Basic Care/Comfort Quiz
Which recommendations would the nurse include in a client's discharge instructions regarding a home skincare program for psoriasis? "Shower twice a day with mild soap and warm water." "Soak the affected areas in hot water on a daily basis." "Apply an alcohol free, moisturizing lotion several times a day." "Cover affected areas when in contact with others."
"Apply an alcohol free, moisturizing lotion several times a day." Moisturizing lotions provide an occlusive film on the skin surface so that usual water loss through the skin is limited, thereby allowing the trapped water to hydrate the stratum corneum. Clients should not excessively expose the skin to water, particularly hot water, increases irritation and scaling. Psoriasis is not a communicable disease and affected areas do not need covering when in contact with others.
Which instructions would the nurse give to an older adult with decreased perception of touch? Select all that apply. One, some, or all responses may be correct. "Use a cane for support when walking." "Hold on to handrails while ambulating." "Look where your feet are placed while walking." "Wear shoes that give good support while walking." "If you are unable to change your position frequently, request assistance."
"Hold on to handrails while ambulating." Correct answer "Look where your feet are placed while walking." Correct answer "Wear shoes that give good support while walking." Correct answer "If you are unable to change your position frequently, request assistance." Decreased perception of touch is a physiological change of the nervous system associated with aging. The client may experience decreased sensory perception that may cause the client to fall. Holding onto the handrails for directional guidance and support may help allow time for careful foot placement. The client should be instructed to look carefully where feet are placed while walking to prevent falling. Good support from wearing shoes while walking may reduce the risk of falling in clients with decreased perception of touch. If the client is unable to change position frequently, the caretaker should change the position of the client every hour while the client is in bed or in a chair. A cane may be useful for a client with a musculoskeletal condition or injury but will not help with decreased sensory perception.
A nursing student is outlining the steps for examining a 4-year-old sick child. Which statement made by the student indicates inadequate learning? "I should give the child time to play around." "I should start the examination by checking the child's fingers and hands." "I should gather all information related to child's sickness from the parents." "I should make judgments when a parent shares the details of a child's illness."
"I should make judgments when a parent shares the details of a child's illness." Correct answer The nurse should refrain from passing judgment when parents explain their child's illness. While examining a 4-year-old sick child, the nurse should allow the child to play for some time so that the child may become acquainted with the new surroundings. The nurse should start the examination by checking nonthreatening areas such as fingers or hands. All information related to a child's illness should be gathered from the child's parents or guardians
As a component of a client's routine physical examination, the nurse calculates the client's body mass index (BMI). The client's weight is 65 kg, and the height is 1.7 meters. What is the client's BMI? Record your answer using one decimal place. BMI
22.5 The formula for BMI is weight in kg ÷ (height in meters) 2. The square of the client's height is 1.7 × 1.7 = 2.89; 65 ÷ 2.89 = 22.5. The desirable BMI for adults is 18.5 to 24.9.
A female client appears disheveled and disorganized. Which intervention would the nurse use to gain the client's involvement in personal hygienic care? Develop a schedule with her and make her responsible for adhering to it. Assist her in bathing and dressing by giving her clear, simple directions. Set a schedule that dictates bathing times and lists appropriate clothing. Bathe and dress her each morning until she is willing to do it for herself.
Assist her in bathing and dressing by giving her clear, simple directions. Clear directions provide the disorganized client with the necessary structure to encourage participation and support a positive self-image. Schedules may increase anxiety, and the client may not have the cognitive ability or enough self-discipline to adhere to schedules. Bathing and dressing the client will increase dependency and add to the client's self-doubt.
