Chapter 47 Flashcards
(Potter 1175) Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall. Fundamentals of Nursing, 8th Edition.
An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.)
1 B/P = 128/84
2 Respirations 26 per minute on room air
3 HR 114
4 Crackles heard on auscultation
5 Pain reported as 3 on scale of 0 to 10 after medication.
2, 3,4
Respirations 26 per minute on room air, HR 114, and Crackles heard on auscultation
A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, “It hurts when I try to breathe, and I can’t catch my breath.” Your first action is to:
1 Call the health care provider to report this change in condition.
2 Give the patient a paper bag to breathe into to decrease her anxiety.
3 Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen.
4 Explain that this is normal after such trauma and administer the ordered pain medication.
- Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen
The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to:
1 Prevent varicose veins.
2 Prevent muscular atrophy.
3 Ensure joint mobility and prevent contractures.
4 Promote venous return to the heart.
4.
A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education?
1 “I usually go swimming with my family at the YMCA 3 times a week.”
2 “I need to ask my doctor if I should have a bone mineral density check this year.”
3 “If I don’t drink milk at dinner, I’ll eat broccoli or cabbage to get the calcium that I need in my diet.”
4 “I’ll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill.”
4 “I’ll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill.”
The patient at greatest risk for developing multiple adverse effects of immobility is a:
1 1-year-old child with a hernia repair.
2 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA).
3 51-year-old woman following a thyroidectomy.
4 38-year-old woman undergoing a hysterectomy.
2 80-year old woman who has suffered a hemorrhagic cerebrovascular accident (CVA)
An older adult who was in a car accident and fractured his femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time?
1 Chronic pain
2 Impaired skin integrity
3 Risk for ineffective cerebral tissue perfusion
4 Risk for activity intolerance
4 Risk for activity intolerance
A patient had a left-sided cerebrovascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore nasogastric (NG) tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately?
1 Pale yellow urine
2 Unilateral neglect
3 Slight movement noted on the R side
4 Coffee ground–like aspirate from the feeding tube
- Coffee ground like aspirate from the feeding tube
A home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a quad-cane. Which of the following must be corrected or removed for the patient’s safety? (Select all that apply.)
1 The rubber mat in the walk-in shower
2 The three-legged stool on wheels in the kitchen
3 The braided throw rugs in the entry hallway and between the bedroom and bathroom
4 The night-lights in the hallways, bedroom, and bathroom
5 The cordless phone next to the patient’s bed
2,3
The three-legged stool on wheels in the kitchen and the braided throw rug in the entry hallway and between the bedroom and bathroom
The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. The nurse would recommend which of the following menus?
1 Cream of broccoli soup with whole wheat crackers and tapioca for dessert
2 Hamburger on soft roll with a side salad and an apple for dessert
3 Low-fat turkey chili with sour cream and fresh pears for dessert
4 Chicken salad on toast with tomato and lettuce and honey bun for dessert
1 Cream of broccoli soup with whole wheat crackers and tapioca for dessert
Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.)
1 Patient’s weight
2 Patient’s level of cooperation
3 Patient’s ability to assist
4 Presence of medical equipment
5 24-hour calorie intake
- 1, 2, 3, 4;
24- hour calorie intake is not correct
A patient of any age can develop a contracture of a joint when:
1 The adductors muscles are weakened as a result of immobility.
2 The muscle fibers become shortened because of disuse.
3 The calcium-to-phosphorus ratio becomes disrupted.
4 There is a deficiency in vitamin D.
- 2
The muscle fibers become shortened because of disuse
Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would reduce this risk? (Select all that apply.)
1 Repositioning patient every 1 to 2 hours while awake
2 Using an objective, valid scale to assess patient’s risk for pressure ulcer development
3 Using a device to relieve pressure when patient is seated in chair
4 Teaching patient how to shift weight at regular intervals while sitting in a chair
5 A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes
- 2, 3, 4, 5
Repositioning patient every 1 to 2 hours while awake is incorrect
Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher?
1 The patient is 5 feet 6 inches and weighs 120 lbs.
2 The patient speaks and understands English.
3 The patient received an injection of morphine 30 minutes ago for pain.
4 You feel comfortable handling a patient of his size and with his level of cooperation.
- 3
The patient received an injection of morphine 30 minutes ago for pain.
A patient with left-sided weakness asks his nurse, “Why are you walking on my left side? I can hold on to you better with my right hand.” What would be your best therapeutic response?
1 “Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you.”
2 “Would you like me to walk on your right side so you feel more secure?”
3 “Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side.”
4 “By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint. (
- 4
“by walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.”
Which is an outcome for a patient diagnosed with osteoporosis?
1 Maintain serum level of calcium.
2 Maintain independence with activities of daily living (ADLs).
3 Reduce supplemental sources of vitamin D.
4 Reverse bone loss through dietary manipulation.
- 2
Maintain independence with activities of daily living (ADL)
Range of motion (ROM)
is the maximum amount of movement available at a joint in one of the three planes
Assessment of patient mobility focuses on ROM, gait, exercise and activity tolerance, and body alignment.
Mobility
Extension
Return head to erect position
anthropometric measurements
Body measures of height, weight, and skinfolds to evaluate muscle atrophy.
anaphylactic reactions
Hypersensitive condition induced by contact with certain antigens.
Adverse effect:
Harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention.
Adduction
Movement of a limb toward the body.
