What is an example of proper body mechanics when lifting?

Correct Answer: D

Rationale: Lifting an object while holding it close to the body (D) is the correct choice because it reduces strain on the spine and engages larger muscle groups more effectively. When the load is near the center of gravity, the back experiences less torque, minimizing the risk of injury. Additionally, keeping the object close allows the legs—which are stronger than the back—to bear most of the weight during the lift. Proper body mechanics also involve bending at the knees, maintaining a neutral spine, and tightening the core, all of which are more easily achieved when the object is held near the torso. Lifting with the back (A) is incorrect because it places excessive stress on the lumbar spine, increasing the risk of herniated discs or muscle strains. The spine is not designed to handle heavy loads in a flexed or twisted position. Instead, the legs should be the primary drivers of the lift, as they contain larger muscle groups capable of generating force safely. Relying on the back shifts the burden to weaker structures, making injury far more likely. Standing with a narrow stance (B) is incorrect because it reduces stability and balance during the lift. A wider stance lowers the center of gravity and provides a stronger base, allowing for better control of the load. A narrow stance increases the likelihood of losing balance, especially when lifting asymmetrical or heavy objects, which could lead to falls or sudden, awkward movements that strain muscles or joints. Lifting excessive weight to strengthen muscles (C) is incorrect because it violates the principle of progressive overload, which should be applied gradually under controlled conditions. Attempting to lift beyond one's capacity with improper form often leads to compensatory movements, such as arching the back or jerking the weight, which can cause acute injuries or long-term damage. Strength training should be structured and supervised, not attempted haphazardly during everyday lifting tasks. Proper body mechanics prioritize safety over momentary exertion, ensuring that the musculoskeletal system is protected. Each incorrect choice disregards biomechanical efficiency and safety, while the correct answer aligns with evidence-based practices for reducing injury risk and maximizing lifting effectiveness. The principles of proper body mechanics are rooted in physics and anatomy, emphasizing load distribution, stability, and the use of the body's strongest muscles to perform work safely.

Correct Answer: A

Rationale: The best initial action is to inquire about the frequency, quality, and location of the pain (Option A). Pain assessment is the first critical step in nursing care because it provides essential information needed to determine the appropriate intervention. Without a thorough understanding of the pain’s characteristics—whether it is sharp, dull, throbbing, localized, or radiating—the nurse cannot effectively advocate for the patient or make informed clinical decisions. Proper pain assessment also helps differentiate between expected cancer-related pain and potential complications, such as a new fracture or infection, which may require immediate medical attention. This step ensures that subsequent interventions, including medication administration, are tailored to the patient’s specific needs rather than being applied generically. Option B (Get the client pain medication) may seem urgent, but administering medication without a proper assessment risks inappropriate dosing, masking critical symptoms, or overlooking complications. Pain management is important, but it must be based on a clear understanding of the pain’s nature and severity. Blindly administering medication could delay identifying a more serious issue, such as pathological fracture or spinal cord compression, which requires additional interventions beyond analgesia. Option C (Ensure the client knows he will have negative effects from immobility) is inappropriate as an initial response. While immobility complications (e.g., muscle atrophy, pressure injuries, or thrombus formation) are legitimate concerns, they are secondary to addressing the patient’s acute pain. Educating the patient about immobility risks at this moment dismisses their immediate distress and fails to prioritize their most pressing need—pain relief. This approach could also erode trust, as the patient may perceive the nurse as minimizing their suffering. Option D (Review the client’s medication administration record) is a useful step but should follow, not precede, a pain assessment. Reviewing the MAR provides information on previously administered medications, scheduled doses, and potential gaps in pain management. However, without first assessing the current pain, the nurse lacks context for interpreting the MAR’s data. For example, if the pain is new or worsening despite recent medication, this could signal a need for reevaluation of the treatment plan rather than simply administering the next scheduled dose. In summary, pain assessment (Option A) is foundational. It ensures patient-centered care, guides safe and effective interventions, and prevents oversight of critical clinical changes. The other options, while relevant, should only be pursued after a thorough assessment or as part of a broader pain management strategy.

