C HAPTER 18: L IFTING , M OVING , AND
P OSITIONING P ATIENTS
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. A patient in the skilled nursing facilit y has left -sided paral ysis from a
stroke several years before, as well as generalized weakness. The nurse
should ensure that which of the following devices is in pl ace to prevent
flexion contractures?
a. A trochanter roll to keep her legs from turning outward
b. A rolled washcloth in the palm of her left hand or a hand splint
c. A protective vest to keep her sitting upright in the chair
d. A trapeze to permit her to change her p osition in bed more easil y
ANS: B
A hand splint or rolled cloth in the palm of her hand (along with range -
of-motion exercises) will help prevent flexion contractures of her hand.
A trochanter roll prevents outward rotation, not flexion.
DIF: Cognitive Level: Application REF: p. 265, Skill 18 -1
OBJ: Theory #3 TOP: Positioning KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity: basic care and comfort
,2. When the post -stroke patient complains to the nurse, “I don’t see why you
are wasting your time doing the passive range -of-motion exercises on m y
legs,” the nurse’s most informative response would be based on the
knowledge that the exercises:
a. guarantee the prevention of pressure ulcers.
b. are part of the basic care given to al l patients.
c. prevent contractures of the hips.
d. maintain the muscle mass of the limb prior to the stroke.
ANS: C
Passive range-of-motion (ROM) exercises, although not part of care
given to all patients, does prevent contractures in persons who are
bedfast. ROM does not guarantee the prevention of pressure ulcers but
helps in the improved circulation of the limbs.
DIF: Cognitive Level: Application REF: p. 272, Skill 18 -3
OBJ: Clinical Practice #3 TOP: Effects of ROM
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrit y: physiological adaptation
3. While the nurse is assisting a patient to ambulate, the patient suddenl y
says, “I’m dizz y. I can’t stand up.” As the patient begins to fall, the nurse
should:
a. tell the patient, “Look up, take some deep breaths, and stand up
straight. You can do it.”
b. call for another nurse or aide to get a wheelchair to return the
patient to her room via wheelchair.
c. step behind the patient, grasp her around the waist or chest, and
slide her down his leg gentl y to the floor.
d. look for the nearest chair and assist the patient to it.
, ANS: C
A patient who is threatening to fall needs to be lowered to the floor to
avoid injury from a fall by allowing the patient to gentl y slide down
the nurse’s leg to the floor.
DIF: Cognitive Level: Anal ysis REF: p. 282, Skill 18-6
OBJ: Clinical Practice #6 TOP: Patient Transfers
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrit y: reduction of risk
4. A patient who is weak from inactivit y following a car accident benefits
most if the nurse provides for:
a. passive range-of-motion (ROM) exercises to all joints four times a
day.
b. active ROM exercises to arms and legs several times a day.
c. active ROM exercises with weights twice a day with 20 repetitions
each.
d. passive ROM exercises to the point of resistance or pain and then
slightl y beyond.
ANS: B
Active ROM is best to restore strength in a weak patient who can
independentl y perform activities of dail y living but is immo bilized
because of injury.
P OSITIONING P ATIENTS
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. A patient in the skilled nursing facilit y has left -sided paral ysis from a
stroke several years before, as well as generalized weakness. The nurse
should ensure that which of the following devices is in pl ace to prevent
flexion contractures?
a. A trochanter roll to keep her legs from turning outward
b. A rolled washcloth in the palm of her left hand or a hand splint
c. A protective vest to keep her sitting upright in the chair
d. A trapeze to permit her to change her p osition in bed more easil y
ANS: B
A hand splint or rolled cloth in the palm of her hand (along with range -
of-motion exercises) will help prevent flexion contractures of her hand.
A trochanter roll prevents outward rotation, not flexion.
DIF: Cognitive Level: Application REF: p. 265, Skill 18 -1
OBJ: Theory #3 TOP: Positioning KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity: basic care and comfort
,2. When the post -stroke patient complains to the nurse, “I don’t see why you
are wasting your time doing the passive range -of-motion exercises on m y
legs,” the nurse’s most informative response would be based on the
knowledge that the exercises:
a. guarantee the prevention of pressure ulcers.
b. are part of the basic care given to al l patients.
c. prevent contractures of the hips.
d. maintain the muscle mass of the limb prior to the stroke.
ANS: C
Passive range-of-motion (ROM) exercises, although not part of care
given to all patients, does prevent contractures in persons who are
bedfast. ROM does not guarantee the prevention of pressure ulcers but
helps in the improved circulation of the limbs.
DIF: Cognitive Level: Application REF: p. 272, Skill 18 -3
OBJ: Clinical Practice #3 TOP: Effects of ROM
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrit y: physiological adaptation
3. While the nurse is assisting a patient to ambulate, the patient suddenl y
says, “I’m dizz y. I can’t stand up.” As the patient begins to fall, the nurse
should:
a. tell the patient, “Look up, take some deep breaths, and stand up
straight. You can do it.”
b. call for another nurse or aide to get a wheelchair to return the
patient to her room via wheelchair.
c. step behind the patient, grasp her around the waist or chest, and
slide her down his leg gentl y to the floor.
d. look for the nearest chair and assist the patient to it.
, ANS: C
A patient who is threatening to fall needs to be lowered to the floor to
avoid injury from a fall by allowing the patient to gentl y slide down
the nurse’s leg to the floor.
DIF: Cognitive Level: Anal ysis REF: p. 282, Skill 18-6
OBJ: Clinical Practice #6 TOP: Patient Transfers
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrit y: reduction of risk
4. A patient who is weak from inactivit y following a car accident benefits
most if the nurse provides for:
a. passive range-of-motion (ROM) exercises to all joints four times a
day.
b. active ROM exercises to arms and legs several times a day.
c. active ROM exercises with weights twice a day with 20 repetitions
each.
d. passive ROM exercises to the point of resistance or pain and then
slightl y beyond.
ANS: B
Active ROM is best to restore strength in a weak patient who can
independentl y perform activities of dail y living but is immo bilized
because of injury.
