- A 52-year-old client with multiple sclerosis is admitted to acute care for a urinary tract infection. The client has intermittent lower extremity weakness (strength 3/5 today), spasticity, limited hip abduction, and reports muscle tightness rated 4/10. What is the nurse's PRIORITY intervention for this client's mobility needs?
Answer: Implement scheduled stretching and range of motion exercises, moving joints slowly to the point of resistance and not forcing movement
This question tests clinical judgment related to mobility and positioning in a client with multiple sclerosis and spasticity. The priority concern is maintaining joint flexibility and reducing muscle tightness to prevent contractures and enhance function. Implementing scheduled stretching and range of motion exercises, moving joints slowly to the point of resistance and not forcing movement, is the best choice as it alleviates spasticity, improves range, and minimizes pain without causing injury. Option B is incorrect because bed rest worsens weakness; option C is lower priority as reflexes do not preclude exercises; option D is incorrect since delegation requires oversight for safety. The decision-making principle is to use gentle, progressive range of motion for spastic limbs to promote mobility. This includes timing exercises when muscles are relaxed to maximize benefits. A transferable strategy is to assess spasticity levels daily and adjust exercise intensity, incorporating client feedback for personalized mobility care.
- A 70-year-old long-term care resident with advanced dementia is nonambulatory and requires a two-person assist for repositioning. Assessment reveals muscle strength 2/5 in lower extremities, contracture risk in the right hand, pain 2/10 at rest, and a stage 1 pressure injury on the right heel (non-blanchable erythema). Which positioning technique should the nurse use to prevent complications?
Answer: Float the heels off the bed using a pillow under the calves and maintain neutral ankle alignment
This question tests clinical judgment related to mobility and positioning in a nonambulatory resident with a heel pressure injury. The priority concern is offloading pressure from the heel to prevent progression of the stage 1 injury while addressing contracture risk. Floating the heels off the bed using a pillow under the calves and maintaining neutral ankle alignment is the best choice as it eliminates direct pressure, promotes healing, and supports proper positioning to avoid further complications. Option A is incorrect because a pillow under the heels still applies pressure; option C is incorrect as massaging can damage fragile tissue; option D is incorrect because tight wraps may impair circulation. The decision-making principle is to use offloading techniques for pressure-prone areas in immobile clients to enhance tissue integrity. This involves incorporating devices like pillows or boots to maintain alignment without compression. A transferable strategy is to conduct regular skin inspections and integrate pressure-relief positioning into care plans for all at-risk clients.
- A 60-year-old client with a recent right-sided ischemic stroke is admitted to an inpatient rehabilitation unit. The client has right arm muscle strength 1/5, limited active elbow extension, and reports no pain (0/10), but the right hand is beginning to show finger flexion tightness. What is the nurse's PRIORITY intervention for this client's mobility needs?
Answer: Initiate a schedule of passive range-of-motion exercises to the right upper extremity and position the hand with a splint or support to maintain functional alignment
This question tests clinical judgment related to mobility and positioning in stroke rehabilitation. The priority concern is preventing permanent hand contractures while the client still has potential for neurological recovery. Initiating passive ROM exercises and positioning with splint/support (A) is the best choice because early intervention prevents irreversible contractures and maintains functional hand position for potential recovery. Avoiding arm movement (B) guarantees contracture development; assessing circulation once per shift (C) delays crucial early intervention; delegating to UAP (D) is inappropriate for specialized neurological care. The decision-making principle is to begin contracture prevention immediately after stroke, as delays result in permanent disability. A transferable strategy is to implement positioning and ROM protocols within 24-48 hours of stroke to maximize functional recovery potential.
- A 57-year-old client with Guillain-Barré syndrome is in an acute care unit and is unable to move the legs. Assessment shows lower extremity strength 0/5, upper extremity strength 3/5, intact sensation, ankle plantar flexion beginning to tighten, and pain 1/10. Which action should the nurse take to improve client mobility?
