A nurse is caring for a client who has limited mobility in his lower extremities
A nurse is caring for a client who has limited mobility in his lower extremities. Click to highlight the assessment findings below that the nurse should report to the provider. Atrophy D. What are some actions that the nurse should take to prevent skin breakdown?. the client states, "I am not sure how this happened. Decreased proprioception B. pdf from NURSING FUNDAMENTA at Rasmussen College. O Have the client use a trapeze bar when changing position. Instruct the client to cough and deep breath every 4 hr. The nurse should assess which client for possible deep venous thrombosis? (Select all that apply. Apr 30, 2024 · The following are the nursing priorities for clients needing assistance with self-care needs and have ADL limitations: Limited physical mobility. Urinary output D. 32) -She has the motivation to participate in self-care. 4. The client exhibits signs of autonomic hyperreflexia. D. Which of the following puts the client at greater risk for developing pneumonia?, a nurse is caring for a Study with Quizlet and memorize flashcards containing terms like A home health nurse is caring for a client who has emphysema and has difficulty with mobility. Turn him regularly. A nurse is planning care for a client who is on bed rest. The nurse plans to implement which activities in the care of the client? See full list on nurseslabs. c)Encourage coughing and deep breathing, and limit fluid intake. deteriorating myelin sheath 3. The nurse is planning care for a client who has limited bed mobility. Perform passive range-of-motion (ROM) exercises. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with a spinal cord injury. Document actions and observations. Which assessment finding led the nurse to this conclusion? (Select all that apply. use warm water when bathing the client b. This practice, along with regular repositioning and skin hydration, mitigates the risk of bedsores which are caused by sustained pressure on bony areas. Use warm water when bathing the client. How should the nurse best position the client?, The nurse is caring for a client who has a lower body injury and who is able to partially assist Study with Quizlet and memorize flashcards containing terms like a nurse is caring for a client who has a wrist fracture. Increased need for sleep D. Which of the following actions should the nurse take to prevent skin breakdown? Place the client in high-Fowler's position. distended large intestine 4. C. What does the nurse recall is the most common cause of this response? 1. a client who has limited mobility in his A nurse is caring for a client who has limited mobility. B) Have the client use a trapeze bar when changing position. Incisional drainage C. Which of the following interventions should the nurse include in the The nurse is providing care for several clients. The nurse understands that an immobile client may have poor body alignment, which may lead to complications. Which of the following actions should the nurse take to prevent skin breakdown? A) Place the client in high-Fowler's position. Hold the container of solution level with the client's upper hip A nurse is caring for a client who has limited mobility in his lower extremities. Peripheral vascular disease 6 Study with Quizlet and memorize flashcards containing terms like The client returns to the provider's office 3 days later. Which of the following should the nurse suspect the client is experiencing? A. Hypoactive bowel sounds. For which client should the nurse anticipate an order for administering 1000 mg of aspirin? A) A 68-year-old client with rheumatoid arthritis who is experiencing hand pain B) A 5-year-old client who is experiencing ankle pain after a fall from a horse C) A 38-year-old client who is experiencing headache pain after a skiing accident D) A 70-year Study with Quizlet and memorize flashcards containing terms like a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. What instruction should be given to the assistive personnel who will be caring for this client? Standard Text: Select all that apply. Recognize and report significant deviations from norms. It is necessary to provide the client with an anti-decubitus mattress, turn the client every 2 hours, and more often if necessary. For which client should the nurse anticipate an order for administering 1000 mg of aspirin? A) A 68-year-old client with rheumatoid arthritis who is experiencing hand pain B) A 5-year-old client who is experiencing ankle pain after a fall from a horse C) A 38-year-old client who is experiencing headache pain after a skiing accident D) A 70-year A nurse is caring for a client who has limited mobility. Always use two personnel to move the client. For which client should the nurse anticipate an order for administering 1000 mg of aspirin? A) A 68-year-old client with rheumatoid arthritis who is experiencing hand pain B) A 5-year-old client who is experiencing ankle pain after a fall from a horse C) A 38-year-old client who is experiencing headache pain after a skiing accident D) A 70-year A nurse is caring for a client who has a new diagnosis of benign prostate hypertrophy and a prescription for doxazosin. Learning Objectives. Decreased cognitive function, The diencephalon of the brain consists of the A. Client drowsy but responses to verbal stimuli. Which of the following actions by the nurse demonstrates correct transfer technique? A. Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. To deselect a finding, click on the finding again. crushed spinal cord, The The client has a diagnosis of multiple sclerosis (MS). During the physical assessment, the nurse should include which components during inspection and palpation of the injury? Select all that apply. correct action is to B)apply pressure-relieving cushions Study with Quizlet and memorize flashcards containing terms like The client returns to the provider's office 3 days later. ) Taking over-the-corner medication for arthritis A myocardial infarction 2 years ago Controlling type 2 diabetes mellitus diet Jan 28, 2024 · Final answer: To prevent skin breakdown in a patient with limited mobility, a nurse should apply pressure-relieving cushions. Which of the following actions should the nurse identify as an indication of correct use?, a Study with Quizlet and memorize flashcards containing terms like 1. A nurse is caring for a client who has limited mobility in his lower extremities. Doing quadriceps-setting and gluteal-setting exercises 4. " Study with Quizlet and memorize flashcards containing terms like A client is undergoing chemotherapy for ovarian cancer which has metastasized. Encourage fluid intake. Which is an internal resource that the client has to help her attain her self-care goals? (Ch. 1. Into which position will the nurse place the client?, 3 During assessment, the nurse notes the client has limited movement of his lower extremities and sways when standing with feet together. Which of the following actions should the nurse take to maintain the client's skin integrity? a. Encourage the client to perform antiembolic exercises every 2 hr. MUSCULOSKELETAL ASSESSMENT INTRODUCTION. client is orientated to person, place, and time. Within 6 hours of being admitted A nurse is caring for a client who has limited mobility in their lower extremities. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is postoperative following abdominal surgery. Have the client use a trapeze bar when changing position. Perform a musculoskeletal assessment. This tool will allow the client to shift their weight Study with Quizlet and memorize flashcards containing terms like a nurse is evaluating a client after injury to the wrist. ) Positioning the chair slightly behind the nurse so that the seat faces the client's bed. Self-care A nurse is caring for a client who has an electrical burn. Palpate joints for pain, swelling, change in temperature, and range of motion. Neuro Assessment B. maintain the client in high-fowler's position The nurse will take the precaution of using an electric razor when assisting the client with shaving. The nurse is providing care for an older adult man whose diagnosis of dementia has recently led to urinary incontinence. Pulselessness Pallor Reflexes Sensation Movement, The nurse is caring for a client in the emergency department with Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to administer a cleansing edema to a client. Which of the following interventions should the nurse plan to implement? A. Before attempting to move a client up in bed, the nurse should review the medical record and the nursing plan of care. place a donut-shaped cushion in the client's chair c. Limited joint mobility 4. The nurse is caring for an elderly client with a fractured hip who is on bed rest. B. Reported pain lvl E. 1. Joint contracture A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. b. Increased myelinization C. Client can move all extremities. Disuse osteoporosis C. The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. com A nurse is caring for a client who has limited mobility in their lower extremities. The nurse identifies that the client is at risk for what? Stroke Falls Pressure ulcers Impaired mobility a. Which action should the nurse include in the plan of care to help maintain skin integrity? A. , The nurse puts elastic stockings on a client following major abdominal Study with Quizlet and memorize flashcards containing terms like 1. Pulling up on the trapeze 2. Massage reddened areas over bony prominences. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who is on bed rest for a month. Bilateral breath Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with diabetes mellitus who is scheduled to have a right below-knee amputation. Hold the container of solution 30 cm (12 in) above the anus. Which of the following actions should the nurse take to prevent skin breakdown? O Place the client in high-Fowler's position. 