ADQ functional Ability 1520 NURSG

After removal of the larynx because of cancer, a client is using a pad and pencil to communicate. The client becomes frustrated and writes, "When can I learn how to speak again?" What is the nurse's best response?

1 "You have to give the incision time to heal." 2 "Every client is different. It's difficult to say." 3 "It must be difficult for you, but be patient. These things take time." Correct 4 "I can have someone from the Laryngectomy Club come to speak with you." The client's frustration and statement indicate readiness to address problems with speech, which may be demonstrated best by a laryngectomized person. Learning about esophageal speech can begin before the suture line heals: practice does not have to begin immediately. The response "Every client is different. It's difficult to say" does not answer the client's question and offers no plans for goal setting. The response "It must be difficult for you, but be patient. These things take time" closes off communication; the client's frustration necessitates the need for positive action.

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply.

1 Difficulty in swallowing Correct 2 Diminished sensation of pain 3 Heightened response to stimuli Correct 4 Impaired hearing of high-frequency sounds 5 Increased ability to tolerate environmental heat Because of aging of the nervous system an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high-frequency sounds. An interference with swallowing is a motor, not a sensory, loss, nor is it an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.

A nurse assesses that several clients have low oxygen saturation levels. Which client would benefit the most from receiving oxygen via a nasal cannula?

1 Has an upper respiratory infection Correct 2 Receives many visitors while sitting in a chair 3 Has a nasogastric tube for gastric decompression 4 Exhibits dry oral mucous membranes from mouth breathing Clients who receive many visitors while sitting in a chair are more mobile and will benefit from a less restrictive form of oxygen administration. The client will be able to talk without the impediment of a mask. An upper respiratory infection causes nasal mucosal edema; the mucous membranes may be irritated by the nasal prongs, and the effectiveness of nasal oxygen may be diminished. One nare is blocked by the nasogastric tube. The effectiveness of nasal cannula oxygen may be diminished. If the client is a mouth breather, the effectiveness of nasal cannula oxygen may be diminished.

Rehabilitation of a client with chronic obstructive pulmonary disease (COPD) involves strategies to decrease hospital admissions and to live a more active life. What should the nurse teach the client to do?

1 Initiate activities to eliminate infection. 2 Inhale during movements that require energy. 3 Implement breathing that uses the thoracic muscles. Correct 4 Incorporate humidification into the home environment. Humidification of the environment helps to prevent thickened secretions. Liquefied secretions are easier to expectorate. Measures to prevent infection are essential; however, infections are impossible to eliminate. Exhaling requires less energy than inhaling; therefore, movements that use energy should be done during exhalation. The use of abdominal muscles rather than thoracic muscles improves the client's breathing.

A nurse is assigned to care for a group of clients who have been found to have depression. Which clinical manifestations does the nurse anticipate? Select all that apply.

1 Labiality of affect 2 Specific food cravings Correct 3 Neglect of personal hygiene Correct 4 "I don't know" answers to questions Correct 5 Apathetic response to the environment Clients with depression are uninterested in their appearance because of low self-esteem. "I don't know" answers to questions type response requires little thought or decision-making, typical of depression. These clients' sense of futility leads to a lack of response to the environment. With depression there is little or no emotional involvement and therefore little alteration in affect. Clients with depression are uninterested in food of any kind.

A client is recuperating from a spinal cord injury at the T4 level and depends on a wheelchair for mobility. What should the nurse teach the client to prepare for use of a wheelchair?

1 Leg lifts to prevent hip contractures Correct 2 Push-ups to strengthen arm muscles 3 Balancing exercises to promote equilibrium 4 Quadriceps-setting exercises to maintain muscle tone Arm strength is necessary for transfers and activities of daily living and for the use of crutches or a wheelchair. Equilibrium is not a problem. The client does not have neurological control of hip contractures and maintaining muscle tone.

A health care provider prescribes daily docusate sodium (Colace) for a client. The nurse determines that the action of this drug in the gastrointestinal (GI) tract is to:

1 Lubricate the feces. 2 Create an osmotic effect. 3 Stimulate motor activity. Correct 4 Lower the surface tension of feces. The detergent action of docusate sodium promotes the drawing of fluid into the stool, which softens the feces. Lubricating the feces in the GI tract is the action of lubricant laxatives such as mineral oil. Creating an osmotic effect in the GI tract is the action of saline laxatives, such as magnesium hydroxide (Milk of Magnesia). Stimulating motor activity of the GI tract is the action of peristaltic stimulants, such as cascara.

When planning care to prevent deformities and contractures in a client with burns, the nurse expects to begin range-of-motion (ROM) exercises when the client's:

1 Pain has lessened Correct 2 Vital signs are stable 3 Skin grafts are healed 4 Emotional status stabilizes ROM should be instituted as soon as it will not compromise the individual's cardiopulmonary status. Pain will continue for some time, and if ROM is delayed until it subsides, contractures will develop. If ROM is delayed until skin grafts heal, contractures will develop. Pain and inability to cope may be prolonged; if ROM is delayed, contractures will develop.

After assessing a 1-year-old child, the nurse concludes that the child has normal development. Which finding supports the nurse's conclusion?

1 The child's head bends toward the side that the nurse strokes. 2 The child's hips move toward the side that the nurse stimulates. 3 The child abducts his or her arms while flexing the elbows when the nurse makes a loud noise. Correct 4 The child's toes hyperextend when the nurse strokes the heel upward across the foot. A normal 1-year-old child will exhibit the Babinski reflex. To assess the Babinski reflex, the nurse strokes the heel of the child upward across the foot, which results in hyperextension of the infant's toes. To assess the rooting reflex, the nurse strokes the child's cheek; the child's head bends toward the side being stroked, and the child begins to suck. This reflex disappears at the age of 4 months. To assess trunk incurvation, the nurse strokes the child's spine. In response the child's hips move to the side of stimulation or toward the stroke. This reflex disappears at the age of 6 months. When assessing the child's startle reflex, the nurse makes a sudden loud noise. In response to the noise the child abducts his or her arms while flexing the elbows. The reflex disappears at the age of 3-4 months. Therefore, the appearance of the rooting reflex, trunk incurvation, or startle reflex in a 1-year-old child would indicate abnormal development. Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or degrading responses.

A staff member tells a nurse that an older client becomes irritable when asked to assist with activities of daily living. On what general information about older adults should the nurse base a response? .

Correct 1 Decreased ability to cope 2 Loss of ability to cooperate 3 Ambivalence toward authority 4 Difficulty performing step procedures Fears and anxieties about themselves and their possessions are common in older adults because of a decreased self-concept and an altered body image; these changes result in a decreased ability to cope. Aging need not necessarily bring about a loss of one's ability to cooperate. The attitude of older adults concerning authority or others in their environment is set; indecision about life situations may be a result of insecurity. Difficulty performing step procedures is noted in the middle stage of Alzheimer disease; usually it is not observed in older adults