Module 6 Flashcards

1
Q

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed?

A

When assisting the client from the bed into a wheelchair, the nurse would take position near the client’s hip, with legs shoulder width apart and one foot near the head of the bed. This ensures that the nurse’s center of gravity is placed near the client’s greatest weight to assist the client to a sitting position safely.

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2
Q

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response?

A

“To preserve the client’s functional ability to grasp and pick up objects.”

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3
Q

What do trochanter rolls do?

A

Trochanter rolls prevent the legs from rotating outward.

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4
Q

What do foot boards do in regard to pt positioning?

A

Foot boards prevent foot drop

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5
Q

What is the purpose of side rails?

A

Side rails help a weak client turn independently and protect the client from falling out of bed.

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6
Q

What is a benefit of regular exercise over time?

A

Regular physical activity over time results in cardiovascular conditioning and therefore decreased heart rate. Regular exercise increases circulating fibrinolysin that serves to break up small clots, thus decreasing the risk for blood clots. Over time, regular exercise leads to improved pulmonary function, including decreased work of breathing. Venous return is improved when contracting muscles compress superficial veins and push blood back to the heart against gravity.

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7
Q

Using proper body mechanics, which motions would the nurse make to move an object?

A

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

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8
Q

The nurse adjusts a client’s bed to a comfortable working height in order to turn the client. What would be the nurse’s next action?

A

When turning a client in bed, the nurse would use a friction-reducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Pushing the client to the opposite side of the bed is not good for back safety. Consult a Safe Patient Handling algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client.

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9
Q

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?

A

When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client’s weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down, if fatigued.

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10
Q

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?

A

When I lift and carry a heavy box of supplies I will keep it at arm’s length from my body.

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11
Q

The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway?

A

Upright
Fowler
Semi-Fowler

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12
Q

The nurse is working to increase functional ability of a client who is bedbound. Which assistive technique should the nurse prioritize in the plan of care?

A

trapeze bar

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13
Q

The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason?

A

Acts to prevent injury to the client and/or nurse

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14
Q

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?

A

transfer belt

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15
Q

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?

A

trochanter rolls

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16
Q

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client?

A

moving the bedroom to the ground floor
removing clutter from the floor
placing nightlights in the bathroom and hallways

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17
Q

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

A

“To prevent your legs from rotating outward.”

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18
Q

Which type of mobility aid would be most appropriate for a client who has poor balance?

A

a cane with four prongs on the end (quad cane)

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19
Q

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client’s weight?

A

Shift their weight back and forth, from back leg to front leg.

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20
Q

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?

A

When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair.

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21
Q

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

A

Sims’

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22
Q

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

A

the 24-month-old child who is unable to walk unassisted

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23
Q

Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer?

A

If the client is in pain, administer the prescribed analgesic sufficiently in advance of the transfer to allow the client to participate in the move comfortably. Clients should be encouraged to assist in their own transfers. During any client-transferring task, if any caregiver is required to lift more than 35 lb (16 kg) of a client’s weight, then the client should be considered to be fully dependent and assistive devices should be used for the transfer. Handling aids should be used whenever possible to help reduce the risk of injury to the nurse and client.

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24
Q

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity?

A

pull the shoulder blade forward and out from under the client

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25
Q

When logrolling a client, the nurse should use supportive devices in turning the client in order to:

A

maintain the natural alignment of the client’s body.
Explanation:
Logrolling is a technique used for turning clients who have had surgery or an injury involving the back or spine. It maintains spinal alignment, thus preventing injury. It is not performed for the purpose of maximizing the client’s participation or preventing blood stasis.

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26
Q

When moving a client up in bed with the assistance of another caregiver, the nurse should:

A

have the client fold the arms across the chest.

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27
Q

The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select?

A

risk for impaired skin integrity

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28
Q

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:

A

steps into the walker when walking.

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29
Q

A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate?