Correct Answer: C

Rationale: The client who is tilting their head (Choice C) is the correct answer because head tilting is a common compensatory behavior observed in individuals with visual impairments, particularly those with refractive errors, strabismus, or unilateral vision loss. Tilting the head adjusts the angle of gaze to optimize visual input, minimize double vision, or align the eyes to use the best-functioning part of the retina. For example, a person with astigmatism may tilt their head to reduce blur, while someone with a muscle imbalance (e.g., superior oblique palsy) may adopt an abnormal head posture to maintain binocular vision. This behavior is a clear clinical indicator of visual difficulty and warrants further assessment. Choice A (the client whose sclera is white) is incorrect because a normal, white sclera is a sign of ocular health, not impairment. Pathological conditions affecting vision—such as cataracts, glaucoma, or retinal disorders—do not typically alter scleral color. While abnormalities like jaundice (yellow sclera) or redness (indicating inflammation) may suggest systemic or localized issues, they are not direct markers of visual acuity loss. A white sclera alone provides no diagnostic value for visual impairment. Choice B (the client who has an intact blink reflex) is incorrect because the blink reflex is a protective, involuntary response mediated by cranial nerves (V and VII) and does not correlate with visual acuity. An intact blink reflex merely confirms normal corneal sensitivity and brainstem function. Individuals with severe visual impairments, including blindness, often retain this reflex. Conversely, its absence (e.g., in facial nerve palsy) does not imply vision loss. This choice distracts from genuine signs of visual dysfunction. Choice D (the client with equal pupils) is incorrect because pupil equality (isocoria) is a normal finding and does not rule out visual impairment. Pupillary size and symmetry assess the autonomic nervous system and optic nerve function but are unrelated to refractive errors, macular degeneration, or other common causes of vision loss. Unequal pupils (anisocoria) may indicate neurological issues (e.g., Horner’s syndrome) but are not specific to visual acuity deficits. Equal pupils lack relevance in identifying clients needing vision-related interventions. In summary, head tilting (C) is the only behavior directly linked to adaptive strategies for visual challenges, while the other options reflect normal physiological states or unrelated neurological functions. Recognizing such compensatory behaviors is critical for early detection and intervention in clients with visual impairments.

Correct Answer: B

Rationale: **Rationale:** **Correct Answer (B: Contractures):** Contractures are a direct and significant negative effect of immobility on the musculoskeletal system. Prolonged immobility leads to shortening and stiffening of muscles, tendons, and ligaments due to disuse and lack of stretching. This occurs because muscles and connective tissues adapt to the shortened position they are held in, losing elasticity and range of motion. For example, if a joint remains bent for an extended period (e.g., a knee or elbow), the surrounding tissues may permanently tighten, making it difficult or impossible to straighten the joint. Contractures can cause pain, limit mobility further, and require physical therapy or surgical intervention to correct. This musculoskeletal complication is distinct from other systems and directly tied to the lack of movement. **Incorrect Answers:** **A: Pressure injury** While pressure injuries (e.g., bedsores) are a serious complication of immobility, they primarily affect the integumentary system (skin and underlying tissues), not the musculoskeletal system. These injuries result from prolonged pressure on skin over bony prominences (e.g., heels, sacrum), reducing blood flow and causing tissue necrosis. Though immobility contributes to pressure injuries, they are not a musculoskeletal-specific effect like contractures. **C: Glucose intolerance** Glucose intolerance is a metabolic consequence of immobility, not a musculoskeletal one. Reduced physical activity decreases muscle mass and insulin sensitivity, impairing the body's ability to regulate blood sugar. However, this is a systemic metabolic issue involving hormonal and cellular processes, not a structural or functional change in muscles, bones, or joints. **D: Incontinence** Incontinence is a urinary or bowel dysfunction often associated with immobility but is unrelated to the musculoskeletal system. It arises from weakened pelvic floor muscles, nerve damage, or reduced mobility preventing timely bathroom access. While immobility can contribute to incontinence, the root cause lies in the urinary or digestive systems, not the muscles, bones, or joints. **Key Distinction:** The question specifically asks about the musculoskeletal system, and **contractures** are the only option directly involving muscles, tendons, and joints. The other choices are secondary effects of immobility but pertain to other body systems. Understanding this system-specific impact is critical for targeted interventions, such as range-of-motion exercises to prevent contractures, while pressure injuries require skin care, glucose intolerance demands metabolic management, and incontinence necessitates bladder or bowel retraining.