ch 28 funds
3.) A patient had a fall, as a result the patient is now a paraplegic, which would be the best choice of stability while providing the "swing through gait" movement? a. Three-point crutches b. Two-point crutches c. Four-point crutches d. Cane
ANS: A A is the answer (pg 577)
9. The nurse correctly selects which intervention to avoid causing shear or friction when moving a patient in bed? a. Using an airflow bed b. Using a slide board c. Using a trochanter roll d. Using a gel mattress
ANS: B A transfer or slide board is made of plastic-like material that reduces friction. Linens easily slide over the board, facilitating bed linen changes. Patients can be repositioned or transferred with a minimum of force required. A trochanter roll prevents outward rolling of the hip when a patient is lying on his/her back. An air-fluidized bed uses airflow to move silicone particles in the bed, creating a watery, fluid-like movement and resulting in lower pressure to avoid or alleviate decubitus ulcers. A foam or gel combination mattress reduces pressure.
7. When providing home-going instructions for a recently discharged patient, which statement by the patient's son would indicate an understanding of methods to prevent complications from immobility? a. "We'll make sure that Dad eats plenty of lean protein foods." b. "We will limit Dad's fluid intake to prevent bladder incontinence." c. "Dad should sit more and restrict the time he walks around the house." d. "His arm sling should be kept on at all times to prevent an elbow contracture."
ANS: A Adequate protein intake will prevent negative nitrogen balance in sedentary patients. Fluid intake is essential for the promotion of skin integrity, prevention of bladder infections, and regular defecation. Ambulation prevents many of the complications of immobility. Maintaining an extremity in one position for an extended period of time may actually cause a contracture.
2.) An 89-year-old patient has been living a very sedentary life, he does not walk around much or eat as much as he should, he has decreased fluid intake as well. What is the FIRST MOST IMPORTANT thing that the nurse should be worried about? Select all that apply: a. Urinary stasis b. Constipation c. Stiff joints d. low blood pressure
ANS: A, B A, B are the most important and most urgent thing because if those things happen then everything else will go downhill, stiff joint are not life threatening, low BP is not a concern because if they were not moving it would be high BP
1. The nurse is teaching a patient about ways to decrease her risk of bone fractures. The following statements by the patient indicate a good understanding. (Select all that apply.) a. "I should do weight-bearing exercises." b. "I should get adequate intake of calcium and vitamin D." c. "I should exercise regularly." d. "I need to do yoga exercises."
ANS: A, B, C Inadequate dietary intake of calcium and vitamin D or impaired calcium metabolism may result in osteoporosis, which increases bone fragility and may lead to fractures. Decreased physical exercise and lack of weight-bearing exercise also contribute to bone fragility, deterioration, and loss of strength. Any type of exercise will help; it does not need to be yoga, but it does need to include weight-bearing exercise.
4. The nurse knows the following items should be included in the documentation of the patient on falls precautions: (Select all that apply.) a. History of any falls b. Falls risk assessment scores c. Patient and family education d. Use of assist devices e. Any fall or reported fall
ANS: A, B, C, D, E The nurse should document the general assessment, include the patient's medical history, subjective and objective data, medication review, musculoskeletal status, and history of falls. Falls assessment and reassessment, patient family education and use of assist devices is also documented. Thoroughly document a fall or reported fall, but do not document that an incident report has been filed in the medical record.
6. The nurse appropriately delegates care of her patient to the properly trained UAP when she: (Select all that apply.) a. assigns the UAP to reposition the patient. b. assigns the UAP to complete the MORSE falls risk scale. c. assigns the UAP to provide range-of-motion exercises. d. assigns the UAP to ambulate the patient in the hallway.
ANS: A, C, D Unlicensed assistive personnel (UAP) provide hands-on care for immobilized patients under the direct supervision of registered nurses. Turning and positioning of patients, range-of-motion exercises, transfers, and assistance with ambulation may be delegated to properly trained UAP. UAPs may not assess patients because that is a nursing responsibility. The MORSE falls risk scale is a risk assessment.
10. The nurse knows the knee-high SCD sleeves are correctly placed on the patient when the following conditions are met: (Select all that apply.) a. Both sleeves are connected to the SCD device. b. Two fingers fit inside when the SCDs are inflated. c. There are no kinks in the tubing. d. The ankle pressure is 55 to 65 mm Hg. e. The cooling control is on.
ANS: A, C, E Proper positioning of the SCD sleeve allows proper fit and application, which decreases the risk of constricting the blood flow or diminishing optimal outcomes. Wrap the sleeve around the leg, and fasten it with Velcro straps. Verify that two fingers fit between the leg and the sleeve when the sleeve is not inflated. Connect the sleeves to the device, ensure that there are no kinks in the tubing, and turn on the cooling and set it to 35 to 55 mm Hg.
