Unit 7 Activity /Exercise CHAPTER 28& Sensory and Perception CHAPTER 31 Practice Questions

Question 1

What are the early signs of hypoxia?
A. irritability and restlessness
B. flushed skin
C. cyanosis
D. Purulent exudate

Answer 1

A. irritability and restlessness

Question 2

What is hypoxia?

Answer 2

decrease of oxygen to tissues in the body

Question 3

The pt is walking around the hallways as a form of excercise, What type of exercise is the pt indicating ?
A.Isometric
B. Isotonic
C. Anerobic
D.Compressive

Answer 3

B. Isotonic

• Isotonic exercise involves active movement with constant muscle contraction. Examples include walking, turning in bed, and self-feeding.
• Isometric exercise requires tension and relaxation of muscles without joint movement. An example is tension and relaxation of pelvic floor muscles (i.e., Kegel exercise).
• Aerobic exercise requires oxygen metabolism to produce energy. Patients may engage in rigorous walking or repeated stair climbing to achieve the positive effects of aerobic exercise.
• Anaerobic exercise builds power and body mass. Without oxygen to produce energy for activity, anaerobic exercise takes place. Heavy weight lifting is an example of anaerobic exercise.

Question 4

A nurse teaches a client how to use an incentive spirometer. Which projected client outcome supports the conclusion that the use of the incentive spirometer was effective?
1. Expiratory volume will be decreased.
2. Inspiratory volume will be increased.
3. Sputum will be expectorated.
4. Coughing will be stimulated.

Answer 4

2. Inspiratory volume will be increased

An incentive spirometer provides a visual goal for and measurement of inspiration. It encourages the client to execute and maintain a sustained inspiration. A sustained inspiration opens airways, increases the inspiratory volume, and reduces the risk of atelectasis.

Question 5

What is hypoxemia

Answer 5

decrease of oxygen in blood

Question 6

What lab would the nurse take to see the coagulation process of a pt during bleeding from an acute gun shot wound?
A.hemoglobin
B.Hematocrit
C.Transferrin
D.platelet

Answer 6

D.platelet

Question 7

What is considered a Preload?
A. Contraction
B. HR x SV
C. Amount of blood & pressure in ventricle at end of diastole
D . SA Node

Answer 7

C. Amount of blood & pressure in ventricle at end of diastole

Question 8

What type of exercise must a nurse implement to prevent a patient from getting footdrop?
A. Flexion
B. Dorsiflex
C. Adduction
D.abduction

Answer 8

B. Dorsiflex

Question 9

What is considered passive ROM?
A. Assist pt 100% & Nurse assist 0%
B. 50/50
C. Nurse assist at 100% and pt 0%
D. Assist pt 30% & pt. 70%

Answer 9

C. Nurse assist at 100% and pt 0%

Question 10

The nurse instructs the patient to walk around the hall way, what type of exercise does this indicate?
A.Isometric
B.Aerobic
C.Anaerobic
D. Isotonic

Answer 10

D. Isotonic

Question 11

The pt has gustatory and olfactory alterations, what foods would you recommend?
A. Highly aromatic smell, foods with spices that induce taste buds
B.bland food like crackers
C.Milk to increase calcium intake
D. Vit A to increase vision

Answer 11

A. Highly aromatic smell, foods with spices that induce taste buds

Question 12

An elderly pt who has been in diagnosed with major depression , which one of these scenarios would be a cause of their acute depression?
A. Alarming sounds , adequate family visitation
B. Sensory deprivation , isolation
C. Sensory overload
D. Prolonged counseling

Answer 12

B. Sensory deprivation , isolation

Question 13

What nursing interventions would be appropriate for a pt that’s going through sensory overload in the ICU ( intensive Care Unit)
A.Turning off monitors and alarms
B. Dimming the lights and lowering the sounds of monitors and alarms
C. Rubbing the pt’s back
D. Extreme family visitation

Answer 13

B. Dimming the lights and lowering the sounds of monitors and alarms

Question 14

1. An uncooperative 70-year-old male with right-sided paralysis from a recent cerebrovascular accident (CVA) has to be transferred from the bed to a wheelchair. Which action indicates the best method to transfer this patient?
   a. A two-person lift is performed, with one person on each side of the patient.
   b. The patient is steadied under the arms and pivoted on his left leg.
   c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP).
   d. A stand assist lift is used with the help of another nurse.