Which interventions would the nurse include in the plan of care for a preschooler diagnosed with celiac disease? Select all that apply. One, some, or all responses may be correct. Avoiding processed foods Adding oat products to the diet Obtaining a dietary prescription Adding wheat products to the diet Administering a fat-soluble vitamin supplement
Avoiding processed foods Correct answer Adding oat products to the diet Correct answer Obtaining a dietary prescription Correct answer Administering a fat-soluble vitamin supplement Correct answer A preschool-aged client who is diagnosed with celiac disease should avoid processed foods (hidden sources of gluten), add oat products to the diet (often tolerated), obtain a dietary prescription (insurance payments for the purchase of specialized food), and receive fat-soluble vitamin supplements. Wheat products contain gluten; therefore these should be avoided
The nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly? Bananas Cantaloupe Green beans Sweet potatoes
Cantaloupe Correct answer Cantaloupe, citrus fruits, and strawberries are foods high in vitamin C. Bananas are high in potassium. Green beans are low in vitamin C. Sweet potatoes are high in vitamin A.
Which information will the nurse consider when planning care for a client with human immunodeficiency virus (HIV) who has been diagnosed with class 3 tuberculosis? Select all that apply. One, some, or all responses may be correct. Class 3 tuberculosis is a clinically active disease, which is contagious. Tuberculosis is the leading cause of mortality in clients infected with HIV. HIV-positive clients are more likely to have multidrug resistant tuberculosis. Individuals with HIV usually have high fevers with active tuberculosis infection. Persons with active tuberculosis are usually treated on an outpatient basis.
Class 3 tuberculosis is a clinically active disease, which is contagious. Correct answer Tuberculosis is the leading cause of mortality in clients infected with HIV. Persons with active tuberculosis are usually treated on an outpatient basis. Class 3 tuberculosis is a clinically active and contagious disease; it is diagnosed either with positive bacteriological studies, or with both a significant reaction to a tuberculin skin test and clinical or x-ray evidence of current disease. Tuberculosis is the leading cause of mortality in clients with HIV infection. Persons with active tuberculosis are usually treated on an outpatient basis, and this does not change based on the client's HIV status. Although clients with HIV are more likely to develop active tuberculosis, they are not more likely to develop multidrug resistant tuberculosis. Immune-compromised clients, such as individuals who are HIV positive, are less likely to have high fever because of a diminished inflammatory and immune response to infection.
Which is a causative factor of urinary frequency occurring in the first trimester of pregnancy? Atony of the detrusor muscle Compression by the enlarging uterus Compromise of the autonomic reflexes Narrowing of the ureteral entrance at the trigone
Compression by the enlarging uterus The uterus and bladder occupy the pelvic cavity and lie closely together; as the uterus enlarges with the growing fetus, it impinges on the space occupied by the bladder, thus compressing the bladder, diminishing bladder capacity and resulting in urinary frequency until the uterus moves up and out of the pelvis in the second trimester. Atony does not cause frequency; more likely it will lead to retention. Compromise of the autonomic reflexes will lead to incontinence rather than frequency. Narrowing of the ureteral entrance at the trigone is unlikely; the uterus does not impinge on this area.
Which description would the nurse expect when the parents of a child with celiac disease describe their child's stools? Large, frothy, green Small, pale, mucoid Large, pale, foul-smelling Moderate, green, foul-smelling
Cottage cheese, crackers, relish dish (celery, olives, sweet pickles) Cottage cheese, crackers, and a relish dish (celery, olives, sweet pickles) have the highest sodium content. Meals consisting of soft-cooked egg, toast, jelly, and skim milk; baked chicken, boiled potatoes, broccoli, and coffee; and fillet of sole, baked potato, and fresh fruit cup (berries and melons) are low in sodium
Which nursing assessment indicates dehydration in an infant? Flat anterior fontanel Decreased urine output Warm skin temperature Slow, labored respirations
Decreased urine output Correct answer Dehydration leads to reduced blood volume, which in turn reduces kidney perfusion, resulting in a decreased urine output. The anterior fontanel is depressed in the dehydrated infant; it is flat in an adequately hydrated infant. A dehydrated infant's skin is cold, and respiration is rapid.
Which clinical finding would the nurse recognize as indicative of moderate dehydration in a 4-month-old infant? Urine output of 50 mL/hr Depressed anterior fontanel History of allergies to certain formulas Capillary refill time of less than 2 seconds
Depressed anterior fontanel A depressed anterior fontanel is a classic sign of moderate dehydration in infants that results from a decrease in cerebrospinal fluid. Urine output of 50 mL/hr indicates adequate hydration; output will be decreased in dehydration. A history of allergies to certain formulas is not a sign of moderate dehydration. Capillary refill time of less than 2 seconds is an expected capillary refill time and is not indicative of moderate dehydration.
