Exam 5 (Ch 31 Test Questions)

Question 1

____ 1. A 15-year-old patient complains of left ankle pain after being tackled while playing football. He asks the nurse what tests he needs to have to determine if he has a strain or a fracture. How should the nurse reply?

1) “You don’t need an x-ray; I can tell by the way your ankle looks and feels whether you have a strain or fracture.”
2) “Sprains, strains, and fractures have similar symptoms at first; you will need an x-ray of the joint to be certain.”
3) “We will need to get a venous Doppler study to make sure that there is not a fracture.”
4) “An arterial Doppler will show whether the blood flow is interrupted, which is common for fractures but not for strains.”

Answer 1

2

Question 2

____ 2. The nurse caring for a frail, malnourished, immobile patient recognizes which of the following as the best treatment to protect the patient’s integument?

1) Offering the patient 6 small meals a day
2) Assisting the patient to sit in a chair 3 times a day
3) Turning the patient at least every 2 hours
4) Administering fluid boluses as directed by the healthcare provider

Answer 2

3

Question 3

____ 3. A 32-year-old male construction worker presents to the emergency department with complaints of headache, abdominal cramps, nausea, lightheadedness, and extreme fatigue. The patient states he started feeling ill while at the job site. The nurse gathers the following data: T = 99.8°F, P = 96, RR = 36, and BP = 136/72. The patient’s skin is cold and clammy, and the patient is having difficulty answering questions. He tells the nurse that he is “never sick,” takes no medicines, and has never been in the hospital. What additional information would be most useful in determining whether he is experiencing heat exhaustion (hyperthermia)?

1) Past medical and surgical history
2) Immunization history
3) Dietary intake for the past 24 hours
4) Environmental temperature

Answer 3

4

Question 4

____ 4. What action is most important in limiting the nurse’s risk of back injuries?

1) Use good body mechanics at all times.
2) Work with another nurse or an aide when lifting and turning patients.
3) Avoid manual lifting by using assistive devices as often as possible.
4) Develop a lift team at the clinical site.

Answer 4

3

Question 5

____ 5. The nurse is helping the patient to perform leg exercises after surgery to prevent thrombophlebitis. Which type of muscle is the patient using for these exercises?

1) Skeletal
2) Smooth
3) Cardiac
4) Slow-twitch fibers

Answer 5

1

Question 6

____ 6. A nurse is caring for a 25-year-old male quadriplegic patient. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?

1) Active ROM
2) Turning the patient every 2 hours
3) Passive ROM
4) Administering glucosamine supplements

Answer 6

3

Question 7

____ 7. A nurse is assessing a 74-year-old male patient for an exercise program to be offered at the local hospital. During the evaluation, the nurse notes the following vital signs: P = 72, RR = 16, BP = 132/70. After 3 minutes of moderate-intensity running on the treadmill, the patient becomes short of breath and states, “I have to stop. I can’t do this anymore.” The nurse measures his vital signs again: P = 152, RR = 40, BP = 172/98. She instructs him to rest. Vital signs return to baseline after 15 minutes. The nurse should recognize his symptoms as associated with which of the following?

1) COPD
2) Orthostatic hypotension
3) Limited activity tolerance
4) Impending respiratory failure

Answer 7

3

Question 8

____ 8. What is the correct method for turning an adult patient who recently sustained a spinal cord injury?

1) Ask the patient to assist with the turn by holding the side rails of the bed.
2) Place a draw sheet under the patient to assist with turning.
3) Request help from another nurse to perform the logrolling technique.
4) Use a mechanical lift for safe turning and protecting the nurse’s back.

Answer 8

3

Question 9

____ 9. An older patient with newly diagnosed osteoporosis asks the nurse to explain her health problem. Which of the following is the correct description of osteoporosis?

1) Loss of bone density that increases the risk of fracture
2) Degenerative joint disease that produces pain and decreased function
3) Chronic inflammatory joint disease that must be treated with steroids
4) Serious infection in the bone that must be treated with antibiotics

Answer 9

1

Question 10

____ 10. When caring for a patient with osteoporosis, which of the following is the most important action to take to minimize progression of the disease?

1) Take a calcium supplement twice a day.
2) Start a weight-bearing exercise program.
3) Avoid any strenuous activity.
4) Schedule regular healthcare checkups.

Answer 10

2

Question 11

____ 11. Which course of action taken by her patient with osteoporosis would allow the nurse to know that her teaching was effective?