Answer 14

Answer: c
According to safe patient handling algorithms, a full-body sling with more than one caregiver is indicated because the patient is uncooperative and able to bear only partial weight. Lifting a patient manually has the potential to injure the patient and the care providers. The stand-and- pivot technique is not indicated because the patient is uncooperative. The stand assist lift is not indicated because the patient is uncooperative.

Question 15

Patient is unable to sit up without sliding due to having a stroke what type risk will the patient develop?
A.Stage 1
B. Partial thickness
C. Pressure and shear
D. Non blanching

Answer 15

C. Pressure and shear

Question 16

What action would you the nurse take with a visual impaired patient during feeding?
A. Assist patient by spoon fed
B. Informed the pt counter clockwise where each item on the plate is
C. Place the tray on their lap
D. Feed pt through a NG tube

Answer 16

B. Informed the pt counter clockwise where each item on the plate is

Question 17

Which nursing diagnosis is most appropriate for a pt. With expressive aphasia?
A. Impaired verbal communication
B. Acute confusion
C. Self care deficit
D Impaired mobility

Answer 17

A. Impaired verbal communication

Question 18

What would be a great nursing intervention for a pt with peripheral neuropathy?
A.give them a hot bubbly bath
B. Put hot sauce in they’re food
C. Encourage the pt to wear gloves in the winter to avoid frostbite
D. Have the pt read a book

Answer 18

C. Encourage the pt to wear gloves in the winter to avoid frostbite

Question 19

What would a patient with peripheral neuropathy be at risk for(tactile alteration)?

A. Measuring they’re weight
B.being able to sense if the bath water is too hot or cold. Or pain
C. Increased weakness in upper and lower joints
D. Incontinence

Answer 19

B.being able to sense of the bath water is too hot or cold. Or pain

Question 20

A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis.
Which assessment of the patient would indicate an adaptation to the sensory deficit?
A. The patient frequently cleans out his ears with a cotton swab.
B. The patient turns one ear toward the nurse during conversation.
C. The patient isolates himself from social situations.
D. The patient asks the nurse to speak loudly during conversations.

Answer 20

B. The patient turns one ear toward the nurse during conversation.

Question 21

A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with attempting to eat his meal and is becoming tearful. The nurse includes which intervention in the patient’s plan of care?
A. Teach the patient about special devices used to assist patients with eating meals.
B. Order the patient food that does not require utensils.
C. Place a consult for a home health nurse.
D. Obtain an order for antidepressant medications.

Answer 21

A. Teach the patient about special devices used to assist patients with eating meals.

Question 22

The nurse would utilize the Snellen chart for assessment of which patient?
A. A patient who is having difficulty remembering how to perform familiar tasks
B. A patient who turns the television up as loud as possible
C. A patient who holds his newspaper 2 inches from his face
D. A patient who frequently reports the incorrect time from the clock across the room

Answer 22

D. A patient who frequently reports the incorrect time from the clock across the room

Question 23

The nurse is caring for a patient who is having difficulty understanding written and spoken word? The nurse suspects the patient has BLANK aphasia.
A. Expressive
B. Receptive
C. Broca’s
D. Wernicke’s

Answer 23

B. Receptive

Question 24

The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient?

