Which nursing intervention is appropriate when a patient starts to fall while ambulating quizlet?

While assessing a patient with a head injury, the nurse suspects damage to the central nervous system (CNS). Why should the nurse assess the patient's voluntary movements? Select all that apply.
1
Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes fractures.
2
Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes impaired mobility.
3
Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes joint degeneration.
4
Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes articular disruption.
5
Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes impaired body alignment.

1, 2, 5

In osteoporosis, the bones remain biochemically normal but have a reduction in density or mass. The cause of osteoporosis is uncertain, and theories vary from hormonal imbalances to insufficient intake of nutrients. Osteoporosis is common in aging adults. Osteomalacia, not osteoporosis, is an uncommon metabolic disease characterized by inadequate and delayed mineralization, resulting in compact and spongy bones. Scoliosis is a structural curvature of the spine associated with vertebral rotation.

The nurse is attending to an older adult patient who has sustained a fall and has broken a femur. The nurse explains to the patient that as the body ages, the bones become weak due to osteoporosis and become more prone to fracture. Which statements are true about osteoporosis? Select all that apply.
1
The cause may be hormonal imbalances or insufficient intake of nutrients.
2
There is a structural curvature of the spine associated with vertebral rotation.
3
Osteoporosis is a disorder of aging and results in the reduction of bone density or mass.
4
There is inadequate and delayed mineralization, resulting in compact and spongy bone.
5
The bone remains biochemically normal but has difficulty maintaining integrity and support.

1

The nurse should teach a diabetic patient that exercise leads to improved glucose control. Diabetic patients should perform low- to-medium intensity exercise. The effect of exercise on blood glucose lasts for 24 hours, not 10 hours. The nurse should instruct the patient to undergo a complete physical examination before starting any physical exercise routine.

What should the nurse teach a diabetic patient about exercise?
1
"Exercise leads to improved glucose control."
2
"You can perform medium- to high-intensity exercise."
3
"The effect of exercise on blood glucose levels often lasts for 10 hours."
4
"You can start an exercise routine on your own without any physical examination."

3

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

When caring for a patient who can assist with positioning, what should the nurse keep in mind?
1
If the center of gravity is higher, the nurse can have more stability.
2
If the base of support is narrower, the nurse can have more stability.
3
If the balancing activity is divided between the arms and legs, there is a reduced risk of back injury.
4
If the nurse's face is towards the direction opposite to movement, this positioning prevents abnormal twisting of the spine.

4

Isometric exercises involve tightening or tensing muscles without moving body parts. There are three categories of exercise: isotonic, isometric, and resistive isometric. Isotonic exercises cause muscle contraction and changes in muscle length. Examples of resistive isometric exercises are push-ups and hip lifting.

1, 3

Inspecting the patient's body alignment, posture, and mobility and observing how the patient's body systems respond to activity and exercise are parts of the assessment phase of a patient diagnosed with impaired physical mobility. Reassessing the patient for signs of improved activity and exercise tolerance is part of the evaluation phase. Consulting and collaborating with members of the health care team to increase activity form a part of the planning phase. Asking for the patient's perception of activity and exercise status after the intervention forms a part of the evaluation phase

Which actions should the nurse perform during the assessment phase when caring for a patient diagnosed with impaired physical mobility? Select all that apply.
1
Inspect the patient's body alignment, posture, and mobility
2
Reassess the patient for signs of improved activity and exercise tolerance
3
Observe the response of the patient's body systems to activity and exercise
4
Consult and collaborate with members of the health care team to increase activity
5
Ask for the patient's perception of activity and exercise status after interventions

1, 3, 5

To maintain body balance, the patient must attain a posture that requires the least muscular work and places the least strain on muscles, ligaments, and bones. To do this, the patient must first separate the feet to a comfortable distance to widen the base of support. Then the patient must try to increase balance by bringing the center of gravity closer to the base of support. The body posture is adjusted such that the vertical line from the center of gravity falls through the base of support to attain body balance. The knees should not be kept closer, because this could decrease the width of the base of support and impair balance. Increasing the distance between the center of gravity and the base of support would also impair the balance of the patient. Knees should be kept wide. Keeping the center of gravity away from the base of support will result in a loss of balance while standing or walking.

A patient is admitted to the hospital with osteoporosis and lower back pain. The patient loses balance when trying to stand and walk. The patient has a nursing diagnosis of body imbalance. What instructions does the nurse give the patient? Select all that apply.
1
Instruct the patient to widen the base of support by separating the feet.
2
Instruct the patient to bring the knees closer together to maintain a broad base.
3
Instruct the patient to lower the center of gravity closer to the base of support.
4
Instruct the patient to keep the center of gravity away from the base of support.
5
Instruct the patient to maintain a vertical line from the center of gravity through the base of support.

2

For patients with stage III or IV pressure ulcers, care should be taken to avoid shearing forces. When pulling a patient up in bed, the bed should be flat or in a Trendelenburg's position. If the patient weighs less than 200 lb (91 kg), friction reducing devices and two to three caregivers are needed. If the caregiver needs to lift more than 35 lb (16 kg) of a patient's weight, then the patient is considered fully dependent and assistive devices should be used.

Which measure should the nurse adopt to reposition a patient in bed?
1
When pulling a patient up in bed, the bed should be in anti-Trendelenburg's position.
2
For patients with stage III or IV pressure ulcers, care should be taken to avoid shearing force.
3
If the patient weighs less than 200 lb (91 kg), friction-reducing devices should be avoided.
4
If the caregiver needs to lift about 55 lb (25 kg) of a patient's weight, the patient is considered fully dependent.

1, 4

A dietitian can help the patient plan a diet for weight reduction. The patient should be advised to set realistic goals for weight reduction. A reduction of 4 pounds over 2 weeks is acceptable. Gastric banding is the surgical procedure used for morbidly obese patients, if dietary measures and medications do not help them. Exercise is a healthy way to lose weight, but it should be gradual. A patient who has never exercised should not start with high-intensity exercises. The patient should start with a mild intensity exercise and gradually increase the intensity. Although her job is one of the reasons for her sedentary lifestyle and weight gain, it is not the only reason. Resigning from the job will not help the patient.

A patient with a body mass index (BMI) of 36 has a sedentary job. The patient states that she has never exercised. The patient has been advised to reduce weight. What actions should the nurse advise the patient to do to promote reduction of weight? Select all that apply.
1
Advise her to discuss her diet with a dietitian.
2
Advise her to undergo gastric banding.
3
Advise her to undergo an intensive exercise training program.
4
Advise her to have realistic goals such as losing 4 pounds over 2 weeks.
5
Advise her to resign from her job immediately because it is the cause of her obesity.

4

Muscle tone, or tonus, is the normal state of balanced muscle tension. Muscle tension can be in various states. Muscle tone helps maintain functional positions such as sitting or standing, without excess muscle fatigue; this tone is maintained through the continual use of muscles. Isotonic (dynamic) contraction is a combination of concentric and eccentric muscle actions for active movement. Isometric (static) contraction causes an increase in muscle tension or muscle work but no shortening or active movement of the muscle.