Week 4 Flashcards
The nurse recognizes that which organization requires that employers comply with ergonomic recommendations?
The Joint Commission (TJC)
National Institute for Occupational Safety and Health (NIOSH)
National League for Nursing (NLN)
American Nurses Association (ANA)
National institute for occupational safety and health.
A nurse is caring for a client who has had a stroke. The nurse knows that the client could develop contractures. Inactivity of which of the following systems could cause contractures?
musculoskeletal system
peripheral nervous system
endocrine system
central nervous system
Musculoskeletal
A male client is being treated on a neurological unit for the effects of a recent stroke. The client’s family members are participating actively in his care and frequently position him in a supine position. The nurse should teach the family members about the benefits of alternative positions in order to reduce the client’s risk of:
skin breakdown.
dyspnea.
contractures.
peripheral edema.
Skin breakdown
A nurse is assessing a client after knee surgery in a health care facility. Which intervention should the nurse follow to avoid complications associated with disuse syndrome?
follow a rigid daily routine for the client
encourage active exercise with a bed trapeze
reposition the client every 4 hours
use a gel mattress on the bed
Encourage active exercise with a a bed trapeze
A 59-year old female client reports to the nurse that she recently began taking alendronate and has been having stomach cramping, nausea, and diarrhea. How will the nurse educate the client?
“Take this medication monthly instead of weekly.”
“These side effects are normal, so do not worry about them.”
“Be sure to drink 8 ounces of water when you take alendronate, and take it on an empty stomach.”
“Discontinue taking the medication immediately.”
“Be sure to drink 8 ounces of water when you take alendronate, and take it on an empty stomach.”
A nurse is caring for a client with a leg fracture. The client is placed on an adjustable bed in the Trendelenburg position. How will this position help the client?
It helps the client look around without twisting and bending.
It promotes the drainage of the upper lobes of the lungs.
It prevents the client from sliding down toward the foot of the bed.
It prepares the client for the ability to eventually stand and walk.
It prevents the client from sliding down toward the foot of the bed.
A nurse is caring for a client with demobilized respiratory secretions. Which device will best mobilize respiratory secretions?
static air mattress
air-fluidized bed
circular bed
oscillating support bed
Oscillating support bed
The nurse is helping the unlicensed assistive personnel (UAP) to complete several tasks. What action(s) by the UAP requires the nurse to intervene? Select all that apply.
The UAP turns the client as a complete unit.
The UAP has the bed at knee-level when making an occupied bed.
The UAP twists to reach behind oneself for a washcloth.
The UAP asks for assistance when transferring a client from the bed to the chair.
The UAP carries the load of linens in a trash bag close to the body.
The UAP has the bed at knee-level when making an occupied bed.,
The UAP twists to reach behind oneself for a washcloth.
The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?
Sims’
lateral
prone
supine
Supine
A nurse is caring for a client with dyspnea in a health care facility. What intervention should the nurse follow to control the speed when repositioning the client?
lowering the side rail and moving the client to one side of the bed
placing one hand on the client’s shoulder and the other on the hip on the far side
replacing pillows behind the back and between the legs and under the upper arm
shifting hands from the posterior of the shoulder and hip to the anterior as the client rolls toward the client’s abdomen
shifting hands from the posterior of the shoulder and hip to the anterior as the client rolls toward the client’s abdomen
A nurse at an extended care facility is caring for a female resident whose spinal curvature is exaggerated by kyphotic changes. How can the nurse best position this resident to reduce pressure on her vertebrae?
in a slight Trendelenburg position
in a prone position
with a small roll or pillow under her neck
with her knees slightly elevated
With a small roll or pillow under her neck.
The occupational nurse is teaching an administrative assistant about proper posture when sitting. Which teaching will the nurse include?
“Cross your legs alternately throughout the day.”
“Keep your knees bent, with the backs of the knees against your chair.”
“The upper and lower thighs are your base of support.”
“Both of your feet should rest on the floor.”
Both of your feet should rest on the floor
The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?
Fowler’s
prone
supine
Sims’
Sims
A nurse in a health care facility is teaching a client to maintain correct standing posture. Which instruction should the nurse give the client to help avoid strain on the joints?
Hold the abdomen up and in.
Bend the head back slightly.
Extend or stretch the waist.
Bend the knees slightly.
