | Cognitive level: Comprehension
2. A patient fractured her right ulna 8 weeks ago and has just had her cast removed. The
orthopedic surgeon prescribes isometric exercises for the right arm. Which of the
following exercises comply with the surgeons orders?
1) Place a foam ball in the right hand and squeeze; hold the squeeze position for 6 to
8 seconds, and replace
2) Grasping the right wrist with the left hand, move the right arm up, down, and side
to side; hold each seconds, and repeat 5 to 10 times.
3) Grasping the right wrist with the left hand, pull the right arm across the body; hold
this position for 6 repeat 5 to 10 times.
4) Press the right hand against a wall; hold this position for 6 to 8 seconds, and
repeat 5 to 10 times.
ANS: 4
Isometric exercise involves muscle contraction without motion. Isometric exercises
are useful for developing strength. This type of exercise is appropriate for the patient
who has had an extremity confined to a cast because muscle atrophy occurs when the
muscle is not used.
PTS: 1 DIF: Difficult REF: V1, m 755 KEY: Nursing process:
Interventions | Client need: PHSI | Cognitive level: Application
3. A patient is on strict bed rest for 5 days. During this time he has not had a bowel
movement; normally, he passes stools daily. He describes feeling bloated and
uncomfortable. What information should the nurse give the patient when explaining
constipation?
1) Immobility often causes constipation.
2) A stool softener daily will relieve the problem.
3) Use of a bedpan results in bloating and constipation.
4) A low-fiber diet will resolve the problem.
, ANS: 1
Immobility slows peristalsis, which leads to constipation, gas, and difficulty
evacuating stools from the rectum. Increasing fiber in the diet often prevents
constipation. A stool softener may be ordered if other measures are unsuccessful.
Some people do find use of a bedpan difficult.
PTS: 1 DIF: Easy REF: V1, m 763 KEY: Nursing process:
Interventions | Client need: PHSI | Cognitive level: Comprehension
4. A patient is on strict bed rest for 5 days. During this time he has not had a bowel
movement; normally, he passes stools daily. He describes feeling bloated and
uncomfortable. A nursing diagnosis that would best address a patient who is on bed rest is
Constipation related to:
1) Change in previous pattern.
2) Immobility.
3) Dietary intake.
4) Change in environment.
ANS: 2
Immobility slows peristalsis, which leads to constipation, gas, and difficulty
evacuating stools from the rectum. Based on the scenario, this nursing diagnosis
would specifically address the patients condition.
PTS: 1 DIF: Moderate REF: V1, m 763; higher-order item with
implied answer KEY: Nursing process: Diagnosis | Client need: PHSI |
Cognitive level: Analysis
5. A 32-year-old paraplegic has been admitted to the hospital for antibiotic therapy to treat
pneumonia. He lives independently and has developed strong upper-body strength to
maximize his independence. Which transfer device should be used when transferring him
from the bed to his wheelchair?
1) Mechanical lift
2) Transfer belt
3) Draw sheet
4) Transfer board
ANS: 4
A transfer board is used by patients with longstanding mobility problems; it offers
them the greatest amount of independence while ensuring safety. Patients using a
transfer board should have sufficient upper-body strength to perform the transfer
safely. A mechanical lift could be used, but it does not promote independence. A
transfer belt is used for clients who are able to stand. A draw sheet is useful for
moving a patient in bed rather than from bed to wheelchair.
PTS: 1 DIF: Easy REF: V1, m 775 KEY: Nursing process:
Evaluation | Client need: SECE | Cognitive level: Comprehension
6. An 82-year-old patient is unsteady on her feet when transferring her position in the room.
She reports feeling a little sore but has no complaints of weakness. What is the
appropriate piece of equipment to use when helping her ambulate?
1) Crutches
2) Transfer belt
3) Cane
, 4) Walker
ANS: 2
Crutches are commonly used when the patient has an injured lower extremity. A cane
or walker is generally used for the patient with a lower extremity injury or weakness.
The most appropriate equipment to use would be a transfer belt. A transfer belt allows
the patient the greatest amount of independence while ensuring safety.
PTS: 1 DIF: Easy REF: V1, pp. 775-776 KEY: Nursing
process: Interventions | Client need: SECE | Cognitive level: Application
7. The nurse is helping an 82-year-old patient to ambulate in the hallway. Suddenly she
states, I feel so light-headed and weak, as her knees begin to buckle. The nurses best
action at this time would be to:
1) Assist the patient to slide down his leg as he guides her to a seated or lying
position.
2) Grab her under the arms and hold her up as he calls for assistance.
3) Immediately release the transfer device and place a wheelchair behind the patient
to prevent a fall.