The nurse is caring for a client after surgical creation of an ostomy. The nurse observes that the stool is formed. The stool is this consistency in which part of the colon? Ileum Ascending Transverse Descending
Descending As the effluent passes through the gastrointestinal system, water is absorbed, and the stool becomes more formed. The stool from an ostomy in the descending colon will be formed. The ileum is a component of the small intestines and produces very liquid stools. The stool from an ostomy in the ascending colon will be liquid because it is the first portion of the large intestine that the stool enters, and fluid has not been reabsorbed yet. The stool from an ostomy in the transverse colon will be soft and pasty because fluid still can be absorbed in the rest of the large intestine.
After abdominal surgery, a client reports pain. Which action would the nurse take first? Reposition the client. Obtain the client's vital signs. Administer the prescribed analgesic. Determine the characteristics of the pain.
Determine the characteristics of the pain. Correct answer The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause of the pain.
Which considerations would be included in caring for an infant who is failing to thrive (FTT)? Select all that apply. One, some, or all responses may be correct. Dietary history Signs of malnutrition Familial stress factors 75th percentile for weight Parent and infant interaction Sustained growth under 5th percentile
Dietary history Correct answer Signs of malnutrition Correct answer Familial stress factors Correct answer Parent and infant interaction Correct answer Sustained growth under 5th percentile Correct answer Dietary history should include type of feedings, because failure to thrive may be a result of an inadequate milk supply in a breast-feeding mother. Signs of malnutrition can affect hair and skin. The infant also may be listless and slow to achieve milestones. Familial stress factors, such as depression and substance abuse, affect the ability of the caregiver to meet the infant's needs. Lack of parent and infant interactions contributes to failure to thrive, because infancy is the time to develop trust or mistrust. Sustained growth under the 5th percentile indicates failure to thrive. It is expected that an infant will double birth weight by 6 months of age. Weight in the 75th percentile indicates thriving.
A client with scleroderma reports difficulty chewing and swallowing. Which intervention would the nurse recommend to facilitate eating safely? Liquefy food in a blender. Eat a mechanical soft diet. Take frequent sips of water with meals. Use a local anesthetic mouthwash before eating.
Eat a mechanical soft diet. Scleroderma causes chronic hardening and shrinking of the connective tissues of any organ of the body, including the esophagus and face; a mechanical soft diet includes foods that limit the need to chew and are easier to swallow. Liquefied foods are difficult to swallow; esophageal peristalsis is decreased, and liquids are aspirated easily. Taking frequent sips of water with meals will not help; it is equally difficult to swallow solids and liquids, and aspiration may result. Using a local anesthetic mouthwash before eating is not necessary; oral pain is not associated with scleroderma.
Which action will the nurse take to prevent skin breakdown for a client who is on bed rest? Massage the bony prominences. Promote range-of-motion activities. Maintain a sheepskin pad under the client. Encourage the client to move in the bed as much as possible.
Encourage the client to move in the bed as much as possible. Correct answer The client who is confined to bed should be encouraged to move in bed to prevent prolonged pressure on any one skin surface. Massaging bony prominences increases the risk of skin breakdown. Although sheepskin material allows air to circulate under the client, it does not prevent prolonged pressure. Range-of-motion exercises move joints to prevent contractures; they do not relieve prolonged pressure.
Which liquid would the nurse recommend that a parent offer an 8-month-old infant who has diarrhea? Formula Skim milk Ginger ale Orange sports drink
Formula Formula or breast milk is recommended because it supplies most of the nutrients that older infants require and promotes hydration. Cow's milk should not be offered to infants because their gastrointestinal systems are not mature enough to tolerate its nutrient components. High-carbohydrate fluids such as ginger ale and sports drinks are contraindicated because they are hypertonic and will aggravate diarrhea.