A. Speaking in a loud voice, enunciating every syllable
B. Having direct conversation with the patient in his affected ear
C. If the patient does not understand what the nurse is saying, repeating the phrase again
D. Speaking with hands, face, and expression:

Answer 24

D. Speaking with hands, face, and expression:

Question 25

The home health nurse is caring for a patient with a tactile deficit; the nurse is concerned about injury related to inability to feel harmful stimuli. The nurse evaluates that the patient is able to safely care for himself when the patient demonstrates which action?
A. Places colored stickers on faucet handles to indicate temperature and keeps a thermometer
near the tub
B. Asks the nurse to test the temperature of the water before entering the bath
C. Replaces all lace-up shoes with Velcro ones and purchases shampoo caps
D. Dispenses all medications onto a plate for easy access in the morning

Answer 25

A. Places colored stickers on faucet handles to indicate temperature and keeps a thermometer
near the rub

Question 26

The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over inability to sleep. Which action by the nurse is most appropriate for this patient?
A. Provide the patient with a therapeutic back rub.
B. Turn off the alarms on the monitoring devices.
C. Administer an opioid medication to help the patient sleep.
D. Provide the patient with earplugs.

Answer 26

D. Provide the patient with earplugs.

Question 27

The client reports to the nurse that there is a ringing in the ears. Which documentation would be most appropriate for the nurse to document in the client’s chart?
1. Complaints of vertigo.
2. Complaints of otorrhea.
3. Complaints of tinnitus.
4. Complaints of presbycusis.

Answer 27

3. Complaints of tinnitus.

Question 28

A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident (stroke. In planning care for this client. the nurse implements which one of the following as an appropriate intervention?
A.Encourage an even gait when walking in place.
B.Assess the extremities for unilateral swelling and muscle atrophy
C.Encourage holding the breath frequently to hyperinflate the client’s lungs.
D.Teach the use of a two-point crutch techniqne for ambulation.

Answer 28

B.Assess the extremities for unilateral swelling and muscle atrophy

Question 29

A client is leaving for surgery and because of preoperative sedation needs complete assistance to transfer from the bed to the stretcher. Which of the following should the
nurse do first’?
A. Elevate the head of the bed.
B.Explain the procedure to the client.
C.Place the client in the prone position
D.Assess the situation for any potentially unsafe complications

Answer 29

D.Assess the situation for any potentially unsafe complications

Question 30

It has been determined that all of the following clients are at risk for falling. Which one requires the nurse’s priority for ambulation?
A. A 16-vear-old with a sprained ankle being discharged from the emergency department
B.A 54-year-old who has taken the initial dose of an antihypertensive medication
C.A 45-year-old postoperative client up and walking for the first time since knee surgery
D.An & 99- year-old who is asthmatic and had a hip replaced 8 months ago

Answer 30

C.A 45-year-old postoperative client up for the first time since knee surgery

Question 31

Why might a sequential compression device (SCD) be applied to the legs of an immobile patient?

A. To stimulate circulation in the deep arterial vascular system
B. To help prevent deep vein thrombosis (DVT)
C. To aid peripheral circulation to reduce the risk of skin breakdown
D. To assist in passive range-of-motion exercise of the patient’s lower extremities

Answer 31

B. To help prevent deep vein thrombosis (DVT)

Rationale: The prevention of DVT by promoting venous circulation is a stated SCD application. Compression devices affect venous, not arterial, blood flow. SCDs are not intended to minimize skin breakdown. SCDs have no role in passive range-of-motion exercise.

Question 32

While preparing to apply a SCD for a postoperative patient, the nurse realizes that which assessment observation contraindicates the application of the device?

A. Having a low-grade fever
B. Taking a prescribed anticoagulant
C. Having dermatitis on the legs
D. Wearing elastic stockings

Answer 32

C. Having dermatitis on the legs

Rationale: The presence of dermatitis or skin ulcers on the leg, or having had a recent skin graft to the leg, contraindicates the application of a SCD, since use of the device is likely to further alter skin integrity.

Question 33

The nurse has applied the SCD to a postoperative patient. The most appropriate way for the nurse to confirm proper fit is to do what?

A. Ask the patient if the device is causing any pain.
B. Ensure that two fingers will fit between the patient’s leg and the device.
C. Follow the manufacturer’s instructions for the application of the device.
D. Ask another nurse to check the patient for proper application of the device.