1) Taking a calcium supplement every day and increasing her phosphorous intake
2) Participating in a low-impact aerobic exercise program at the gym three times a week
3) Using a wheelchair to reduce the risk of spontaneous fractures to her legs and feet
4) Seeking healthcare by scheduling a follow-up examination with bone density testing

Answer 11

2

Question 12

____ 12. Which of the following is true of synarthroses? Joints are:

1) Freely movable.
2) Capable of only limited movement.
3) Immovable.
4) Painful with movement.

Answer 12

3

Question 13

____ 13. A man has been admitted to the hospital unit with a medical diagnosis of chronic obstructive pulmonary disease (COPD). He is receiving supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assist him with his breathing?

1) Fowler’s position
2) Sims’ position
3) Lateral recumbent position
4) Lateral position

Answer 13

1

Question 14

____ 14. A nurse has been asked to design an exercise program with the goal of increasing a client’s muscular strength and endurance. Which exercise program would specifically focus on meeting that goal?

1) Flexibility training
2) Resistance training
3) Aerobic conditioning
4) Anaerobic conditioning

Answer 14

2

Question 15

____ 15. In order to achieve balance, body mass must be distributed around which point?

1) Center of body alignment
2) Center of balance
3) Center of gravity
4) Base of support

Answer 15

3

Question 16

____ 16. A frail 78-year-old man is admitted to the hospital after a fall at home resulted in a left hip fracture. After surgery, he is to begin ambulating with a walker but must avoid weight-bearing on his left lower leg. What is the best intervention to help him use his walker?

1) Aerobic exercise with deep breathing
2) Quadriceps and gluteal repetitions
3) Isometric toning of lower legs
4) Arm resistance training

Answer 16

4

Question 17

____ 17. Identify the most appropriate nursing diagnosis for promoting the safety of a frail, elderly patient after hip replacement surgery, who also has a history of emphysema.

1) Impaired Mobility related to weakness
2) Ineffective Breathing Pattern related to disease process
3) Activity Intolerance related to injury
4) Risk for Injury related to medical condition

Answer 17

4

Question 18

____ 18. What would be the most appropriate goal for a frail, elderly patient with a nursing diagnosis of Risk for Injury after hip surgery?

1) Remain free from injury or falls throughout hospital stay.
2) Increase activity tolerance by discharge from hospital.
3) Demonstrate effective breathing when ambulating.
4) Increase mobility by discharge from hospital.

Answer 18

1

Question 19

____ 19. A 16-year-old was hospitalized 3 weeks ago. He has been confined to bed throughout his hospital stay because of a crushed pelvis. His parents tell the nurse, “Our son is just staring off into space; he won’t talk to us. We are worried because he has not even listened to his music CDs, watched television, or played his video games for 2 days. That is so unlike him.” What is the best response the nurse can make?

1) “I will inform his physician and see if we can get your son started on an antidepressant.”
2) “He is at a critical time in his life; adolescents are often moody, and being in the hospital with an injury will only make that worse.”
3) “Your son had a major injury, and his immobility can cause feelings of isolation and depression.”
4) “He is bored because he has been in the hospital for 3 weeks; I’ll try to find some new activities for him.”

Answer 19

3

Question 20

____ 20. A healthy, 32-year-old man wants to start a fitness program to increase his muscle tone and muscle strength. What advice should the nurse offer him? “The United States Department of Health and Human Services recommends:

1) That exercising even once a week is beneficial.”
2) 30 minutes or more of moderate-intensity physical activity three times a week.”
3) 1 hour, three times a week of moderate-intensity physical activity.”
4) 150 to 300 minutes or more of moderate-intensity physical activity per week.”

Answer 20

4

Question 21

____ 21. A patient fractured her right ulna 8 weeks ago and has just had her cast removed. The orthopedic surgeon prescribes isometric exercises for the right arm. Which of the following exercises comply with the surgeon’s orders?

1) Place a foam ball in the right hand and squeeze; hold the squeeze position for 6 to 8 seconds, and repeat 5 to 10 times.
2) Grasping the right wrist with the left hand, move the right arm up, down, and side to side; hold each position for 6 to 8 seconds, and repeat 5 to 10 times.
3) Grasping the right wrist with the left hand, pull the right arm across the body; hold this position for 6 to 8 seconds, and repeat 5 to 10 times.
4) Press the right hand against a wall; hold this position for 6 to 8 seconds, and repeat 5 to 10 times.