2. The nurse knows that a patient with a compromised cardiopulmonary system has a diminished capacity for exercise because of the following: (Select all that apply.) a. Decreased tissue perfusion b. Loss of sensation c. Hemiparesis d. Diminished respiratory capacity
ANS: A, D Compromised cardiac function, decreased tissue perfusion, and diminished respiratory capacity directly affect a person's ability to perform activities of daily living (ADLs) and exercise. Hemiparesis and loss of sensation are associated with nervous system disorders.
9. The nurse is providing discharge education for her patient who is going home with a walker. Which statement by the patient indicates a good level of understanding of safety in the home? (Select all that apply.) a. "I need to remove the throw rugs." b. "I should make sure I only take a bath." c. "I cannot use the stairs." d. "I need to place a nonskid mat in front of the kitchen sink"
ANS: A, D To ensure patients do not have hazards that can cause falls at home, the nurse should evaluate where the living quarters are. If the patient has stairs, they need to be able to safely learn how to use the stairs. They need to remove throw rugs that are a trip hazard and place nonskid mats in front of sinks, tubs, and showers. They can shower with a bench or chair in the shower for sitting.
10. The nurse knows active assistive range of motion is: a. when the patient is able to independently move all joints. b. when the patient is able to partially move all joints. c. when the caregiver must move the patient's joints. d. when the patient is performing isotonic exercises.
ANS: B Active assistive range of motion occurs when the caregiver minimally assists the patient or the patient minimally assists himself or herself in the movement of joints through a full motion. Active range of motion occurs when the patient has full independent movement of all joints; this is also known as isotonic exercise. Passive range of motion occurs when the caregiver moves the patient's joints through a full motion. This exercise does not maintain or improve strength but maintains flexibility and prevents contractures and atrophy.
2. The nurse is implementing generalized falls precautions for his patients who are at risk for falls. Which intervention indicates a lack of understanding of these precautions? a. The bed is placed in the low position. b. The patient is wearing socks. c. The patient's cell phone is by the bedside. d. The patient's call light is within reach.
ANS: B If the patient is ambulatory, require the use of nonskid footwear. Socks can be slippery unless they have a grip surface on them. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient's reach. Keep the call light in reach and remind the patient to use it and keep the bed in the low position.
3. The nurse is educating the patient about the effects of immobility on the body. The following statements by the patient indicate a need for further education: (Select all that apply.) a. "I can become very weak." b. "I will gain weight." c. "I will lose muscle tone." d. "I can get bed sores."
ANS: B Immobility may cause weakness, instability, anorexia, elimination alterations, decreased muscle tone, circulatory stasis, and skin breakdown. Knowing the effects of immobility on various body systems allows the nurse to quickly assess a patient's risk and recognize signs of impending complications.
5. An appropriate goal for the patient who is postoperative day one from a hip fracture with the nursing diagnosis Impaired physical mobility is: a. the patient will interact with others. b. the patient will ambulate to the bathroom with assistance. c. the patient will have no skin breakdown. d. the patient will have a physical therapy consult.
ANS: B Patients with a diagnosis of Impaired physical mobility should have a goal aimed at improving their mobility. Although immobility can impact social isolation and skin breakdown, those goals are not appropriate for this diagnosis. Have a physical therapy consult is not a goal but an intervention.
11. The nurse appropriately delegates care to the UAP when she: a. instructs the UAP to assess the patient's skin during a bath. b. instructs the UAP to reposition the patient using the trapeze. c. instructs the UAP to assess the patient's ability to perform range-of-motion exercises. d. instructs the UAP to notify the health care provider of any changes.
ANS: B Repositioning a patient can be delegated to unlicensed assistive personnel (UAP); the nurse should provide proper instruction regarding specific positioning techniques, individualized patient concerns, and circumstances that require notifying a nurse. UAP may not perform assessments but should notify the nurse about any skin or musculoskeletal issues, not the health care provider.
12. The nurse knows that manual lifting should only be done in the following situations: a. Patients who are less than 150 lb b. Life-threatening situations c. Postsurgical patients d. Patients who are less than 200 lb
ANS: B The National Institute for Occupational Safety and Health (NIOSH) and the American Nurses Association (ANA) support the Safe Patient Handling and Movement Guidelines released in March 2010. Under these guidelines and position statements, manual lifting should be used in a few extreme situations instead of using mechanical lift devices, such as in life-threatening situations, for pediatric or small patients, or for patients who mostly are bearing their own weight. Postsurgical patients may not fit the criteria. Patients less than 150 or 200 lb may not fit the criteria.
7. The nurse is correctly demonstrating the use of a transfer belt when engaging in the following: (Select all that apply.) a. The belt is placed around the patient's hips. b. The belt is secure, leaving only enough room for the nurse to grasp the belt. c. The nurse stands on the weaker side. d. The nurse holds the belt on the side of the patient.
ANS: B, C Transfer belts should be used for patients with an unsteady gait or generalized weakness. Canvas transfer or gait belts are applied snugly around the patient's waist, leaving only enough room for the nurse to grasp the belt firmly during ambulation. Some belts may have handles. If the patient has a weaker side, the nurse should stand on that side and hold the gait belt firmly at the back of the patient's waist while ambulating.