3. It can be a temporary, permanent or worsening problem and has the potential to create more significant issues such as skin breakdown, infections, falls, and social isolation. The nurse understands these symptoms to be suggestive of which of the following findings?, A client is hospitalized when presenting to the emergency department with right-sided weakness. Which of the following actions should the nurse take?, A hospice nurse is reviewing religious practices of a A nurse in a long-term care facility is caring for an older adult client and notes their muscles have become smaller and weaker. How should the nurse assess body alignment in this client? Select all that apply. hemodynamic changes related to tilt table positioning 2. cerebellum and midbrain. Peripheral neuropathy 5. The client spends most of his day in a reclining chair. Modify assessment techniques to reflect variations across the life span. 2. Which of the following actions should the nurse take to prevent skin breakdown? 1) Place the client in a prone position for most of the day 2) Encourage the client to frequently change positions 3) Apply pressure to bony prominences with the palm of the hand 4 May 20, 2024 · A nurse is caring for a client who has limited mobility in their lower extremities. Message bony prominences. Performing active range of Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is postoperative following abdominal surgery Exhibit 1 Nurse's Notes: 1100: Client received from PACU; Initial vital signs recorded. administration 27. Place a turn sheet on the bed. The inability to move freely can affect a client’s ability to perform ADLs and self-care tasks. Reposition the client every 4 hr. Which of the following actions should the nurse take to prevent skin breakdown? 1) Reposition the client every 2 hours 2) Apply lotion to the client's skin 3) Encourage the client to sit for long periods of time 4) Use a pressure-relieving mattress View Fundamentals_Proctored_2020-33. Request that a respiratory therapist discuss the technique for incentive spirometry. 13. This service began with the client's admission to the hospital. Abdominal Nov 2, 2023 · To prevent skin breakdown in patients with limited mobility, a nurse should regularly reposition the patient, keep the skin clean and dry, use pressure-relieving devices, provide nutritional support, and educate the patient about their care. medulla oblongata and Oct 10, 2023 · A nurse is caring for a client who has limited mobility in his lower extremities. Study with Quizlet and memorize flashcards containing terms like A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. Psoriasis 2. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with a recent lower extremity injury. Study with Quizlet and memorize flashcards containing terms like While conducting an assessment, the nurse concludes that a client is at risk for developing a deep venous thrombosis. The nurse assesses which factors that can put this client at risk for amputation? Select all that apply. Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. Which action should the nurse take?, A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What are some actions that the nurse should take to prevent skin breakdown? An 86-year-old woman is admitted to the unit with chills and a fever of 104 degree F. The nurse is caring for a client with multiple areas of skin breakdown on the back. A client with right sided hemiparesis has limited mobility. You are the nurse caring for a Jan 18, 2024 · A nurse is caring for a client who has limited mobility in his lower extremities. Sarcopenia B. Explanation: A nurse caring for a client with limited mobility in their lower extremities can take Study with Quizlet and memorize flashcards containing terms like A nurse is communicating with a client who has aphasia after having a stroke. Exhibit 1: Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination. A medic is caring for a client who has limited mobility in his lower extremities. She has been experiencing increased nausea and vomiting associated with treatment. Prioritizing interventions to improve mobility and providing assistive devices is crucial. Explanation: Positioning the arms across the chest improves assistance, reduces friction, and prevents hyperextension of the neck. Flexing and extending the feet 3. A. expected, unexpected, or unrelated to clients fracture?, A nurse is caring for a client who has undergone an open reduction internal fixation to correct a fracture. correct action is to B)apply pressure-relieving cushions Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with diabetes mellitus who is scheduled to have a right below-knee amputation. In which position will the nurse choose to place the client to improve arterial oxygenation?, 2. massage reddened areas over bony prominences d. Place a donut-shaped cushion in the client's chair. Which of the following pieces of information should the nurse include?, as a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following interventions should the nurse identify as a priority?, A nurse is contributing to the plan of care for a client who has COPD. which assessment finding demonstrates an injury to the range of motion?, a nurse is caring for a client with a cast on the right forearm. Restrict the client's fluid intake. The nurse can request that another team member discuss the use of the spirometer to see if that team member can encourage the client to use it; however, this is not the priority action that the nurse should take. To prevent self-injury, which of the