Which approach would the nursing staff take to fulfill the nutritional needs of a client experiencing periods of extreme mania and hyperactivity? Accepting that the client will eat when hungry Allowing the client to prepare meals to eat when desired Frequently offering high-calorie snacks that the client can hold Leaving food in the client's room that can be eaten when desired
Frequently offering high-calorie snacks that the client can hold The nursing staff would frequently offer high-calorie snacks that the client can hold. Hyperactive clients burn up many calories, which must be replenished. Because such clients will not take the time to sit down to eat, providing them with food that they can carry sometimes helps. The client with mania will probably not be aware of hunger and may go without food for a dangerously long time. The client with mania is not capable of preparing food at this time. The client with mania will not be aware of hunger and will not independently initiate eating.
A child has a respiratory tract infection with a low-grade fever. When teaching the parents, which intervention would the nurse emphasize? Encouraging high-calorie snacks to prevent weight loss Keeping the toddler wrapped in blankets to prevent shivering Giving small amounts of clear liquids frequently to prevent dehydration Using cool-water baths to prevent the child's fever from increasing further
Giving small amounts of clear liquids frequently to prevent dehydration Fluid is lost through perspiration and the increased metabolic rate associated with a fever; an intake of small, frequent amounts of fluids will replenish lost fluid and prevent dehydration. Although caloric intake is important, it is not the priority. Keeping the toddler wrapped in blankets to prevent shivering interferes with the radiation of heat from the body; dressing the toddler in light clothing will help reduce the fever. Cool baths may produce shivering; this will increase the fever; a low-grade fever is part of the body's adaptive mechanism that limits the multiplication of microorganisms.
Which food choices can be safely eaten by the child with celiac disease? Apple crisp and milk Hamburger patty and fries Spaghetti and meatballs Chicken tenders and sauce
Hamburger patty and fries Celiac disease impairs the body's ability to handle gluten. Hamburgers, potatoes, and fat for cooking do not contain gluten. The "crisp" in apple crisp is made with flour. Spaghetti is made of flour, and meatballs may have added bread crumbs. Chicken tenders are dipped in flour or crumbs, both of which contain gluten.
During a routine prenatal visit, a client tells the nurse that she often gets muscle weakness and leg cramps. Which condition would the nurse suspect, and which suggestion is made to correct the problem? Hypercalcemia; avoid eating hard cheeses Hypocalcemia; increase her intake of milk Hyperkalemia; consult her health care provider Hypokalemia; increase intake of green leafy vegetables
Hypocalcemia; increase her intake of milk The most likely cause is a disturbance in the ratio of calcium to phosphorus, with the amount of serum calcium reduced and the serum phosphorus increased; milk and other dairy products are excellent sources of calcium. Leg cramps are related to hypocalcemia, not to hypercalcemia. An increased potassium level manifests as muscle weakness. A low potassium level should be treated with increasing bananas and oranges, not green leafy vegetables.
A 16-month-old toddler has had large, frothy, foul-smelling stools since the introduction of table foods and is irritable and apathetic. The child is diagnosed with celiac disease and a gluten-free diet is prescribed. Which response would the nurse anticipate in the child after 2 days on the diet? Return of appetite Increase in weight Improved behavior Cessation of diarrhea
Improved behavior Correct answer' A favorable change in behavior occurs in 2 to 3 days and attests to the effectiveness of the diet; other improvements take longer. A return of appetite takes more than several days of therapy; anorexia redevelops during episodes of diarrhea. An increase in weight and cessation of diarrhea each take more than several days of therapy.
Laboratory results for a client with small cell lung cancer reflect urine with a high specific gravity and a serum sodium level of 127 mEq/L. The client has gained 7 pounds in 3 days, has decreased urine output, and no edema is noted. Which nursing interventions are appropriate for this client? Select all that apply. One, some, or all responses may be correct. Initiate furosemide (Lasix). Introduce a potassium-restricted diet. Start an IV of hypertonic saline solution. Institute a fluid restriction of 800 to 1000 mL/day. Set a goal of increasing sodium by 15 to 20 mEq/L in the next 24 hours.