A

The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight.
Explanation:
During any client-transferring task, if the lift is more than 35 lb (16 kg) of a client’s weight, consider the client to be fully dependent and use assistive devices for the transfer. The nurse would encourage the client to help with the transfer if the client is able and can safely assist. Pain medication would not be indicated after the transfer unless a pain assessment indicated this action. The nurse would not grab and hold the client by the arms. This action could cause injury to the client.

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30
Q

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct?

A

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.
Explanation:
Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight alignment when the client is being turned. The nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement. The nurse should avoid twisting the client’s head, spine, shoulders, knees, or hips while logrolling. A chair is not used with logrolling.

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31
Q

It is appropriate for the nurse to recommend smoking cessation for clients with hypertension because nicotine

A

increases the heart rate, constricts arterioles, and reduces the heart’s ability to eject blood.

32
Q

The nurse is caring for an elderly client with a diagnosis of hypertension, who is taking several antihypertensive medications. Which safety precaution is the nurse most likely to reinforce?

A

Changing positions slowly related to possible hypotension
Explanation:
The elderly have impaired cardiovascular reflexes and thus are more sensitive to the extracellular volume depletion caused by diuretics and to the sympathetic inhibition caused by adrenergic antagonists. The nurse teaches clients to change positions slowly when moving from a lying or sitting position to a standing position. This will help prevent falls.

33
Q

Which of the following is the nurse most correct to recognize as a direct effect of client hypertension?

  • Renal dysfunction resulting from atherosclerosis
  • Anemia resulting from bone marrow suppression
  • Hyperglycemia resulting from insulin receptor resistance
  • Emphysema related to poor gas exchange
A

Renal dysfunction resulting from atherosclerosis
Explanation:
The nurse is most correct to realize high blood pressure damages the arterial vascular system and accelerates atherosclerosis. The effect of the atherosclerosis impairs circulation to the kidney, resulting in renal failure

34
Q

According to the classification of hypertension diagnosed in older adults, hypertension that can be attributed to an underlying cause is termed

A

secondary.

35
Q

A nurse is educating about lifestyle modifications for a group of clients with newly diagnosed hypertension. While discussing dietary changes, which point would the nurse emphasize?

A

It takes 2 to 3 months for the taste buds to adapt to changes in salt intake. Knowing this may help the client adjust to reduced salt intake. The client should be advised to limit alcohol intake.

36
Q

Management of hypertension includes three of the following four goals, depending on the primary and secondary causes.

A

Impairing the synthesis of norepinephrine.
Modifying the rate of myocardial contraction.
Decreasing renal absorption of sodium.
Explanation:
Increasing the force of cardiac output would only increase peripheral resistance, thus increasing blood pressure. The other actions would all help regulate hypertension.

37
Q

A client, newly admitted to the nursing unit, has a primary diagnosis of renal failure. When assessing the client, the nurse notes a blood pressure (BP) of 180/100. The nurse knows that this is what kind of hypertension?

A

Secondary

38
Q

A client who was recently diagnosed with prehypertension is to meet with a dietitian and return for a follow-up with the cardiologist in 6 months. What would this client’s treatment likely include?

A

nonpharmacological interventions

39
Q

The nurse is instructing a client who is newly prescribed an antihypertensive medication. Which nursing instruction is emphasized to maintain client safety?

A

Sit on the edge of the chair and rise slowly.

40
Q

An older adult client visits the clinic for a blood pressure check. The client’s hypertension is not well controlled, and a new blood pressure medicine is prescribed. What is important for the nurse to teach this client about blood pressure medicine?

A

A possible adverse effect of blood pressure medicine is dizziness when you stand.
Explanation:
A possible adverse effect of all antihypertensive drugs is postural hypotension, which can lead to falls. Teaching should include tips for managing syncope and dizziness.

41
Q

A nurse is teaching about lifestyle modifications to a group of clients with known hypertension. Which statement would the nurse include in the education session?

A

Engage in aerobic activity at least 30 minutes/day most days of the week.