4) Instruct the patient to grab the rail in the hallway while he calls for assistance.
ANS: 1
If a patient becomes weak or begins to fall when walking, do not attempt to hold the
patient up. Instead, protect the patient as you guide her to a seated or lying position.
Create a wide base of support, and project forward the hip closest to the patient.
Assist the patient to slide down your leg as you call for help. Protect the patients head
as her body descends.
PTS: 1 DIF: Moderate REF: V1, m 778 KEY: Nursing
process: Interventions | Client need: SECE | Cognitive level: Application
8. According to the U.S. Department of Health and Human Services 2008 Physical Activity
Guidelines for Americans, which of the following statements about the benefits of
physical activity is correct?
1) The risks of physical activity outweigh the health benefits.
2) Physical activity in excess of recommendations for age is harmful.
3) Combining aerobic and muscle-strengthening activities promotes better health.
4) Lesser amounts of activity provide little to no health benefits.
ANS: 3
The combination of aerobic and bone- and muscle-strengthening physical activities
leads to health benefits for people of all ethnic groups and ages. Physical activity is
safe for almost everyone, and the health benefits of physical activity far outweigh the
risks. Additional health benefits are provided by increasing to 300 minutes a week of
moderate-intensity aerobic physical activity, or 150 minutes a week of vigorous-
intensity physical activity, or an equivalent combination of both. For all individuals,
some activity is better than none.
PTS: 1 DIF: Easy REF: V1, m 757 KEY: Nursing process:
Planning | Client need: HPM | Cognitive level: Recall
9. A nurse is caring for a 25-year-old male quadriplegic patient. Which of the following
treatments would the nurse perform to decrease the risk of joint contracture and promote
, joint mobility?
1) Active ROM
2) Turning the patient every 2 hours
3) Passive ROM
4) Administering glucosamine supplements
ANS: 3
Passive ROM involves moving the joints through their ROM when the patient is
unable to do so for himself. Passive ROM promotes joint mobility. Active ROM
would not be possible for a quadriplegic patient. Turning the patient every 2 hours
prevents skin breakdown but does not promote mobility or prevent contracture.
Glucosamine is a building block for the formation and repair of cartilage. However,
there is inconclusive, scientific evidence regarding the benefit of this substance to
improve joint function.
PTS: 1 DIF: Moderate REF: V1, m 754; higher-order item,
answer can be derived from text | V1, m 776; higher-order item, answer can be
derived from text KEY: Nursing process: Interventions | Client need:
PHSI | Cognitive level: Application 7.
10. A nurse is assessing a 74-year-old male patient for an exercise program to be offered at
the local hospital. During the evaluation, the nurse notes the following vital signs: P = 72,
RR = 16, BP = 132/70. After 3 minutes of moderate-intensity running on the treadmill,
the patient becomes short of breath and states, I have to stop. I cant do this anymore. The
nurse measures his vital signs again: P = 152, RR = 40, BP = 172/98. She instructs him to
rest. Vital signs return to baseline after 15 minutes. The nurse should recognize his
symptoms as associated with which of the following?
1) COPD
2) Orthostatic hypotension
3) Limited activity tolerance
4) Impending respiratory failure
ANS: 3
To assess for activity tolerance, assess and record vital signs before and after exercise.
A rapid change from baseline vital signs or a slow return to baseline indicates limited
activity tolerance. COPD, a form of chronic lung disease, would primarily exhibit
signs of shortness of breath, difficulty getting enough air, fatigue, and elevated heart
rate during exercise. In this scenario, the blood pressure is elevated, which is not a
predominant finding with COPD. Air hunger signals impending respiratory failure.
Orthostatic hypotension is a temporary lowering of blood pressure when suddenly
standing up. It is not a finding related to exercise.
PTS: 1 DIF: Moderate REF: V1, m 767 KEY: Nursing process:
Diagnosis | Client need: SECE | Cognitive level: Analysis
11. What is the correct method for turning an adult patient who recently sustained a spinal
cord injury?
1) Ask the patient to assist with the turn by holding the side rails of the bed.
2) Place a draw sheet under the patient to assist with turning.
3) Request help from another nurse to perform the logrolling technique.
4) Use a mechanical lift for safe turning and protecting the nurses back.
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. A healthy, 32-year-old man wants to start a fitness program to increase his muscle tone
and muscle strength. What advice should the nurse offer him? The United States
Department of Health and Human Services recommends:
1) That exercising even once a week is beneficial.
2) 30 minutes or more of moderate-intensity physical activity three times a week.
3) 1 hour, three times a week of moderate-intensity physical activity.