Answer: Perform passive range of motion to all extremities and use positioning devices to maintain neutral ankle alignment and prevent foot drop
This question tests clinical judgment related to mobility and positioning in a client with Guillain-Barré syndrome and lower extremity paralysis. The priority concern is preventing foot drop and contractures through maintained alignment despite absent strength. Performing passive range of motion to all extremities and using positioning devices to maintain neutral ankle alignment and prevent foot drop is the best choice as it preserves joint function, supports circulation, and aids potential recovery. Option B is incorrect because active lifts are impossible; option C is incorrect as avoiding exercises increases risks; option D is incorrect since delegation requires supervision for accuracy. The decision-making principle is to initiate preventive range of motion and splinting early in paralytic conditions. This involves monitoring for tightening to adjust interventions. A transferable strategy is to assess neurological status and incorporate supportive devices into daily care for clients with motor deficits.
- A 79-year-old long-term care resident is bedbound after a recent hip fracture and has urinary incontinence. Assessment shows muscle strength 2/5 in both legs, limited hip movement due to pain rated 5/10, and intact skin except for blanchable redness on the coccyx. Which positioning technique should the nurse use to prevent complications?
Answer: Implement a turning schedule with at least every-2-hour repositioning and use moisture barriers while minimizing shear during turns
This question tests clinical judgment related to mobility and positioning in a bedbound resident with incontinence and hip fracture. The priority concern is preventing skin breakdown on the coccyx while managing pain and aspiration risk. Implementing a turning schedule with at least every-2-hour repositioning and using moisture barriers while minimizing shear during turns is the best choice as it reduces pressure, controls moisture, and prevents further erythema progression. Option A is incorrect because less frequent repositioning increases risk; option B is lower priority without addressing turning; option D is incorrect as prone positioning may not be tolerated and could increase discomfort. The decision-making principle is to combine frequent repositioning with skin protection strategies in incontinent, immobile clients. This includes using low-friction techniques to avoid shear injuries. A transferable strategy is to utilize risk assessment tools like the Norton Scale to guide positioning frequency and interventions for vulnerable populations.
- A 58-year-old client with an acute ischemic stroke has left-sided hemiplegia and is on bed rest in an acute care unit. Assessment shows left arm strength 0/5, left leg strength 1/5, flaccid tone, shoulder pain 4/10 with movement, and limited passive shoulder abduction due to discomfort. Which action should the nurse take to improve client mobility?
Answer: Perform passive range of motion to the affected extremities, supporting the shoulder and moving joints slowly through the available range
Passive range of motion, supporting the shoulder and moving slowly through the available range, is correct because it maintains joint flexibility, prevents contractures, and respects the client's shoulder pain. Delegating the same activity to unlicensed assistive personnel because it is basic daily living is wrong: a flaccid hemiplegic shoulder requires the nurse's assessment of joint support and tolerance before each movement. Avoiding movement until voluntary strength returns is also wrong because immobility increases the risk of contractures and does not protect the shoulder; supported passive motion done correctly does not worsen subluxation. Placing a pillow directly under the axilla is incorrect because it positions the shoulder in an internally rotated/adducted posture, which can increase pain rather than relieve it. The priority is early, supported, pain-conscious range of motion, not avoidance, blanket delegation, or improper positioning.
- An 81-year-old client with a history of rheumatoid arthritis is admitted to a medical unit for heart failure exacerbation. The client reports hand and wrist pain 7/10, has decreased grip strength (3/5), limited finger extension, and morning stiffness. Which positioning technique should the nurse use to prevent complications and support function?
Answer: Place rolled washcloths in the client's hands to maintain functional alignment and reduce risk of flexion contractures
Placing rolled washcloths in the client's hands is the correct positioning. It keeps the wrist and fingers in a neutral, supported posture, preserves available grip, and reduces the forces that lead to flexion contractures. Immobilizing both hands flat on the mattress may limit pain at first, but it does not maintain functional alignment and it promotes stiffness. The tight elastic wrap around the fingers can impair circulation and forces a prolonged extended posture, which is not safe functional support. Positioning the wrists in full flexion with pillows may decrease pain with extension temporarily, but it increases the risk of flexion contractures and reduces function. The goal is a supportive position that keeps the hand aligned and usable rather than immobilizing, compressing, or over-flexing it.