Answer 33

B. Ensuring that 2 fingers will fit between the pt’s leg

Rationale: Ensuring that two fingers can be inserted between the patient’s skin and the device is the standard method for determining proper fit. The patient’s complaint of pain may indicate that the device is too tight but does not indicate whether it is too loose.

Question 34

What is Glaucoma

Answer 34

Glaucoma is a serious medical condition of the eye. It causes increased intraocular pressure, which puts pressure on the optic nerve, leading to loss of peripheral visual fields and possibly blindness. Because there are no early symptoms of glaucoma, screening is done during routine eye examinations.

Question 35

What is Meineire Disease

Answer 35

Ménière disease is associated with vertigo, or the sensation that objects are moving around the person; tinnitus, or a ringing or other abnormal sound in the ear; and progressive hearing loss. Fluid build up of the ear

Question 36

What is veritigo

Answer 36

vertigo, or the sensation that objects are moving around the person; DIZZINESS

Question 37

what is peripheral neuropathy

Answer 37

Damage to sensory nerve fibers in the arms and legs leads to peripheral neuropathy, nerve damage away from the center of the body. Patients may not be able to feel sharp objects or discern extreme hot and cold temperatures, leaving them vulnerable to injury. Peripheral neuropathy occurs in patients with diabetes mellitus and renal disease.

CANNOT FEEL OR HAVE ANY SENSATION IN UPPER OR LOWER EXTREMITIES

Question 38

what is delirium

Answer 38

Delirium is a reversible state of acute confusion. It is characterized by a disturbance in consciousness or a change in cognition that develops over 1 to 2 days and is caused by a medical condition.

Question 39

what is dementia

Answer 39

Dementia, which is a permanent decline in mental function, has a subtle onset. It is characterized by the decline in many cognitive abilities, including reasoning, use of language, memory, computation, judgment, and learning.

Question 40

what is depression

Answer 40

Depression is a mood disorder characterized by a sense of hopelessness and persistent unhappiness. Signs and symptoms of depression are loss of interest, sadness for an extended period of time, decreased self- esteem, sleeping too much or insomnia, and changes in eating pa erns.

Question 41

what is Macular Degeneration

Answer 41

Macular degeneration is the leading cause of visual defects in the United States. It typically begins after the age of 50 years; loss of vision occurs in the central visual fields. Visual acuity is diminished. Causes include diabetes, genetics, smoking, and hypertension; however, some affected patients do not have these risk factors.

Question 42

What is Diabetic Retinopathy

Answer 42

Diabetic retinopathy is a complication of diabetes mellitus in which the blood vessels of the retina become damaged. Because the retina is the area of the eye that contains the photoreceptors, destruction of these cells leads to loss of vision. Usually, visual loss starts with distortion of the image, but the condition can lead to blindness.

Question 43

What is cataract

Answer 43

BLURRY VISION
CLOUDY

Clouding of the lens of the eye is called a cataract. Cataracts cause blurring of vision and usually occur with aging. The visual deficit can be corrected with surgery, which usually is performed only if vision is severely affected. The clouded lens is removed, and a new lens is placed in the eye.

Question 44

What is a immobile patient at risk for select all that apply?
A. risk for falls
B. pulmonary edema
C. blood clots
D. contractures
E. Muscle atrophy

Answer 44

C,D,E

Question 45

What is aphasia?Expressive and receptive

Answer 45

Some speech problems that occur after a stroke or other traumatic brain injury include different types of aphasia, or speech or language impairment. The patient with receptive aphasia, also known as Wernicke aphasia (named for the area of the temporal lobe that interprets language), cannot comprehend wri en or spoken language. The auditory pathway is intact, but words do not make sense. In expressiveaphasia, or Broca aphasia, the damage is to the motor speech area of the frontal lobe. In this type of aphasia, patients understand language but are unable to answer questions, name common objects, or express simple ideas.