Initiate furosemide (Lasix). Correct answer Institute a fluid restriction of 800 to 1000 mL/day. Correct answer This client is experiencing syndrome of inappropriate antidiuretic hormone (SIADH), which is most often caused by cancer, and especially small cell lung cancer. It is appropriate to initiate furosemide to promote diuresis. Instituting a fluid restriction of 800 to 1000 mL/day will encourage weight reduction and a gradual increase in serum sodium concentration and osmolality. Hypertonic saline solution is generally not necessary unless the hyponatremia is severe.
The nurse anticipates that an infant's diet that consists of only mashed potatoes and milk will result in a deficiency of which nutrient? Iron Vitamins Potassium Amino acids
Iron Correct answer Potatoes and whole milk are not adequate sources of iron; by the time a child is 8 months of age, fetal iron stores are depleted and exogenous iron sources are needed. Milk contains vitamins A, C, and D. Potatoes are a rich source of potassium. There are amino acids in milk because it is an animal protein.
Which meal selection by a client on a 2-g sodium diet indicates that more diet teaching is needed? Soft-cooked egg, toast, jelly, skim milk Baked chicken, boiled potatoes, broccoli, coffee Fillet of sole, baked potato, fresh fruit cup (berries and melons) Cottage cheese, crackers, relish dish (celery, olives, sweet pickles)
Large, pale, foul-smelling Correct answer Children with celiac disease have a gluten-induced enteropathy and are unable to absorb fats from the intestinal tract, resulting in stools that are large and fatty or frothy, not mucoid. Although the stools are large and frothy, they are pale because of their high fat content. The stools are large and foul-smelling and have little color.
A client with hemiparesis voices a reluctance to use a cane. Which rationale would the nurse use to explain the cane's purpose to the client? Maintain balance to improve stability Relieve pressure on weight-bearing joints Prevent further injury to weakened muscles Aid in controlling involuntary muscle movements
Maintain balance to improve stability Hemiparesis creates instability. Using a cane provides a wider base of support and therefore greater stability. Hemiparesis affects muscle strength on one side of the body; the joints are not directly affected. Activity should strengthen, not injure, weakened muscles. The use of a cane will not prevent involuntary movements if they are present.
Which education would the nurse provide to a parent to encourage a preschool child to sleep? Eliminate naps to ensure sleepiness. Watch a television show to wind down. Make sure that the sleep space is dark and quiet. Offer a glass of hot chocolate before bedtime.
Make sure that the sleep space is dark and quiet. Dark, quiet sleep environments promote sleep; light and noise disrupt the sleep cycle and are alerting. Preschoolers typically still require a nap; elimination of naps could lead to becoming overly tired, which often results in sleep difficulty. Television is both alerting and exposes the child to light, which disrupts melatonin release, both of which disrupt sleep. Coffee, tea, colas, and chocolate are stimulants that do not promote sleep.
Which findings would the nurse expect when caring for a client with cor pulmonale? Select all that apply. One, some, or all responses may be correct. Weight loss Neck vein distension Lower extremity edema Right upper quadrant abdominal tenderness Lower than normal hemoglobin and hematocrit Elevated B-type natriuretic peptide (BNP) levels
Neck vein distension Correct answer Lower extremity edema Correct answer Right upper quadrant abdominal tenderness Correct answer Elevated B-type natriuretic peptide (BNP) levels Correct answer Cor pulmonale is right-sided heart failure caused by pulmonary hypertension secondary to chronic obstructive pulmonary disease. The client will have clinical manifestations of right-sided heart failure such as neck vein distension, peripheral edema, hepatomegaly with right upper quadrant tenderness and elevated BNP due to atrial enlargement. Weight gain would be expected because of fluid retention. Chronic hypoxemia in cor pulmonale leads to polycythemia with increases in hemoglobin and hematocrit and increased blood viscosity.
A client is diagnosed with celiac disease. Which foods would the nurse teach the client to avoid? Select all that apply.One, some, or all responses may be correct. Corn Cheese Oatmeal Rye bread Fruit juice
Oatmeal Correct answer Rye bread Correct answer Gluten is found in rye, oats, wheat, and barley, which should be avoided because gluten in these grains is irritating to the gastrointestinal mucosa in clients with celiac disease. Gluten is found in oatmeal and rye bread and should be avoided. Gluten is not found in corn. Gluten is not found in milk and dairy products. Gluten is not found in fruit.