- A 69-year-old client is post-operative day 2 after open reduction and internal fixation of a right ankle fracture. The client is non–weight-bearing on the right leg, has pain 5/10, right leg strength 3/5 due to immobilization, and is eager to walk to the bathroom. Which action should the nurse take to improve client mobility?
Answer: Teach and assist the client to use a walker while maintaining non–weight-bearing status and to pivot on the unaffected leg
This question tests clinical judgment related to mobility and positioning in a post-operative ankle fracture client. The priority concern is facilitating safe ambulation while adhering to non-weight-bearing status to promote healing and independence. Teaching and assisting the client to use a walker while maintaining non–weight-bearing status and to pivot on the unaffected leg is the best choice as it ensures fracture stability, reduces pain, and supports mobility without compromising recovery. Option B is incorrect because any weight-bearing violates orders; option C is incorrect as hopping without devices risks falls; option D is incorrect since delaying ambulation leads to deconditioning. The decision-making principle is to employ assistive devices and techniques that respect weight-bearing restrictions for orthopedic clients. This involves demonstrating proper use to prevent secondary injuries. A transferable strategy is to evaluate pain and strength before mobility, providing education on device use to foster safe self-care in similar scenarios.
- A 67-year-old client is 8 hours post-operative after coronary artery bypass graft surgery and is on telemetry in an acute care unit. Assessment shows pain 6/10 at the sternotomy site, lower extremity strength 4/5, dizziness when sitting up, and oxygen saturation 95% on 2 L/min nasal cannula. Which action should the nurse take to improve client mobility?
Answer: Assist the client to change positions gradually (supine to sitting to standing), monitor symptoms, and ambulate with assistance as tolerated
This question tests clinical judgment related to mobility and positioning in a post-operative CABG client. The priority concern is facilitating safe mobility to prevent deconditioning and complications while addressing dizziness and pain. Assisting the client to change positions gradually (supine to sitting to standing), monitoring symptoms, and ambulating with assistance as tolerated is the best choice as it promotes hemodynamic stability, reduces orthostatic risks, and enhances recovery. Option B is incorrect because independent ambulation risks falls; option C is incorrect as bed rest worsens deconditioning; option D is incorrect since delegation overlooks the need for nursing assessment. The decision-making principle is to use progressive positioning changes with monitoring in post-surgical clients to build tolerance. This involves assessing symptoms at each stage to ensure safety. A transferable strategy is to incorporate vital sign checks and symptom evaluation into mobility progression plans for all post-operative clients.
- A 46-year-old client with a spinal cord injury at T6 is admitted to an inpatient rehabilitation unit. The client has paraplegia with lower extremity strength 0/5, intact upper extremity strength 5/5, no lower extremity sensation, and reports no pain. Which action should the nurse take to improve client mobility?
Answer: Perform passive range of motion of the hips, knees, and ankles daily and use footboards or splints to maintain functional alignment
This question tests clinical judgment related to mobility and positioning in a client with paraplegia from spinal cord injury. The priority concern is preventing contractures and maintaining lower extremity alignment in the absence of sensation and strength. Performing passive range of motion of the hips, knees, and ankles daily and using footboards or splints to maintain functional alignment is the best choice as it preserves joint mobility, prevents deformities, and supports future rehabilitation potential. Option B is incorrect because limiting movement exacerbates spasticity and contractures; option C is incorrect as delegation without instruction risks errors; option D is incorrect since pillows under knees promote flexion contractures. The decision-making principle is to employ regular range of motion and supportive devices for insensate limbs to mitigate immobility effects. This involves scheduling interventions consistently and monitoring for skin integrity. A transferable strategy is to collaborate with rehabilitation specialists to design mobility plans that include preventive positioning for long-term function.
