ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 34 : Activity Questions
Question 1 of 5
A nurse is assisting a patient who is 2 days postoperative from a cesarean section dangle in preparation for sitting in a chair. After assisting the patient to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action?
Correct Answer: C
Rationale: If a patient becomes faint and their knees buckle when moving from bed to a chair or ambulating, the nurse should stop the activity, as the patient has demonstrated a clear risk for falling. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. When vital signs are stable, another attempt can be made with the assistance of another staff. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position and prevent hypotension related to a sudden change from the supine position.
Question 2 of 5
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?
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.
Question 3 of 5
A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: 'Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self.' Based on this data, which score would the patient receive on the Katz index?
Correct Answer: B
Rationale: The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding. The patient is independent in bathing (1 point), toileting (1 point), continence (1 point), and feeding (1 point), but requires help with dressing and transferring, so no points are awarded for those activities. Thus, the total score is 4.
Question 4 of 5
Two nurses are repositioning a patient and pulling the patient up in bed. Which of these steps is most appropriate to prevent injury to the nurses?
Correct Answer: D
Rationale: The nurses should face the direction the patient will move and rock in synchrony prior to moving the patient in that direction. A lifting or repositioning sheet or device is used to decrease friction and facilitate movement. While the patient can cross their arms, they can also be instructed to press their feet into the mattress to assist movement. The bed should be at the level of the nurses' elbows, not hips, to maintain proper ergonomics and prevent injury.
Question 5 of 5
A nurse is getting a patient with right hemiparesis out of bed to the chair. What will the nurse say to the patient?
Correct Answer: C
Rationale: When transferring a patient, the chair is placed on the unaffected or stronger side, rather than the weaker or affected side. Lifting and carrying a patient unless absolutely necessary poses an unnecessary risk for injury to patient and staff. Patients should wear proper shoes, sturdy slippers, or hospital-issued socks with grips to prevent sliding and/or falling.