Which nutrition-related problem would the nurse address when teaching childhood nutrition to a group of parents whose children have Down syndrome? Rickets Obesity Anemia Rumination
Obesity Obesity is a common nutritional problem of children with Down syndrome. It is thought to be related to excessive caloric intake and impaired growth. Rickets is a nutritional disorder related to vitamin D deficiency; it is usually not encountered in these children. Anemia is the most common nutritional problem in children with iron deficiency. Rumination is an eating disorder of infancy characterized by repeated regurgitation without a gastrointestinal illness.
How does the teaching method for a preschooler differ from that for a toddler? Preschoolers are encouraged to learn together. The use of play for learning is discouraged in preschoolers. Preschoolers need to make decisions about health and health promotion. The use of pictures and short stories is avoided to facilitate learning in preschoolers.
Preschoolers are encouraged to learn together. Toddlers are not socially developed enough to participate in group learning activities. Preschoolers are mature enough to expand beyond the family and be involved in group activities with other children or individuals. In both toddlers and preschoolers, play is used to teach any method or procedure. An adolescent should be involved in making decisions about his or her health and health promotion. In both toddlers and preschoolers, learning is accompanied by pictures and short stories.
In addition to iron, which nutrients are necessary for red blood cell synthesis? Select all that apply. One, some, or all responses may be correct. Protein Calcium Vitamin C Vitamin D Carbohydrates
Protein Vitamin C Correct answer Protein is essential for the synthesis of blood proteins, albumin, fibrinogen, and hemoglobin. Vitamin C (ascorbic acid) influences the removal of iron from ferritin (making more iron available for the production of heme) and influences the conversion of folic acid to folinic acid. Calcium, vitamin D, and carbohydrates are not involved in the synthesis of red blood cells.
A client with myasthenia gravis experiences generalized weakness. Which nursing intervention would the nurse integrate into the client's plan of care? Maintain strict bed rest for this client. Provide the client frequent rest periods. Reassure the client there are many other tasks awaiting him or her. Arrange for a relative to be present with the client.
Provide the client frequent rest periods. Spacing activities encourages maximum functioning within the limits of the client's strength and fatigue. The client should avoid bed rest and limited activity because doing so may lead to muscle atrophy and calcium depletion. Although pointing out things the client can do is important, this does not address the client's concerns. Arranging for a relative to be present is unnecessary if the nursing staff observes the client closely. However, permit visitors if requested by the client or family.
Which procedure would the nurse use to elevate the head of an infant in a spica cast? Use of a donut head pad Inserting pillows under the shoulders Padding the edge of the cast with folded diapers Raising the entire mattress at the head of the crib
Raising the entire mattress at the head of the crib When elevation of the head is desired, the entire mattress or crib should be raised at the head of the crib. A donut head pad is used to diminish pressure, not elevate the head. Pillows under the head or shoulders of a child in a spica cast will thrust the chest forward against the cast, resulting in discomfort and respiratory distress. Padding the edge of the cast with folded diapers will not help elevate the infant's head.
Which behavior indicates a client has entered the second stage of labor? Restless, thrashing about Complaint of sudden, intense back pain Report of feeling pressure on the rectum Request for medication to relieve pain from the strong contractions
Report of feeling pressure on the rectum During the second stage the presenting part is low in the birth canal and may cause strong sensations of pressure on the rectum; at this time the cervix is fully dilated and the urge to push is great. Restlessness and thrashing about usually begin during the transition phase of the first stage of labor. Complaints of sudden, intense back pain may occur with persistent posterior pressure; however, usually the pain does not have a sudden onset. Asking for medication to relieve pain from the strong contractions usually occurs during the active phase of the first stage of labor.
A child who is cognitively impaired and blind does not speak or respond to the nurse. Which would the nurse do when entering the child's room? Blink the room's lights before starting care. Start care and explain actions as care is given. Nonverbally acknowledge the child before starting to give care. Say the child's name and touch the child's arm before starting care.