4) 150 to 300 minutes or more of moderate-intensity physical activity per week.
ANS: 4
Exercise involves physical activity and increases muscle tone and strength. The U.S.
Department of Health and Human Services recommends 150 to 300 minutes or more
of moderate- or vigorous-intensity physical activity per week.
PTS: 1 DIF: Moderate REF: V1, m 757 KEY: Nursing
process: Interventions | Client need: HPM | Cognitive level: Comprehension
2. A patient fractured her right ulna 8 weeks ago and has just had her cast removed. The
orthopedic surgeon prescribes isometric exercises for the right arm. Which of the
following exercises comply with the surgeons orders?
1) Place a foam ball in the right hand and squeeze; hold the squeeze position for 6 to
8 seconds, and replace
2) Grasping the right wrist with the left hand, move the right arm up, down, and side
to side; hold each seconds, and repeat 5 to 10 times.
3) Grasping the right wrist with the left hand, pull the right arm across the body; hold
this position for 6 repeat 5 to 10 times.
4) Press the right hand against a wall; hold this position for 6 to 8 seconds, and
repeat 5 to 10 times.
ANS: 4
Isometric exercise involves muscle contraction without motion. Isometric exercises
are useful for developing strength. This type of exercise is appropriate for the patient
who has had an extremity confined to a cast because muscle atrophy occurs when the
muscle is not used.
PTS: 1 DIF: Difficult REF: V1, m 755 KEY: Nursing process:
Interventions | Client need: PHSI | Cognitive level: Application
3. A patient is on strict bed rest for 5 days. During this time he has not had a bowel
movement; normally, he passes stools daily. He describes feeling bloated and
uncomfortable. What information should the nurse give the patient when explaining
constipation?
1) Immobility often causes constipation.
2) A stool softener daily will relieve the problem.
3) Use of a bedpan results in bloating and constipation.
4) A low-fiber diet will resolve the problem.
, ANS: 1
Immobility slows peristalsis, which leads to constipation, gas, and difficulty
evacuating stools from the rectum. Increasing fiber in the diet often prevents
constipation. A stool softener may be ordered if other measures are unsuccessful.
Some people do find use of a bedpan difficult.
PTS: 1 DIF: Easy REF: V1, m 763 KEY: Nursing process:
Interventions | Client need: PHSI | Cognitive level: Comprehension
4. A patient is on strict bed rest for 5 days. During this time he has not had a bowel
movement; normally, he passes stools daily. He describes feeling bloated and
uncomfortable. A nursing diagnosis that would best address a patient who is on bed rest is
Constipation related to:
1) Change in previous pattern.
2) Immobility.
3) Dietary intake.
4) Change in environment.
ANS: 2
Immobility slows peristalsis, which leads to constipation, gas, and difficulty
evacuating stools from the rectum. Based on the scenario, this nursing diagnosis
would specifically address the patients condition.
PTS: 1 DIF: Moderate REF: V1, m 763; higher-order item with
implied answer KEY: Nursing process: Diagnosis | Client need: PHSI |
Cognitive level: Analysis
5. A 32-year-old paraplegic has been admitted to the hospital for antibiotic therapy to treat
pneumonia. He lives independently and has developed strong upper-body strength to
maximize his independence. Which transfer device should be used when transferring him
from the bed to his wheelchair?
1) Mechanical lift
2) Transfer belt
3) Draw sheet
4) Transfer board
ANS: 4
A transfer board is used by patients with longstanding mobility problems; it offers
them the greatest amount of independence while ensuring safety. Patients using a
transfer board should have sufficient upper-body strength to perform the transfer
safely. A mechanical lift could be used, but it does not promote independence. A
transfer belt is used for clients who are able to stand. A draw sheet is useful for
moving a patient in bed rather than from bed to wheelchair.
PTS: 1 DIF: Easy REF: V1, m 775 KEY: Nursing process:
Evaluation | Client need: SECE | Cognitive level: Comprehension
6. An 82-year-old patient is unsteady on her feet when transferring her position in the room.
She reports feeling a little sore but has no complaints of weakness. What is the
appropriate piece of equipment to use when helping her ambulate?
1) Crutches
2) Transfer belt
3) Cane
, 4) Walker
ANS: 2
Crutches are commonly used when the patient has an injured lower extremity. A cane
or walker is generally used for the patient with a lower extremity injury or weakness.
The most appropriate equipment to use would be a transfer belt. A transfer belt allows
the patient the greatest amount of independence while ensuring safety.