Bend the knees slightly
A nurse is preparing an older adult client for a rectal examination. The nurse uses trochanter rolls to prevent the legs from turning outward. Which intervention would allow the nurse to anchor the body in the correct position?
rolling the sheet around the blanket
placing a roll between the client’s ankles
folding the sheet lengthwise in half and placing it under the hips
permitting the legs to rest against the trochanter rolls
Folding the sheet lengthwise in half and placing it under the hips
A nurse is performing a general physical assessment for a client. What is the most important thing the client can do to promote work endurance?
twist and stretch muscles during work
hold objects closer to the body
keep the feet apart when holding objects
rest between periods of exertion
Rest between periods of exertion
A client is postoperative day 2 following hip replacement surgery, and the nurse is helping the physical therapist ambulate the client for the first time since surgery. How can the nurse and therapist best assist the client from a seated position at the edge of the bed to a standing position?
have the therapist pull the client into a standing position while the nurse gently pushes from behind
apply a transfer belt around the client’s waist
utilize a mechanical ceiling lift
have the nurse and the therapist each grasp one of the client’s arms
Apply a transfer belt around the clients waist
The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?
thrombus formation
skeletal contractures
oliguria
pooling of secretions
Thrombus formation
A nurse is caring for an 85-year-old client in an extended-care facility. What position will the nurse recommend to help prevent skin breakdown?
Fowler position
Sims position
prone position
lateral position
Prone position
A client with a diagnosis of chronic obstructive pulmonary disease has been experiencing debilitating periods of dyspnea since being admitted to the health care facility. What position is most likely to alleviate this client’s shortness of breath?
Prone position
Lateral oblique position
High Fowler position
Sims position
High Fowler position
The nurse is performing discharge teaching with the family of a male client who has limited mobility and a significant cognitive deficit. The nurse has described the phenomenon of foot drop to the client’s family and should describe what intervention to prevent its development?
applying a foot splint correctly to maintain neutral foot positioning
flexing the client’s feet at the ankles three to four times daily
providing vigilant skin care to the client’s feet and keeping his toenails trimmed
using a transfer belt correctly when repositioning the client
applying a foot splint correctly to maintain neutral foot positioning
The nurse is caring for an 84-year-old client. While assessing the client, the nurse notes that the client has an unsteady gait and weak muscle strength and tires easily with physical exertion. How will the nurse document this finding?
poor alignment
disuse syndrome
functional position
low energy
Disuse syndrome
The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client?
Sims’
prone
supine
slight Trendelenburg
Slight trendelenburg
Which definition best describes functional ability?
A- the physical, psychological, cognitive, and social ability to carry on the normal activities of life
B- the ability to effectively adapt physically, psychologically, cognitively, and socially to an illness state
C- the ability to function as a contributing member of society
D- the ability of the human body to carry out necessary functions to live.
A- the physical, psychological, cognitive, and social ability to carry on the normal activities of life
_________ refers to the amount of assistance needed to meet life activities
Dependency
Which concepts represent major determinants of functional ability? (Select all that apply) A- family dynamics and coping B- mobility and gas exchange C- elimination and sexually D- cognition and culture
All of the above
Which of the following would be included in a functional assessment screening? A- martial status B- financial stability C- gender D- social participation
D- social participation
Which of the following are considered instrumental activities of daily living? Select all that apply A-bathing B- cleaning house C- grocery shopping D- managing money E- eating
B- cleaning house
C- grocery shopping
D- managing money
Functional ability is a crucial consideration in virtually all areas of health care. In the rehabilitation setting, what is the primary focus of functional ability?
A- determining the cost of assisting the patient with basic activities of daily living and IADLd
B- determining how the rehabilitation team will assist the patient with achieving total independence with BADLs or ADLs
C- restoring the patients functional ability and evaluating the functional outcomes of treatment by means of a functional assessment
D- getting the patient ready for discharge to a long term facility
C- restoring the patients functional ability and evaluating the functional outcomes of treatment by means of a functional assessment
The nurse explains to the client that an advantage to a performance based functional assessment tool is:
A- it can be performed quickly
B- that objective information provides a more accurate measurement of status
C- it involves answering a series of questions and can easily be performed in the office
D- the nurse must observe the patient performing various tasks of daily living
B- that objective information provides a more accurate measurement of status
Which patient would least likely be at risk for impaired functional ability?
A- a 71 year old patient with a 10 year history of rheumatoid arthritis
B- a 25 year old patient recently diagnosed with postpartum depression
C- a 21 year old patient admitted to the hospital with acute gastroenteritis
D- a 12 year old patient with Down syndrome
C- a 21 year old patient admitted to the hospital with acute gastroenteritis
Which functional assessment tool would be beneficial for the nurse to use when assessing a patient who has recently been treated for breast cancer with chemotherapy and radiation therapy?
A- functional activities questionnaire
B- folstein mini mental status examination
C-functional status scale
D- the Edmonton functional assessment tool
D- the Edmonton functional assessment tool
Which of the following diseases/disorders is most closely associated with a primary functional problem? A- multiple sclerosis B- cerebral palsy C- osteoarthritis D- Parkinson’s disease
B- cerebral palsy
The nurse is caring for a client with an above-the-knee amputation who has just received a new prosthesis. Which crutch-walking gait will the nurse teach?
four-point
swing-through
two-point
three-point partial weight-bearing
Three point partial weight bearing
The nurse is caring for a client with postural hypotension. Which nursing intervention is appropriate?
applying antiembolism stockings before rising
using a gait belt to quickly get the client out of bed
using a tilt table to move from supine to standing
asking the client to dangle before moving from a reclining position
Asking the client to dangle before moving from a reclining position.