Question 46

A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span.
A nurse should recognize these as classic signs of which condition?
A. Mania
B. Delirium
C. Dementia
D. Parkinsonism

Answer 46

C. Dementia

Question 47

A geriatric nurse is teaching student nurses about the development of delirium in older adults. Which statement by the nurse is most accurate?
A. “Taking multiple medications may lead to adverse interactions or toxicity.”
B. “Age-related cognitive changes may lead to alterations in mental status.”
C. “Lack of rigorous exercise may lead to decreased cerebral blood flow.”
D. “Decreased social interaction may lead to profound isolation and psychosis.”

Answer 47

A. “Taking multiple medications may lead to adverse interactions or toxicity.”

Question 48

What are the causes of delirium?

Answer 48

Some causes of delirium are drug or alcohol use, the side effects of medication, infections, fluid and electrolyte imbalances, low oxygen level, and pain. Delirium may occur in patients in the intensive care unit (ICU) because of sensory overload.

Question 49

Which one of these clients will be at HIGH risk for Sensory Deprivation?
A. A patient with adequate family visitation
B. An elderly patient in a nursing home with no family visitation
C. A 24 year old at a party
D. A 15 year old in piano practice with her classmates

Answer 49

B. An elderly patient in a nursing home with no family visitation

Question 50

What is the best activity for a patient to decrease the risk of atrophy and contractures?
A. Active Range of Motion
B. Passive Range of Motion
C. Active Assistance
D. No range of motion

Answer 50

A. Active Range of Motion

Question 51

What exercise would you recommend for a patient with urinary stasis secondary to being on bed rest (causes a decrease of muscle tone during immobilization)?
A. Isotonic
B. Isometric
C. Aerobic
D. Anaerobic

Answer 51

B. Isometric

Kegal exercises

Isometric (static or setting) exercise - are those in which muscle contraction occurs without moving the joint - Plank, squatting, kegals

Question 52

A patient is currently doing a chest press? What type of exercise does this indicate?
A. Anaerobic
B.Isotonic
C.Isometric
D. Isokinetic

Answer 52

D. Isokinetic

Isokinetic (resistive) exercises - involves muscle contraction or tension against resistance. Chest press, shoulder press, leg press, squatting

Question 53

What is an IMMOBILE patient at risk for?
A. Atelectasis
B. Presbycusis
C. Risk for falls
D. Glaucoma

Answer 53

A. Atelectasis

Atelectasis (collapse of lobe or entire lung)- Ventilation decreased - pooled secretions may accumulate in a dependent area of the Bronchiole and effectively block it. The combination of decreased surfactant and blockage with mucus can cause atelectasis - Immobile or postoperative patients are at greatest risk

Question 54

Crepitation - palpable of audible crackling or grating sensation produced by joint movement and frequently experienced in joints that have suffered repeated trauma overtime

Answer 54

Crepitation - palpable of audible crackling or grating sensation produced by joint movement and frequently experienced in joints that have suffered repeated trauma overtime

Question 55

What nursing intervention would be best for a pt with visual alterations?
A. Larger bolded font lettering and words
B. smaller font to promote straining of the eye
C. spicy food
D. water

Answer 55

A. Larger bolded font lettering and words

Question 56

Types of Exercises

Answer 56

TYPES OF EXERCISES

• [ ] Isotonic muscle shortens to produce muscle contraction and active movement - running, walking, swimming, cycling,
• [ ] Isometric (static or setting) exercise - are those in which muscle contraction occurs without moving the joint - Plank, squatting, kegals
• [ ] Isokinetic (resistive) exercises - involves muscle contraction or tension against resistance. Chest press, shoulder press, leg press, squatting Aerobic Exercise - is activity during which the amount of oxygen taken into the body is greater than that used to perform the activity - running, jogging, walking, sprinting, outdoor cycling
• [ ] Anaerobic exercise - does not draw out enough oxygen from the bloodstream - Weight lifting, and sprinting