Clinical Nursing Skills and Techniques 8th Edition by Anne Griffin Perry Patricia A. Potter Wendy Ostendorf Test Bank

Clinical Nursing Skills and Techniques  8th Edition by Anne Griffin Perry Patricia A. Potter Wendy Ostendorf  Test Bank
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Chapter 9: Safe Patient Handling, Transfer, and Positioning

MULTIPLE CHOICE

1. A nurse should be aware of safety measures to prevent personal injury when lifting or moving patients. An appropriate principle to follow is:
a. bend at the waist for lifting.
b. tighten the stomach muscles and pelvis.
c. keep the weight to be lifted away from the body.
d. carry or hold the weight 1 to 2 feet above the waist.

ANS: B
Tighten the stomach muscles and tuck the pelvis; this provides balance and protects the back. Bend at the knees; this helps to maintain the nurses center of gravity and lets the strong muscles of the legs do the lifting. Keep the weight to be lifted as close to the body as possible; this action places the weight in the same plane as the lifter and close to the center of gravity for balance.

DIF: Cognitive Level: Application REF: Text reference: p. 197
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Lifting KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

2. The most prevalent and debilitating occupational health hazard among nurses is:
a. footdrop.
b. pressure ulcers.
c. musculoskeletal disorders.
d. contractures.

ANS: C
Musculoskeletal disorders are the most prevalent and debilitating occupational health hazard among nurses. Little improvement has been noted in the incidence of musculoskeletal injuries among health care workers. In 1989, 4.2 lost-workday injury cases per 100 were reported; in 2000, 4.1 cases per 100 were reported. Plantar flexion contracture or footdrop is a complication seen in bedridden patients. Pressure ulcers and contractures are complications that can develop in patients who do not maintain correct body alignment.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 198
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

3. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient may have to be turned more frequently than every 2 hours.
c. This patient may be allowed to remain in his favorite position as long as he doesnt complain of discomfort.
d. Skin breakdown is not an issue for this patient.

ANS: B
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the center of gravity is not aligned. Cluttered hallways and bedside areas increase the patients risk for falling. Dehydration or edema may require more frequent position changes because patients are prone to skin breakdown.

DIF: Cognitive Level: Application REF: Text reference: p. 198
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

4. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position?
a. Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension

ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop in blood pressure) when transferred.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 199
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

5. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury during transfers?
a. Diabetes mellitus
b. Myocardial infarction
c. A cerebrovascular accident
d. An upper extremity fracture

ANS: C
Certain conditions increase a patients risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus, myocardial infarction, or upper extremity fracture does not increase the patients risk for injury.

DIF: Cognitive Level: Application REF: Text reference: p. 198
OBJ: Describe procedures for safely lifting patients. TOP: Cerebrovascular Accident
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6. To assist the patient to a sitting position on the side of the bed, what should the nurse do first?
a. Raise the height of the bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patients legs over the side of the bed.

ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient and the nurse to raise the patient to a sitting position.
The bed should be in the low position. The patient is turned to face the nurse after the head of the bed is raised 30 degrees. The patients legs are positioned over the edge of the bed after the head of the bed is raised and the patient is turned to face the nurse.

DIF: Cognitive Level: Application REF: Text reference: p. 201
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse do?
a. Grab the patient under the axilla to lift.
b. Have the patient move forward with the weak side.
c. Have the patient put on shoes with nonskid soles.
d. Place the chair in a position 90 degrees opposite the bed.

ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Always have the patient wear shoes during transfer; bare feet increase the risk for falls. A transfer belt allows the nurse to maintain stability of the patient during transfer and reduces the risk of falling. A transfer belt provides movement of the patient at the center of gravity. Patients should never be lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patients strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.

DIF: Cognitive Level: Application REF: Text reference: p. 203
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which would be the best technique for transferring the patient?
a. Using three nurses and a slide board
b. Using the three-person lift technique
c. Raising the head 30 degrees
d. Having the patient keeps arms to the side

ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can tolerate. This maintains alignment of the spinal column. Cross the patients arms on the chest to prevent injury to the arms during transfer.

DIF: Cognitive Level: Application REF: Text reference: pp. 205-206
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

9. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to:
a. lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. deep the check valve open when the patient is seated in the chair.

ANS: C
The sling should extend from shoulders to knees (hammock) to support the patients body weight equally. Raise the bed to a high position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left open, the boom may continue to lower and injure the patient.

DIF: Cognitive Level: Application REF: Text reference: pp. 207-208
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

10. When preparing to move a patient in bed, the nurse should:
a. expect that the patients comfort level will decrease.
b. make sure that all pillows used in the previous position stay in position.
c. raise the bed to a comfortable working height.
d. plan on moving the patient herself because other nurses are busy.

ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurses center of gravity and reduces the risk for back injury. Proper positioning reduces stress on the joints. The patients comfort level should increase. The nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.

DIF: Cognitive Level: Application REF: Text reference: p. 211
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity

11. An appropriate procedure to use when moving a patient up in bed is for the nurse to:
a. raise the head of the bed.
b. start by flexing the patients knees and hips.
c. place a pillow under the patients shoulders.
d. instruct the patient to inhale and hold still.

ANS: B
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables the nurse to assess body alignment and reduces the pull of gravity on the patients upper body. The nurse should remove the pillow from under the patients head and shoulders and place the pillow at the head of the bed. This prevents striking the patients head against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out, thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.

DIF: Cognitive Level: Application REF: Text reference: p. 212
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowlers position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to:
a. support his calves with pillows.
b. place a large pillow behind his head to prevent extension.
c. place a pillow behind his upper back.
d. avoid using pillows if the patient does not have use of the hands and arms.