Later today, a client will mobilize for the first time since surgery. The client has a history of orthostatic hypotension and experienced a fall prior to admission. How can the nurse best normalize the client’s blood pressure to ensure safety during mobilization?
Withhold beta-blockers, diuretics or ACE inhibitors until the client has successfully mobilized.
Obtain a walker for the client to use when mobilizing for the first time.
Encourage the client’s fluid intake throughout the morning.
Have the client dangle at the edge of the bed for several minutes prior to standing.
Have the client dangle at the edge of the bed for several minute prior to standing
The nurse is evaluating a client’s use of a leg prosthetic. Which client behavior indicates that further nursing teaching is necessary?
cleanses the stump each morning
cleans the valve on the prosthesis with a small brush
uses clean wool stump socks daily
lies supine periodically throughout the day
Cleanses the stump each morning
Which client would benefit the most from the use of a walker to assist in ambulation?
client who needs brief, temporary assistance ambulating
client who requires considerable assistance with balance
client who needs permanent assistance when walking
client who has weakness on one side of the body
Client who requires considerable assistance with balance
A male client with a history of type 1 diabetes has had a below-the-knee (BK) amputation. The client states that he is eager to be fitted for his prosthesis and to resume activities of daily living. When assisting the client with his adjustment to using his prosthesis, the nurse should prioritize what nursing diagnosis?
Risk for Sedentary Lifestyle
Risk for Impaired Skin Integrity
Risk for Impaired Bed Mobility
Risk for Disuse Syndrome
Risk for impaired skin integrity
The nurse is educating a client who will be using crutches for approximately 6 weeks. Which exercise would be beneficial to help with crutch use?
flexion and extension of the arms and the wrists
quadriceps setting exercises
gluteal setting exercises
sit-ups
Flexion and extension of the arms and wrists
The nurse is caring for an older adult client who is recovering from hip surgery. Which assistive device will the nurse use to facilitate client ambulation?
crutches
walker
gait belt
cane
Walker
Which client would benefit the most from the use of a forearm crutch to assist in ambulation?
client who requires considerable assistance with balance
client who needs permanent assistance when walking
client who cannot bear weight with the hands and wrists
client who has weakness on one side of the body
Client who needs permanent assistance when walking
A nurse is caring for a client who is on complete bed rest while recovering from hip surgery 12 hours ago. When the client is able to start walking, which ambulation aid will most likely be recommended for use?
cane
forearm crutch
walker
axillary crutch
Walker
The nurse is caring for a client who has generalized weakness and requires crutches to ambulate. Which crutch-walking gait will the nurse teach?
three-point partial weight-bearing
swing-through
four-point
two-point
Four point
An older adult client with weakness on one side of the body needs to use a cane for walking. How should the nurse determine the correct height of the cane to be used by the client?
The cane’s handle should be at waist level.
The cane should provide elbow flexion of 50.
The cane’s handle should be straight with a hand grip.
The cane’s handle should be parallel with the hip.
The canes handle should be parallel with the hip
A nurse is caring for a client whose fractured leg is in a cast. Which ambulatory device could the nurse suggest for the client to use at the health care facility?
walker
cane
axillary crutch
platform crutch
Axillary crutch
A 91-year-old female client was admitted to the geriatric unit of the hospital with diagnoses of Hyponatremia, Dehydration, and Failure To Thrive. The care team is aware of the importance of early ambulation and has taken steps to facilitate this. How can the client be best prepared to begin ambulating?
Teach the client about energy conservation techniques.
Use a mechanical ceiling lift when transferring the client into or out of bed.
Educate the client on the correct use of forearm crutches.
Assist the client with the performance of isometric exercises.
Assist the client with the performance of isometric exercises
A client with a right lower limb prosthesis uses a cane for additional stability. Which behavior demonstrates to the nurse that the client is ambulating appropriately?
raises hip to swing prosthesis forward
holds cane in left hand
looks at cane while walking
places right limb on first step when going downstairs
Holds cane in left hand
The nurse is preparing to assist the client from a supine to a standing position using a tilt table. What action by the nurse will prevent the client from fainting when using the table?
apply elastic stockings to both lower extremities
If the client develops hypotension, maintain the upright position.
tilt the table at once until the client is in a vertical position
have the client’s feet 2 inches (5 centimeters) above the footboard during transfer
Apply elastic stocking to both lower extremities
A nurse is assisting a client to ambulate at the health care facility using a walking belt. How does the walking belt assist the client when ambulating?