Say the child's name and touch the child's arm before starting care. Letting the child know that the nurse is in the room is vital; vocal and tactile contact will accomplish this. The child is blind and cannot see blinking lights. The nurse would let the child know that someone is present before beginning care. Nonverbal acknowledgment is difficult because the child is blind.
The nurse would intervene to prevent unlicensed assistive personnel (UAP) from providing which food to a woman with hyperemesis gravidarum? Crackers Dry toast Baked chicken Scrambled eggs
Scrambled eggs Once her vomiting stops, a woman with hyperemesis should start eating bland foods like crackers, dry toast, and baked chicken. Scrambled eggs are too rich for a woman who has been vomiting, at least in the beginning stage of her recovery.
The nurse is teaching a school-aged child with juvenile idiopathic arthritis (JIA) activities to prevent the loss of joint function. Which activities would the nurse caution the child to avoid? Bicycle riding Walking to school Isometric exercises Sedentary activities
Sedentary activities Prolonged sitting in one position can lead to stiffness and flexion contractures and should be avoided. Riding a bicycle helps maintain joint mobility, which is advantageous. Walking promotes functional movement and is beneficial. Isometric exercises are beneficial because they help maintain muscle tone.
A client with an acute exacerbation of rheumatoid arthritis is in severe pain and tells the nurse, "The only time I am pain free is when I lie perfectly still." Which complication would the nurse explain that could be prevented by daily exercise? Paresthesias of the feet Shortening of the muscles Development of osteoblasts Loss of coordination
Shortening of the muscles Flexion and extension prevent tightening of muscles and tendons. Abnormal sensations (paresthesias) are related to neurological, not musculoskeletal, alterations. Weight bearing, not exercise, promotes the development of osteoblasts. Loss of muscular coordination is the result of cerebellar changes; it is not related to immobility.
Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration? Good cry Grimace Absent respiration Slow, weak cry
Slow, weak cry Correct answer A slow, weak cry would be scored as a 1 in the category of respiration in the Apgar scoring system. A good cry would receive a score of 2. A grimace is a sign that is evaluated in the category of reflex irritability, not respiration. Absent respiration would receive a score of 0 in the respiration category of the Apgar score system.
Which are indicators of nutritional risk in a pregnant client who is of normal weight? Select all that apply. One, some, or all responses may be correct. Smoker Twin gestation Hemoglobin of 12 g/dL (120 mmol/L) Term delivery 2 years ago Fasting blood sugar of 80 mg/dL (4.4 mmol/L)
Smoker Twin gestation Smokers generally have a nutrient-poor diet and are at risk for continuing the same diet through pregnancy. Multifetal pregnancies require nutrition above the normal requirements for pregnancy. A hemoglobin reading of 12 g/dL (120 mmol/L) and fasting blood sugar of 80 mg/dL (4.4 mmol/L) are normal values. Caffeine intake of 180 mg/day is less than the daily recommended intake.
Which description of pain would the nurse expect a client with a ureteral calculus to report? Boring-type pain that is located in the flank Dull and constant at the costovertebral angle Located at the level of the kidneys and occurring with each urination Spasmodic and radiating from the side to the suprapubic area
Spasmodic and radiating from the side to the suprapubic area Pain with ureteral stones is caused by spasm (renal colic) and is excruciating and intermittent; it follows the path of the ureter to the bladder down to the groin. Pain is spasmodic and excruciating, not boring, dull, or constant. Pain intensifies as the calculus lodges in the ureter and spasms occur in an attempt to dislodge it. Pain at the costovertebral angle can indicate urinary tract infection. The pain is episodic and not located at the level of the kidneys.
Which action would the nurse implement when providing care for a client with continuous bladder irrigations? Monitor urinary specific gravity to determine hydration. Subtract irrigant from output to determine urine volume. Record urinary output every hour to determine kidney function. Obtain a 24-hour urine specimen to determine urine concentration.