42
Q

The nurse is administering medications on a medical-surgical unit. A client is ordered to receive 40 mg oral nadolol for the treatment of hypertension. Before administering the medication, the nurse should

A

check the client’s heart rate.
Explanation:
Nadolol is a beta-blocker. A desired effect of this medication is to reduce the pulse rate in clients with tachycardia and elevated blood pressure (BP). The nurse should check the client’s heart rate (HR) before administering nadolol to ensure that the pulse is not less than 60 beats per minute.

43
Q

A client is being seen at the clinic for a routine physical when the nurse notes the client’s blood pressure is 150/97. The client is considered to be a healthy, well-nourished young adult. What type of hypertension does this client have?

A

Essential (primary)

44
Q

A client with high blood pressure is receiving an antihypertensive drug. When developing a client teaching plan to minimize orthostatic hypotension, which instruction should the nurse include?

A

“Flex your calf muscles, avoid alcohol, and change positions slowly.”
Explanation:
Measures that minimize orthostatic hypotension include flexing the calf muscles to boost blood return to the heart, avoiding alcohol and straining at stool, changing positions slowly, eating a high-protein snack at night, wearing elastic stockings, and holding onto a stationary object when rising. Although the client should rest between demanding activities and consume plenty of fluids and fiber (contained in fruits and vegetables) to maintain a balanced diet, these measures don’t directly relieve orthostatic hypotension.

45
Q

When measuring the blood pressure in each arm of a healthy adult client, the nurse recognizes that which statement is true?

A

Pressures should not differ more than 5 mm Hg between arms.

46
Q

A 77-year-old client presents to the local community center for a blood pressure (BP) screening; BP is recorded as 180/90 mm Hg. The client has a history of hypertension but currently is not taking the prescribed medications. Which question is most appropriate for the nurse to ask the client first?

A

“Can you tell me the reasons you aren’t taking your medications?”
Explanation:
It is important for the nurse to first ascertain why the client is not taking prescribed medications. Adherence to the therapeutic program may be more difficult for older adults. The medication regimen can be difficult to remember, and the expense can be a challenge. Monotherapy (treatment with a single agent), if appropriate, may simplify the medication regimen and make it less expensive.

47
Q

Papilledema is a fairly common symptom of elevated blood pressure. The best way to detect this condition is through:

A

ophthalmic examination.
Explanation:
Papilledema is an edema of the optic nerves, and thus needs an ophthalmic examination for detection.

48
Q

A client experiences orthostatic hypotension while receiving furosemide to treat hypertension. How will the nurse intervene?

A

Instruct the client to sit for several minutes before standing.
Explanation:
To minimize the effects of orthostatic hypotension, the nurse should instruct the client to rise slowly, such as by sitting for several minutes before standing. Administering I.V. fluids would be inappropriate (unless the client were dehydrated) because doing so would counteract the effects of furosemide and could cause fluid imbalance. Administering a vasodilator, isosorbide, would further reduce the client’s blood pressure, worsening orthostatic hypotension. Inserting an indwelling urinary catheter would make it easier to monitor urine output, but wouldn’t minimize the effects of orthostatic hypotension.

49
Q

A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. What are risk factors for cardiovascular problems in clients with hypertension?

A
Smoking
 Diabetes mellitus
 Physical inactivity
  Explanation:
Risk factors for cardiovascular problems in clients with hypertension include smoking, dyslipidemia, diabetes mellitus, impaired renal function, obesity, physical inactivity, age, and family history.
50
Q

What are postural reflexes and why are they important?

A

They resist displacement of the body caused by gravity or acceleratory forces and do the following:

  1. maintain upright posture of the body
  2. Restore posture if disturbed
  3. Provide suitable background for performance of voluntary movements
51
Q

Why does Fowler’s position support cardiac and respiratory function?

A

Allows abdominal organs to drop in this position and provides maximal space in the thoracic cavity

52
Q

What are some cardiovascular benefits of exercise?

A
  1. increased heart efficiency
  2. decreased heart rate and blood pressure
  3. increased blood flow to all body parts
  4. improved venous return
  5. increased circulating fibrinolysis (substance that breaks up small clots)
53
Q

What are some benefits of exercise on the respiratory system?