PTS: 1 DIF: Easy REF: V1, pp. 775-776 KEY: Nursing
process: Interventions | Client need: SECE | Cognitive level: Application
7. The nurse is helping an 82-year-old patient to ambulate in the hallway. Suddenly she
states, I feel so light-headed and weak, as her knees begin to buckle. The nurses best
action at this time would be to:
1) Assist the patient to slide down his leg as he guides her to a seated or lying
position.
2) Grab her under the arms and hold her up as he calls for assistance.
3) Immediately release the transfer device and place a wheelchair behind the patient
to prevent a fall.
4) Instruct the patient to grab the rail in the hallway while he calls for assistance.
ANS: 1
If a patient becomes weak or begins to fall when walking, do not attempt to hold the
patient up. Instead, protect the patient as you guide her to a seated or lying position.
Create a wide base of support, and project forward the hip closest to the patient.
Assist the patient to slide down your leg as you call for help. Protect the patients head
as her body descends.
PTS: 1 DIF: Moderate REF: V1, m 778 KEY: Nursing
process: Interventions | Client need: SECE | Cognitive level: Application
8. According to the U.S. Department of Health and Human Services 2008 Physical Activity
Guidelines for Americans, which of the following statements about the benefits of
physical activity is correct?
1) The risks of physical activity outweigh the health benefits.
2) Physical activity in excess of recommendations for age is harmful.
3) Combining aerobic and muscle-strengthening activities promotes better health.
4) Lesser amounts of activity provide little to no health benefits.
ANS: 3
The combination of aerobic and bone- and muscle-strengthening physical activities
leads to health benefits for people of all ethnic groups and ages. Physical activity is
safe for almost everyone, and the health benefits of physical activity far outweigh the
risks. Additional health benefits are provided by increasing to 300 minutes a week of
moderate-intensity aerobic physical activity, or 150 minutes a week of vigorous-
intensity physical activity, or an equivalent combination of both. For all individuals,
some activity is better than none.
PTS: 1 DIF: Easy REF: V1, m 757 KEY: Nursing process:
Planning | Client need: HPM | Cognitive level: Recall
9. A nurse is caring for a 25-year-old male quadriplegic patient. Which of the following
treatments would the nurse perform to decrease the risk of joint contracture and promote
, joint mobility?
1) Active ROM
2) Turning the patient every 2 hours
3) Passive ROM
4) Administering glucosamine supplements
ANS: 3
Passive ROM involves moving the joints through their ROM when the patient is
unable to do so for himself. Passive ROM promotes joint mobility. Active ROM
would not be possible for a quadriplegic patient. Turning the patient every 2 hours
prevents skin breakdown but does not promote mobility or prevent contracture.
Glucosamine is a building block for the formation and repair of cartilage. However,
there is inconclusive, scientific evidence regarding the benefit of this substance to
improve joint function.
PTS: 1 DIF: Moderate REF: V1, m 754; higher-order item,
answer can be derived from text | V1, m 776; higher-order item, answer can be
derived from text KEY: Nursing process: Interventions | Client need:
PHSI | Cognitive level: Application 7.
10. A nurse is assessing a 74-year-old male patient for an exercise program to be offered at
the local hospital. During the evaluation, the nurse notes the following vital signs: P = 72,
RR = 16, BP = 132/70. After 3 minutes of moderate-intensity running on the treadmill,
the patient becomes short of breath and states, I have to stop. I cant do this anymore. The
nurse measures his vital signs again: P = 152, RR = 40, BP = 172/98. She instructs him to
rest. Vital signs return to baseline after 15 minutes. The nurse should recognize his
symptoms as associated with which of the following?
1) COPD
2) Orthostatic hypotension
3) Limited activity tolerance
4) Impending respiratory failure
ANS: 3
To assess for activity tolerance, assess and record vital signs before and after exercise.
A rapid change from baseline vital signs or a slow return to baseline indicates limited
activity tolerance. COPD, a form of chronic lung disease, would primarily exhibit
signs of shortness of breath, difficulty getting enough air, fatigue, and elevated heart
rate during exercise. In this scenario, the blood pressure is elevated, which is not a
predominant finding with COPD. Air hunger signals impending respiratory failure.
Orthostatic hypotension is a temporary lowering of blood pressure when suddenly
standing up. It is not a finding related to exercise.
PTS: 1 DIF: Moderate REF: V1, m 767 KEY: Nursing process:
Diagnosis | Client need: SECE | Cognitive level: Analysis
11. What is the correct method for turning an adult patient who recently sustained a spinal
cord injury?
1) Ask the patient to assist with the turn by holding the side rails of the bed.
2) Place a draw sheet under the patient to assist with turning.
3) Request help from another nurse to perform the logrolling technique.
4) Use a mechanical lift for safe turning and protecting the nurses back.
