Chapter 23: Body Mechanics, Positioning and Moving |Fundamental Nursing Skills and Concepts 12th Edition, Timby
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Course
Fundamental Nursing Skills and Concepts
Institution
Fundamental Nursing Skills And Concepts
MULTIPLE CHOICE
1. The nurse explains to the unlicensed assistive personnel (UAP) that a shearing force is applied to the patient when:
a. a lifting sheet is used to move the patient to a stretcher.
b. the patient is pulled up in bed without being lifted.
c. the patient is seated in a wheelch...
Chapter 23: Body Mechanics,
Positioning and Moving
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. The nurse explains to the unlicensed assistive personnel (UAP) that a shearing force is
applied to the patient when:
a. a lifting sheet is used to move the patient to a stretcher.
b. the patient is pulled up in bed without being lifted.
c. the patient is seated in a wheelchair without a pressure cushion.
d. the patient is left in the supine position.
ANS: B
When a patient is pulled up in bed without being lifted up first, shearing force is
applied on the bony prominences and tissues of the back, which predisposes the
patient to a pressure ulcer.
DIF: Cognitive Level: Comprehension REF: k 262 OBJ: Theory #3
TOP: Positioning KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity: basic
care and comfort
2. A patient who has had spinal surgery is not permitted to bend at the waist or to sit in a
chair. To position the patient correctly in bed, the nurse:
a. places her in low- or semi-Fowlers position only.
b. uses logrolling to accomplish position changes from side to side.
c. moves the top half of her body first, then the middle, and finally her legs.
d. keeps her in a prone position to keep pressure off her back.
ANS: B
Logrolling, or moving the patients body as one unit, is used after back surgery or
trauma or when twisting or flexion must be avoided. Logrolling is accomplished using
a sheet and at least two persons.
DIF: Cognitive Level: Application REF: k 268 OBJ: Theory #3
TOP: Positioning KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity: basic
care and comfort
3. A patient in the skilled nursing facility has left-sided paralysis from a stroke several years
before, as well as generalized weakness. The nurse should ensure that which of the
following devices is in place to prevent flexion contractures?
a. A trochanter roll to keep her legs from turning outward
b. A rolled washcloth in the palm of her left hand or a hand splint
c. A protective vest to keep her sitting upright in the chair
d. A trapeze to permit her to change her position in bed more easily
ANS: B
, A hand splint or rolled cloth in the palm of her hand (along with range-of-motion
exercises) will help prevent flexion contractures of her hand. A trochanter roll
prevents outward rotation, not flexion.
DIF: Cognitive Level: Application REF: k 265, Skill 18-1 OBJ:
Theory #3 TOP: Positioning KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity: basic care and
comfort
4. When the post-stroke patient complains to the nurse, I don’t see why you are wasting
your time doing the passive range-of-motion exercises on my legs, the nurses most
informative response would be based on the knowledge that the exercises:
a. guarantee the prevention of pressure ulcers.
b. are part of the basic care given to all patients.
c. prevent contractures of the hips.
d. maintain the muscle mass of the limb prior to the stroke.
ANS: C
Passive range-of-motion (ROM) exercises, although not part of care given to all
patients, does prevent contractures in persons who are bedfast. ROM does not
guarantee the prevention of pressure ulcers but helps in the improved circulation of
the limbs.
DIF: Cognitive Level: Application REF: k 272, Skill 18-3 OBJ:
Clinical Practice #3 TOP: Effects of ROM KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
physiological adaptation
5. While the nurse is assisting a patient to ambulate, the patient suddenly says, Im dizzy. I
can’t stand up. As the patient begins to fall, the nurse should:
a. tell the patient, Look up, take some deep breaths, and stand up straight. You can
do it.
b. call for another nurse or aide to get a wheelchair to return the patient to her room
via wheelchair.
c. step behind the patient, grasp her around the waist or chest, and slide her down his
leg gently to the floor
d. look for the nearest chair and assist the patient to it.
ANS: C
A patient who is threatening to fall needs to be lowered to the floor to avoid injury
from a fall by allowing the patient to gently slide down the nurses leg to the floor.
DIF: Cognitive Level: Analysis REF: k 282, Skill 18-6 OBJ:
Clinical Practice #6 TOP: Patient Transfers KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
reduction of risk
6. A patient who is weak from inactivity following a car accident benefits most if the nurse
provides for:
a. passive range-of-motion (ROM) exercises to all joints four times a day.
b. active ROM exercises to arms and legs several times a day.
c. active ROM exercises with weights twice a day with 20 repetitions each.
d. passive ROM exercises to the point of resistance or pain and then slightly beyond.
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