A
  1. increased alveolar ventilation
  2. decreased work of breathing
  3. improved diaphragmatic excursion
54
Q

Benefits of exercise on the musculoskeletal system?

A
  1. increased muscle efficiency (strength) and flexibility
  2. increased coordination
  3. reduced bone loss
  4. increased efficiency of nerve impulses
55
Q

What are some risks for a cardiac event that are r/t exercise?

A
  1. man >45 yrs; woman >55 yrs
  2. family history of heart disease before 55 in men and 65 in women
  3. current smoker or quit smoking in the past 6 mo
  4. Not exercised for atleast 30 min. 3 days a week for 3 mo. or more
  5. overweight or obese
  6. High BP or high cholesterol
  7. Impaired glucose tolerance
56
Q

What are some things we would assess for mobility?

A
General ease of movement 
alignment 
joint structure and function 
muscle mass, tone, and strength 
endurance
57
Q

This is considered the normal range of BP

A

Systolic: <120
Diastolic: <80

58
Q

This is considered elevated BP

A

Systolic: 120-129
Diastolic: <80

59
Q

This is considered Hypertension Stage 1:

A

Systolic: 130-139
OR
Diastolic: 80-89

60
Q

This is considered hypertension Stage 2:

A

Systolic: < or equal to 140
OR
Diastolic: < or equal to 90

61
Q

This is considered a hypertensive crisis:

A

Systolic: < 180
And/ OR
Diastolic: < 120

62
Q

What is primary Hypertension and how prevalent is it?

A

Accounts for about 95% of hypertension and occurs when the cause can not be determined

63
Q

What is secondary hypertension?

A

Hypertension caused by another disease, usually endocrine like Cushing syndrome (too many cortisol/ aldosterone made)

64
Q

What are some risk factors for hypertension?

A
Stress 
high salt diet- water follows sodium and salt causes constriction by muscle constriction 
obesity 
physical inactivity 
low potassium diet 
sleep apnea 
too much alcohol 
african american descent 
Male b/c estrogen protects women
65
Q

Why can older people have a higher target BP of 150/90?

A

Lower target may increase risk for orthostatic hypotension increasing the risk for falls and fractures

66
Q

What does glucose in the urine indicate?

A

Diabetes mellitus

67
Q

What does an increased BUN and creatinine level on a BMP incidcate?

A

kidney disease

68
Q

What might a lipid profile show that would contribute to an MI or stroke?

A

high level cholesterol, LDL, triglycerides and low HDL

69
Q

How does as 12 lead EKG help assess hypertension?

A

it provides information on the rhythm of the heart

70
Q

What does an echocardiography check for?

A

remodeling or hypertrophy of the heart (e.g. L ventricular hypertrophy)

71
Q

What is a dietary intervention for hypertension?

A

DASH diet- dietary approach to stop hypertension

focuses on vegetables, fruits, low fat dairy, whole grains, fish, poultry, lean meats and nuts

72
Q

How much sodium should a patient with hypertension have per day?

A

2400 MG or 1 & 1/4 tsp

73
Q

What is the recommended amount of activity per week?

A

150 minutes a week of moderate-intensity aerobic exercise

2 days a week of muscle strength training

74
Q

What would be considered moderate alcohol consumption?

A

1 drink for women, 2 for men

12 oz beer, 8 oz mal liquor, 5 oz wine, 1.5 oz distilled spirits/ liquor

75
Q

Why does an ACE inhibitor cause a cough?

A

B/c it blocks an enzyme produced in the lungs (bradykinin)

76
Q

What is the difference between a hypertensive emergency and a hypertensive urgency?

A

Emergency: life threatening requires immediate tx to prevent target organ damage (MI, intracranial hemorrhage)
Tx: IV diuretics
Urgency: BP very elevated but no evidence of target organ damage
tx: fast acting oral medication- labetalol (Alpha & beta blocker) and nafitapine (calcium channel blocker)