- A 77-year-old long-term care resident is immobile due to advanced chronic obstructive pulmonary disease and generalized weakness. Assessment shows muscle strength 2/5, pain 3/10 in the shoulders, and developing redness on the scapulae; the resident slides down in bed frequently. Which positioning technique should the nurse use to prevent complications?
Answer: Use a drawsheet to lift and reposition the resident to reduce shear, keeping the head of bed as low as tolerated
The resident is at risk for shear and pressure injury from repeated sliding, and the reddened scapulae are an early warning sign. Using a drawsheet lets staff lift and reposition the body instead of dragging skin over the sheets, so friction and shear are reduced. Keeping the head of the bed as low as tolerated lessens the downward gravitational force that causes sliding. Pulling the resident up by grasping under the axillae uses the arms and shoulders as handles; this creates shear, increases shoulder pain, and does not protect the scapulae. Keeping the head of the bed at 90 degrees makes sliding worse and increases shear and pressure; a pillow under the knees does not fix that. Positioning the resident semi-prone on a flat bed without pillows does not reduce sliding or shear, and it can leave bony areas unsupported. Therefore, the best response is the drawsheet lift repositioned technique with the lowest tolerated head-of-bed position.
- A 52-year-old client with multiple sclerosis is hospitalized for a urinary tract infection and has decreased mobility. The client has bilateral lower-extremity muscle strength 3/5, ankle dorsiflexion limited to 5 degrees (normal approximately 20 degrees), and reports calf tightness 4/10 during movement. Which action should the nurse take to improve client mobility?
Answer: Apply foot-drop splints and perform active-assisted range-of-motion exercises to the ankles several times daily within tolerance
The priority is preventing ankle contractures and preserving functional dorsiflexion for safe ambulation in a client at risk for foot drop. Applying foot-drop splints maintains a neutral ankle position, and active-assisted range-of-motion exercises preserve joint flexibility and muscle extensibility when performed several times daily within the client's tolerance.
Placing pillows under the knees keeps the feet in a prolonged plantar-flexed position, which increases the risk of plantar flexion contracture and does not actively stretch the calf. Assessing the gait pattern for safety after discharge teaching is completed is too late — gait should be evaluated before and during teaching, and assessment alone does not improve mobility. Delegating ankle range-of-motion exercises to family members without nurse supervision is unsafe because family members lack the training to perform the exercises correctly, and unsupervised technique risks injury.
The correct action is proactive: use positioning devices and active-assisted exercises immediately to prevent contractures, rather than passive comfort, delayed assessment, or unsafe delegation.
- A 60-year-old client with Parkinson disease is hospitalized for pneumonia. The client has bradykinesia, shuffling gait, muscle rigidity, lower extremity strength 4/5, and reports fatigue; pain is 1/10. Which action should the nurse take to improve client mobility?
Answer: Encourage the client to take large steps and use a wide base of support, providing a walker and close standby assistance
This question tests clinical judgment related to mobility and positioning in a client with Parkinson disease and pneumonia. The priority concern is improving gait stability and reducing fall risk while managing bradykinesia and fatigue. Encouraging the client to take large steps and use a wide base of support, providing a walker and close standby assistance, is the best choice as it counters shuffling, enhances balance, and promotes safe mobility to aid pneumonia recovery. Option B is incorrect because close feet reduce stability; option C is lower priority as no new order is needed; option D is incorrect since assistive devices are essential for safety. The decision-making principle is to adapt mobility aids and techniques to specific gait impairments for safe ambulation. This includes providing cues and support to overcome movement disorders. A transferable strategy is to assess gait patterns and fatigue levels to select appropriate assistive devices and supervision for clients with neurological conditions.
- A 64-year-old client is 2 days post-operative after a knee arthroplasty and has a prescription for early ambulation. Current assessment shows pain 5/10 after medication, quadriceps strength 3/5 on the operative leg, and the client requires a walker; the client is slightly unsteady when standing. Which action should the nurse take to improve client mobility?