Subtract irrigant from output to determine urine volume. The total amount of irrigation solution instilled into the bladder is eliminated with urine and therefore must be subtracted from the total output to determine the volume of urine excreted. An accurate specific gravity cannot be obtained when irrigating solutions are instilled into the bladder. Hourly outputs are indicated only if there is concern about renal failure or oliguria. A 24-hour urine test is not accurate if the client is receiving continuous bladder irrigations.
Which statement describes the primary reason why the nurse raises three of the four side rails on the bed of an 83-year-old client who is postanesthesia for a fractured hip? The action is a safety measure because of the client's age. Clients older than 60 years of age should use side rails. The side rails serve as handholds to facilitate the client's ability to move in bed. All older adults are disoriented for several days after anesthesia.
The action is a safety measure because of the client's age. The need to use side rails for safety is important with any older client because the client could fall or try to get out of bed without assistance. Not all clients over 60 years of age require use of three side rails. The nurse must evaluate each individual based on mental and physical status. The client may use the side rails to move around in bed, but safety is always first. Disorientation for a few days after anesthesia does occur in some older adults, but not with all older adults.
Which outcome indicates range-of-motion exercises have been effective for a child with juvenile idiopathic arthritis (JIA)? The knees are more mobile. The pedal pulses become stronger. Subcutaneous nodules at the joints recede. The child states that the pain is diminished.
The knees are more mobile. The exercises are done to preserve function by mobilizing restricted joints. Circulation is not affected by the arthritic process. Exercise does not affect the subcutaneous nodules in the joints. Exercises are done to restore joint function; they do not necessarily relieve pain.
Which treatment is beneficial for a client with muscle spasm? Thermotherapy Muscle massage Frequent position changes Muscle-strengthening exercise regimen
Thermotherapy Thermotherapy, the use of heat therapy, eases pain and muscle contraction; therefore, it is useful in treating muscle spasms. Muscle massage stimulates muscle tissue contraction and may worsen a muscle spasm. Frequent position changes are beneficial for a client with contracture. A muscle-strengthening exercise regimen is beneficial for a client with muscle atrophy.
Which clinical signs of hydration would the nurse assess in a toddler experiencing a sickle cell crisis? Select all that apply. One, some, or all responses may be correct. Turgor of tissue Edema of the ankles Specific gravity of urine Amount of urinary output Texture of mucous membranes
Turgor of tissue Correct answer Texture of mucous membranes Correct answer Loss of tissue elasticity ( decreased tissue turgor) indicates dehydration. Skin that takes 30 or more seconds to return to its original position after being pinched (tenting) is a sign of dehydration. Dry mucous membranes indicate inadequate hydration; moist mucous membranes indicate adequate hydration. The problem is dehydration, not retention of fluid; ankle edema is associated with interstitial fluid accumulation around the ankles. The amount and specific gravity of urine are not reliable indicators of hydration because the kidneys' ability to concentrate urine is impaired in sickle cell anemia.
Which steps would the nurse take for managing an adolescent who sustained drug poisoning? Select all that apply. One, some, or all responses may be correct. Induce gastric lavage. Give ipecac syrup to the client. Turn the head of the client to the side. Empty the mouth to clean the residue of the drug. Call local poison control center before any intervention.
Turn the head of the client to the side. Correct answer Empty the mouth to clean the residue of the drug. Correct answer Call local poison control center before any intervention. Correct answer The nurse would turn the head of the client to the side to avoid aspiration. The nurse would empty the mouth if there is any remaining drug. If the victim is conscious and alert, the nurse would call the local poison control center or the national toll-free poison control center number before attempting any intervention. The nurse would refrain from inducing vomiting in the client because there is a risk of aspiration. Ipecac syrup causes vomiting, so it is no longer recommended for routine treatment of poisoning.
The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem? Dehydration Skin breakdown Electrolyte imbalances Urinary tract infections
Urinary tract infections Clients in the early stages of spinal cord damage experience an atonic bladder; the characteristics include the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output. Dehydration is not a major problem after spinal cord injury. Pressure-relieving devices and position changes are most essential in preventing skin breakdown. An electrolyte imbalance is not a major problem after spinal cord injury.