following actions should the nurse take when lifting?, a nurse is evaluating a client's use of a cane. When caring for a client with limited mobility of the lower extremities, the nurse should be careful not to damage the skin or pressure ulcers. What is the result of this decrease? A. GI Assessment F The nurse is planning care for a client who has limited bed mobility. Peripheral vascular disease 6 Study with Quizlet and memorize flashcards containing terms like A nurse is planning an in-service training session about nutrition. Bilateral breath . The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. Bony deformity 3. Study with Quizlet and memorize flashcards containing terms like A client is admitted with weakness, expressive aphasia, and right hemianopia. Keep the container of solution at a level to maintain client comfort. The client's family asks the nurse for information about this type of care. Sep 17, 2023 · In caring for a client who has limited mobility in his lower extremities, the nurse needs to consider strategies for preventing skin breakdown, which is a common issue in such cases. What nursing intervention should be most appropriate to address the nursing diagnosis? Use pressure-relieving devices when the client is in bed or in a Study with Quizlet and memorize flashcards containing terms like As adults age, peripheral nerve function and impulse conduction decrease. The brain MRI reveals an infarct. Which of the following actions should the nurse take to maintain the client's skin integrity? A. With the clients permission, the nurse is answering questions from the family about bis status. ) Placing the client's left leg in front of the right The nurse is providing care for several clients. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity? 1. For which client should the nurse anticipate an order for administering 1000 mg of aspirin? A) A 68-year-old client with rheumatoid arthritis who is experiencing hand pain B) A 5-year-old client who is experiencing ankle pain after a fall from a horse C) A 38-year-old client who is experiencing headache pain after a skiing accident D) A 70-year Study with Quizlet and memorize flashcards containing terms like A nurse in a long term care facility is reviewing prescriptions for a client receiving mechanical ventilation. Maintain the client in high-Fowler's position. which of the following responses should the nurse make? he is doing well, although he might be in the hospital for some time he has an electrical burn. When planning this patients care, what intervention should the nurse avoid? A) Scheduled toileting B) Indwelling catheter C) External condom catheter D) Incontinence pads, 2. Which nursing interventions would be included on the plan of care? a)Provide only passive range of motion (ROM), and decrease stimulation. he is stable, and we will update you with any changes he has an electrical burn, which A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. b)Have the client lie as still as possible, and give adequate pain medication. Stand at the head of the bed to pull the client up. Among the options provided, having the client use a trapeze bar when changing positions is the most suitable. Which of the following actions should the nurse take to prevent skin breakdown? A nurse is caring for a client who has limited mobility in their lower extremities. The nurse is providing care for several clients. Which of the following physiological responses to prolonged immobility should the nurse expect?, A nurse is reinforcing teaching with a young adult client who has a family history The nurse is providing care for several clients. the client is being evaluated today for a potential sprain in the right ankle. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate. Oct 25, 2021 · Impaired physical mobility is a common nursing diagnosis that is often multifactorial. Petechiae, which are small red or purple spots on the skin, is associated with severe thrombocytopenia (low platelet count), indicating an increased risk of bleeding. What should the nurse do?, Which statement reflects nursing management of the client with expressive aphasia? and more. Find step-by-step Health solutions and your answer to the following textbook question: A nurse is caring for a client who has limited mobility in his lower extremities. ) The client capillary refill less than 3 sec in one lower extremity & 4 sec in the other The client w/ sharp, stabbing pain in the right lower extremity only when walking The client w/ cyanosis of the right lower extremity The client w/ bilateral lower extremity edema but slightly greater in the Jan 28, 2024 · Final answer: To prevent skin breakdown in a patient with limited mobility, a nurse should apply pressure-relieving cushions. The client has been prescribed hip precautions. Which of the following actions should the nurse take first? A. A client who has been lying prone reports shortness of breath and a sensation of choking. -She has good have the client fold the arms across the chest. . " Client alert and oriented x 3. Which of the following explanations should the nurse provide? a. jvwzr dfoq fnwpsgd lppao zugy xdfvqw alqv ebyimj cbaz cqc