Answer: Assist the client to ambulate using a gait belt and walker, staying on the weaker side and allowing rest periods as needed
This question tests clinical judgment related to mobility and positioning in post-operative knee replacement. The priority concern is promoting safe ambulation while preventing falls and supporting healing through appropriate weight-bearing. Assisting with gait belt and walker, staying on the weaker side with rest periods (A) is the best choice because it provides necessary support, positions the nurse for optimal assistance, and allows for fatigue management. Independent ambulation (B) is unsafe with 3/5 strength and unsteadiness; hopping (C) violates weight-bearing protocols; waiting for zero pain (D) delays necessary mobility. The decision-making principle is to provide graduated assistance matching the client's current abilities while ensuring safety. A transferable strategy is to position yourself on the client's weaker side during ambulation and use appropriate assistive devices based on strength assessment.
- A 62-year-old client with right-sided weakness after a stroke is in long-term care and spends most of the day in bed. Assessment shows right arm strength 1/5, right leg strength 2/5, limited shoulder external rotation, and pain 3/10 with shoulder movement. Which action should the nurse take to improve client mobility?
Answer: Support the affected arm on pillows with the shoulder in neutral alignment and perform gentle passive range of motion without pulling on the arm
This question tests clinical judgment related to mobility and positioning in a stroke client with weakness and limited shoulder mobility. The priority concern is preventing shoulder complications like subluxation while improving range and reducing pain. Supporting the affected arm on pillows with the shoulder in neutral alignment and performing gentle passive range of motion without pulling on the arm is the best choice as it maintains positioning, enhances comfort, and preserves joint integrity. Option B is incorrect because dependent positioning worsens swelling; option C is incorrect as forceful motion causes injury; option D is incorrect since avoiding movement leads to stiffness. The decision-making principle is to use supportive elevation and gentle exercises for hemiplegic shoulders. This includes monitoring for pain to guide intensity. A transferable strategy is to integrate arm support into bedding routines and assess range regularly for progressive mobility in neurological clients.
- An 82-year-old long-term care resident with advanced dementia is bedbound and incontinent. Skin assessment shows nonblanchable erythema over the sacrum, and the resident has limited hip and knee movement with bilateral lower-extremity muscle strength 2/5; pain is 2/10 at rest. Which positioning technique should the nurse use to prevent complications?
Answer: Position the resident in a 30-degree lateral side-lying position with pillows to offload the sacrum and bony prominences
This question tests clinical judgment related to mobility and positioning for pressure injury prevention. The priority concern is preventing progression of the stage 1 pressure injury (nonblanchable erythema) while maintaining skin integrity. Positioning in a 30-degree lateral side-lying position with pillows to offload the sacrum (A) is the best choice because it redistributes pressure away from the affected area and other bony prominences. High-Fowler position (B) increases sacral pressure and shear forces; massaging reddened areas (C) can cause tissue damage; repositioning every 4 hours (D) is insufficient for a bedbound resident with existing skin breakdown. The decision-making principle is to offload pressure from areas showing early tissue damage while maintaining frequent position changes. A transferable strategy is to use the 30-degree lateral position and pillows to create air gaps under pressure points for at-risk clients.
- A 59-year-old client is 6 hours post-operative after a laparoscopic cholecystectomy. Assessment shows pain 4/10, lower extremity strength 5/5, mild nausea, and the client has not yet ambulated. Which action should the nurse take to improve client mobility?
Answer: Assist the client to sit at the edge of the bed and ambulate in the hallway with supervision as tolerated
This question tests clinical judgment related to mobility and positioning in a post-operative cholecystectomy client. The priority concern is initiating early mobility to prevent complications like atelectasis and thrombosis despite mild symptoms. Assisting the client to sit at the edge of the bed and ambulate in the hallway with supervision as tolerated is the best choice as it promotes lung expansion, circulation, and recovery while ensuring safety. Option B is incorrect because bed rest until flatus delays benefits; option C is lower priority as SCD removal may not be needed; option D is incorrect since bowel movement assessment does not delay mobility. The decision-making principle is to encourage progressive ambulation early post-surgery with supervision for stability. This includes addressing nausea to facilitate participation. A transferable strategy is to use post-op protocols that include mobility milestones, assessing tolerance through symptoms for individualized progression.