Answer 21

4

Question 22

____ 22. A patient is on strict bed rest for 5 days. During this time he has not had a bowel movement; normally, he passes stools daily. He describes feeling bloated and uncomfortable. What information should the nurse give the patient when explaining constipation?

1) Immobility often causes constipation.
2) A stool softener daily will relieve the problem.
3) Use of a bedpan results in bloating and constipation.
4) A low-fiber diet will resolve the problem.

Answer 22

1

Question 23

____ 23. A patient is on strict bed rest for 5 days. During this time he has not had a bowel movement; normally, he passes stools daily. He describes feeling bloated and uncomfortable. A nursing diagnosis that would best address a patient who is on bed rest is Constipation related to:

1) Change in previous pattern.
2) Immobility.
3) Dietary intake.
4) Change in environment.

Answer 23

2

Question 24

____ 24. A 32-year-old paraplegic has been admitted to the hospital for antibiotic therapy to treat pneumonia. He lives independently and has developed strong upper-body strength to maximize his independence. Which transfer device should be used when transferring him from the bed to his wheelchair?

1) Mechanical lift
2) Transfer belt
3) Draw sheet
4) Transfer board

Answer 24

4

Question 25

____ 25. An 82-year-old patient is unsteady on her feet when transferring her position in the room. She reports feeling a little sore but has no complaints of weakness. What is the appropriate piece of equipment to use when helping her ambulate?

1) Crutches
2) Transfer belt
3) Cane
4) Walker

Answer 25

2

Question 26

____ 26. The nurse is helping an 82-year-old patient to ambulate in the hallway. Suddenly she states, “I feel so light-headed and weak,” as her knees begin to buckle. The nurse’s best action at this time would be to:

1) Assist the patient to slide down his leg as he guides her to a seated or lying position.
2) Grab her under the arms and hold her up as he calls for assistance.
3) Immediately release the transfer device and place a wheelchair behind the patient to prevent a fall.
4) Instruct the patient to grab the rail in the hallway while he calls for assistance.

Answer 26

1

Question 27

____ 27. According to the U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans, which of the following statements about the benefits of physical activity is correct?

1) The risks of physical activity outweigh the health benefits.
2) Physical activity in excess of recommendations for age is harmful.
3) Combining aerobic and muscle-strengthening activities promotes better health.
4) Lesser amounts of activity provide little to no health benefits.

Answer 27

3

Question 28

____ 28. When encouraging a fitness program for older adults, what must the nurse consider?

1) Older adults should engage in 75 to 150 minutes of moderate-intensity physical activity per week.
2) More than 150 minutes of moderate-intensity physical activity can be harmful to bones.
3) Structured calisthenics programs achieve greater health benefits for older adults.
4) Older adults at risk for falling should do activities that maintain or improve balance.

Answer 28

4

Question 29

____ 1. Which of the following body systems must interact to produce mobility and locomotion? Choose all that apply.

1) Digestive system
2) Muscles
3) Skeleton
4) Nervous system

Answer 29

2,3,4

Question 30

____ 2. Which of the following patients would you expect to be at risk for decreased activity? Choose all that apply.

1) Older adult who walks at the mall for physical activity
2) Someone living in a skilled nursing facility
3) Healthy adult who works as a computer programmer
4) Obese child who enjoys video games

Answer 30

2,3,4

Question 31

____ 3. A patient has started a fitness program. What program features illustrate that he has started a well-rounded program?

1) Flexibility
2) Isometric exercises
3) Resistance training
4) Aerobic conditioning

Answer 31

1,3,4

Question 32

____ 4. The nurse is instructing a patient about the need to replace fluid before, during, and after exercise in order to avoid dehydration. She should teach the patient to determine the amount of fluid to consume on the basis of:

1) Duration of exercise
2) Environmental temperature.
3) Level of fitness.
4) Degree of thirst.

Answer 32

1,2

Question 33

____ 5. Which of the following actions represent proper body mechanics for nurses providing care as well as teaching patients about safe body movements? Choose all that apply.

1) Stand with the body in alignment and erect posture.
2) Bend at the waist to lift heavy objects from the floor.
3) Use a wide base of support with your feet at shoulder width.
4) Keep objects close to your body when carrying them.

Answer 33

1,3,4