It aids the client in extending the leg.
It enables the client to stand and support body weight.
It helps the client to practice ambulating.
It allows the nurse to support the client.
It allows the nurse to support the client
A client’s plan of care specifies the goal that the client perform quadriceps setting four times daily. The nurse has explained the rationale for this exercise to the client and is now teaching the client to perform the exercises safely and effectively. What instructions should the nurse provide to the client?
“Flex the muscles in your thighs and then slowly rotate your feet outward.”
“Slowly alternate between tightening the muscles in your thighs and then relaxing them.”
“Slowly bend your leg at the knee then gradually return it to a straight position.”
“Progressively tighten your muscles in your toes and then your calves.”
“Slowly alternate between tightening the muscles in your thighs and then relaxing them.”
A nurse is caring for an older client with osteoarthritis who is recovering from the West Nile virus. Isometric exercises have been prescribed. What will the nurse teach the client about isometric exercises?
Isometric exercises will improve muscle tone and strength.
Isometric exercises promote tissue perfusion for quick recovery.
Isometric exercises measure the extent of muscle weakness caused by the virus.
Isometric exercises will promote cardiovascular conditioning.
Isometric exercises will improve muscle tone and strength
When preparing to teach a client about quadriceps setting, the nurse recognizes that which muscles will be involved? Select all that apply.
gluteus medius
vastus intermedius
vastus medialis
gluteus minimum
gluteus maximus
vastus lateralis
rectus femoris
vastus intermedius,
vastus medialis,
vastus lateralis,
rectus femoris
A nurse uses a tilt table to assist a client who is recovering from a spinal injury. Just before using the tilt table, the nurse applies an elastic stocking to the client. What is the purpose of applying this stocking?
It enables the client to stand and support the body.
It aids the client in extending the legs.
It helps to compress the vein walls.
It helps the client to normalize blood pressure.
It helps to compress the vein walls.
A client presents with a flare of lupus. Which statement made by the client would cause the nurse to suspect a stress reaction?
“I have a fever with this flare.”
“I just had a baby 3 weeks ago.”
“My lupus typically flares twice a year.”
“My joints hurt more with this flare.”
“I just had a baby 3 weeks ago”
A nurse is trying to assess a client’s stress type; however, the client is very depressed and quiet and does not reply to the nurse’s questions. The nurse is unable to maintain her calm while repeating the questions. Where is the nurse going wrong in assessing the client?
The nurse should demonstrate confidence and expertise.
The nurse should not assess the client’s stress type.
The nurse should take help from the senior physician.
The nurse should calm him first by giving him a sedative.
The nurse should demonstrate confidence and expertise
The nurse is obtaining data for a client experiencing a sympathetic response to a medication. Which symptom(s) will the nurse document that will correlate with the medication effects? Select all that apply.
heart rate is 58 beats/min
skin is pale
bowel sounds are hypoactive in all quadrants
pupils are constricted and pinpoint
urine output is decreased to less than 30 ml/h
skin is pale,
bowel sounds are hypoactive in all quadrants,
urine output is decreased to less than 30 ml/h
A nurse is sent to care for a client who recently had a stroke and is unable to perform activities of daily living. How should the nurse assist the client to get back to performing normal activities?
by suggesting certain medications
by exercising the client regularly
by asking the client’s family to be near
by suggesting complete bed rest
By exercising the client regularly
An adolescent client is brought to the clinic by the parents, who inform the nurse that they are concerned that the adolescent is using maladaptive coping mechanisms to deal with a bullying issue at school. Which statement(s) by the parents should the nurse report to the health care provider as correlating with the use of maladaptive coping mechanisms? Select all that apply.
“Friends come over frequently to watch television or play video games.”
“We have found evidence of drug use, which is very unlike our adolescent.”
“The school counselor is seeing our adolescent once a week to check in and see how things are going in school.”
“We have tried to discuss the issues so we can find a solution but are met with anger and hostility.”
“Our adolescent is sleeping a lot more than usual.”
“We have found evidence of drug use, which is very unlike our adolescent.”,
“We have tried to discuss the issues so we can find a solution but are met with anger and hostility.”
“Our adolescent is sleeping a lot more than usual.”
After failing a nursing exam, the nursing student states, “That exam was written terribly.” What coping strategy would the nursing instructor identify?
suppression
repression
rationalization
denial
Rationalization
The mission statement of a large health care organization states the objective of providing holistic care for clients. A nurse should be aware that holism is important for which reason?
Interplay between the mind and the body can have a profound influence on health.
Health is promoted when clients receive as few interventions as possible.
The nurse must address deficits in clients’ spiritual knowledge.
Each individual has an intuitive understanding of what he or she must do to maintain health.
Interplay between the mind and the body can have a profound influence on health.