- A 72-year-old long-term care resident with a history of type 2 diabetes and limited mobility after a stroke requires extensive assistance to turn in bed. Assessment shows right-sided weakness (muscle strength 2/5), cannot reposition independently, reports sacral discomfort rated 3/10, and has non-blanchable erythema over the sacrum. Which positioning technique should the nurse use to prevent complications?
Answer: Reposition the client at least every 2 hours using a 30-degree lateral tilt with pillows to offload the sacrum
This question tests clinical judgment related to mobility and positioning in a client at risk for pressure injuries. The priority concern is preventing the progression of non-blanchable sacral erythema to a pressure ulcer due to immobility and comorbidities. Repositioning the client at least every 2 hours using a 30-degree lateral tilt with pillows offloads the sacrum effectively, reducing pressure and shear forces while promoting tissue perfusion and preventing further skin breakdown. Option A is incorrect because the supine position with head elevation does not offload the sacrum; option C is incorrect as massaging reddened areas can cause tissue damage; option D is incorrect because heating pads may burn fragile skin and are not indicated for erythema. The decision-making principle is to use evidence-based repositioning techniques that minimize pressure on bony prominences in immobile clients. This involves assessing skin integrity regularly and incorporating supportive devices like pillows to maintain alignment. A transferable strategy is to perform a Braden Scale assessment to identify mobility risks and develop a tailored turning schedule that balances comfort and prevention.
- A 45-year-old client with a C6 spinal cord injury is in an acute rehabilitation unit. The client has spasticity and limited active movement in the lower extremities (muscle strength 1/5), passive hip flexion to 80 degrees with resistance, and reports shoulder pain 3/10 from wheelchair transfers. Which action should the nurse take to improve client mobility?
Answer: Perform passive range-of-motion exercises to each lower-extremity joint slowly through the available range and stop with pain or marked resistance
The client with C6 spinal cord injury has spasticity, limited active movement, and pain from transfers; the priority is preserving joint mobility without causing harm. Performing passive range-of-motion exercises slowly through the available range and stopping with pain or marked resistance is correct because it maintains joint flexibility while respecting the limits imposed by spasticity and pain. Avoiding range-of-motion exercises until spasticity completely resolves is wrong because waiting leads to contractures and delays rehabilitation. Delegating passive range-of-motion exercises to unlicensed assistive personnel is wrong because this client's spasticity and pain require nursing assessment of resistance and discomfort; a standard sequence does not address that judgment. Requesting a provider order for soft restraints is wrong because restraints increase contracture risk and are a safety hazard, not a mobility intervention. The best action is the one that safely stretches joints and stops at the point of significant resistance, allowing the nurse to monitor the client's response.
- A 67-year-old client is 1 day post-operative after a total hip arthroplasty and is receiving opioid analgesics. The client reports pain 7/10 with movement, has right lower-extremity muscle strength 3/5, and becomes dizzy when sitting at the edge of the bed; blood pressure drops from 132/78 supine to 104/66 sitting. What is the nurse's PRIORITY intervention for this client's mobility needs?
Answer: Have the client dangle at the bedside until the dizziness resolves, then stand with assistance and a walker
This question tests clinical judgment related to mobility and positioning in a post-operative client with orthostatic hypotension. The priority concern is preventing falls while promoting safe progressive mobility after hip surgery. Having the client dangle at the bedside until dizziness resolves, then stand with assistance and a walker (B) is the best choice because it addresses orthostatic hypotension through gradual position changes and ensures safety with appropriate assistive devices. Ambulating immediately to the hallway (A) is unsafe given the client's dizziness and blood pressure drop; requesting PT evaluation (C) delays necessary mobility; delegating to UAP (D) is inappropriate for an unstable client requiring nursing assessment. The decision-making principle is to progress mobility gradually while monitoring for orthostatic changes, especially in post-operative clients receiving opioids. A transferable strategy is to always assess vital signs with position changes and allow time for physiologic adaptation before advancing mobility.