ANS: A
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the heels. This sometimes is referred to as floating heels. Rest the patients head against the mattress or on a small pillow. This prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment. Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion contractures of arms and wrists.

DIF: Cognitive Level: Application REF: Text reference: p. 213
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

13. To position a patient with hemiplegia in Fowlers position, the nurse should:
a. elevate the head of the bed 15 to 30 degrees.
b. place the patient in the prone position.
c. position a spastic hand with the fingers extended using hand rolls.
d. position the patients head with slight hyperextension of the neck.

ANS: C
Position a spastic hand with the wrist in neutral position or slightly extended; fingers should be extended with the palm down or may be left in relaxed position with the palm up. Position the patient in supine position. Elevate the head of the bed 45 to 60 degrees. This increases comfort, improves ventilation, and increases the patients opportunity to relax. Adjust the head of the bed according to the patients condition. For example, those with increased risk for pressure ulcers will remain at a 30-degree angle. Position the head on a small pillow with the chin slightly forward. If the patient is totally unable to control head movement, avoid hyperextension of the neck. Too many pillows under the head may cause or worsen neck flexion contracture.

DIF: Cognitive Level: Application REF: Text reference: p. 214
OBJ: Describe positioning techniques for the supported Fowlers, supine, prone, 30-degree lateral side-lying, and Sims positions.
TOP: Supporting a Hemiplegic Patient in Fowlers Position
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

14. In positioning the patient in the prone position, one way to improve breathing is to:
a. support the arms in a flexed position level at the shoulders.
b. place a pillow under the lower legs.
c. place a small pillow under the patients abdomen.
d. support the patients head with a small pillow.

ANS: C
Placing a small pillow under the patients abdomen below the level of the diaphragm reduces pressure on the breasts of some female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not directly improve breathing. Turning the patients head to one side and supporting it with a small pillow is designed to reduce flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.

DIF: Cognitive Level: Application REF: Text reference: pp. 214-215
OBJ: Describe positioning techniques for the supported Fowlers, supine, prone, 30-degree lateral side-lying, and Sims positions. TOP: Hand Rolls
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

15. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.

ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patients comfort before moving. Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.

DIF: Cognitive Level: Application REF: Text reference: p. 200
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

16. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should:
a. allow the patient to lie on his right side continuously because he seems comfortable.
b. prevent the patient from lying on his right side until he no longer wishes to lie on that side.
c. frequently assess the patient and turn him more frequently.
d. allow the patient to lie on his right side until a pressure ulcer develops and he can no longer lie on that side.

ANS: C
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of assessment and turning is to prevent complications of immobility.

DIF: Cognitive Level: Analysis
REF: Text reference: p. 198 |Text reference: pp. 210-211 |Text reference: p. 218
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

17. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.

ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs reduces the risk for back injury.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 198
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

18. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll?
a. Under the small of the back
b. Behind the knees when supine
c. Alongside the ilium to mid-thigh
d. In the palm of the hand with fingers flexed

ANS: C
The nurse should place the trochanter roll alongside the ilium to mid-thigh. The trochanter roll is a rolled wedge, pillow, or sandbag placed by the lateral aspect of the leg between the iliac crest and the knees to prevent external hip rotation.

DIF: Cognitive Level: Application REF: Text reference: pp. 213-214
OBJ: Describe the use of the trochanter. TOP: Trochanter Rolls
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. Patients at risk for complications and/or injury from improper positioning include patients with which of the following? (Select all that apply.)
a. Poor nutrition
b. Loss of sensation
c. Impaired muscle development
d. Poor circulation

ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer. Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility, and impaired muscle development.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 198
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

2. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the nurse realizes that mobilization: (Select all that apply.)
a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.

ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patients rehabilitation.

DIF: Cognitive Level: Analysis REF: Text reference: pp. 210-211
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

3. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.)
a. Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques

ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting techniques. Consider individual patient problems during transfer.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 199
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

4. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.)
a. Head erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated

ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee.

DIF: Cognitive Level: Application REF: Text reference: p. 205
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. Which of the following risk factors contribute to complications of immobility? (Select all that apply.)
a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation

ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological changes associated with aging predispose older adults to greater risks for developing complications of immobility.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 211
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all that apply.)
a. Thrombus
b. Pressure ulcer
c. Kyphosis
d. Contractures

ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 198
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

COMPLETION

1. The coordinated effort of the musculoskeletal and nervous systems in maintaining balance, posture, and body alignment is known as _______________.

ANS:
body mechanics
Body mechanics is the coordinated effort of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing activities of daily living. Body mechanics also facilitates body movement so that a person can carry out a physical activity without using excessive muscle energy.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 198
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Body Mechanics KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

2. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened foot into a plantar-flexed position.

ANS:
footdrop
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at walking.

DIF: Cognitive Level: Comprehension REF: Text reference: pp. 213-214
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

3. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal independence is known as ________________.

ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to regain optimal independence as quickly as possible.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 199
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

4. Awareness of posture and changes in equilibrium is known as _______________.

ANS:
proprioceptive function
Assess the patients proprioceptive function (awareness of posture and changes in equilibrium). Determine the stability of the patients balance for transfer.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 200
OBJ: Assess for alterations in body alignment. TOP: Proprioceptive Function
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.

ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 210
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

6. Body balance is achieved when a wide _____________ exists.

ANS:
base of support
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical line can be drawn from the center of gravity through the base of support.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 210
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

7. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb, the nurse places _________________ in the patients hands.

ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in opposition to the fingers.

DIF: Cognitive Level: Application REF: Text reference: p. 214
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

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