1. Bones function in what important roles within the body? (Select all that apply.) a. Regulate potassium levels b. Maintain calcium balance c. Protect critical organs d. Produce blood cells e. Control motor activity
ANS: B, C, D Bones assist in the maintenance of both calcium and phosphorus balance within the body. Bones protect vital organs, such as the lungs, that are surrounded by the rib cage. The role of bone marrow is critical to blood cell formation. Potassium levels are regulated by the kidneys. The nervous system controls motor activity.
5. The nurse knows the following indicates orthostatic hypotension: (Select all that apply.) a. A decrease in systolic blood pressure by 30 mm Hg b. A decrease in diastolic blood pressure by 10 mm Hg c. An increase in heart rate by 30 beats/min d. An increase in systolic blood pressure by 20 mm Hg
ANS: B, D A drop in systolic blood pressure of 20 mm Hg, an increase in heart rate of 20 beats/min, or a drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as orthostatic hypotension.
2. What actions by the nurse are critical to ensure patient safety? (Select all that apply.) a. Place the call light on the patient's nightstand. b. Clean up fluid spills on the floor immediately. c. Instruct the patient to wear socks when ambulating. d. Keep linens and intravenous tubing off the floor. e. Return the bed to low position prior to exiting the room.
ANS: B, D, E Cleaning up spills, keeping items off the floor, and returning the bed to low position are all essential to prevent patient injury. The call light should be placed within reach of the patient on the bed or attached to the patient's gown. Non-skid slippers or shoes should be worn by the patient when ambulating.
6. To prevent injury to a patient during logrolling, which action by the nurse is most important? a. Place an ankle foot orthotic on the patient prior to movement. b. Remove the patient's drawsheet to avoid lower extremity entanglement. c. Position a pillow between the patient's legs to maintain body alignment. d. Raise all four side rails prior to initiating logrolling independently.
ANS: C A pillow is positioned between a patient's legs during logrolling to maintain spinal alignment. Ankle foot orthotics are used to prevent footdrop and would not be indicated during logrolling. A drawsheet is critical during logrolling to prevent potential injury to both caregivers and patients in most cases. Side rails are lowered when a caregiver is positioned next to the side of the bed so that the patient can be reached without back strain to the nurse.
The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicates a good understanding? a. "An example of this type of exercise is walking." b. "An example of this type of exercise is running." c. "An example of this type of exercise is Kegels." d. "An example of this type of exercise is weight lifting."
ANS: C 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). Isotonic exercise involves active movement with constant muscle contraction, such as walking, turning in bed, and self-feeding. 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, such as heavy weight lifting.
3. The nurse is educating the family of a patient on falls risk precautions. Which of the following statements by the family indicates a need for further education? a. "I should keep the wheelchair locked unless using it to move Mom." b. "I should always leave the bathroom light on." c. "I should use nonskid socks, not shoes." d. "I should keep her cell phone close to her bed."
ANS: C Leave lights on or off at night, depending on the patient's cognitive status and personal preference. Keep the wheels of any wheeled device (e.g., bed, wheelchair) in the locked position. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient's reach. If the patient is ambulatory, require the use of nonskid footwear (socks or shoes).
8. The nurse is preparing to assist her patient to walk to the bathroom after medicating her with a narcotic for pain management. Of what possible adverse effect should the nurse be immediately aware? a. Constipation b. Depression c. Dizziness d. Pain relief
ANS: C Potential adverse side effects of narcotics include respiratory depression, hypotension, confusion, sedation, constipation, and dizziness. The nurse should be immediately aware of dizziness during ambulation because of the safety risks. Pain relief is expected. Depression is not an immediate adverse side effect. Constipation will not impact the nurse's ability to safely ambulate the patient.
1. The nurse knows rheumatoid arthritis affects the musculoskeletal system by causing: a. muscle weakness. b. muscle wasting. c. muscle inflammation. d. muscle mobility.
ANS: C Rheumatoid arthritis and osteoarthritis cause inflammation of joints, resulting in pain and limited joint mobility, not muscle mobility. Genetic disorders such as muscular dystrophy result in muscle weakness and gradual muscle wasting.
4. The nurse is performing passive range-of-motion exercises on his patient when the patient begins to complain of pain. What is the first thing the nurse should do? a. Notify the health care provider. b. Hyperextend the joint. c. Stop the range of motion. d. Switch to active range of motion.
ANS: C Stop range-of-motion exercises if the patient begins to complain of pain or if resistance to movement is experienced. Never hyperextend or flex a patient's joints beyond the position of comfort. Active range of motion is when the patient moves the joint. Notifying the health care provider would happen after you stopped.
6. An appropriate goal for the patient who is postoperative day one from abdominal surgery and on bed rest with the nursing diagnosis Impaired skin integrity is: a. the patient will ambulate twice a day. b. the patient will eat 50% of meals. c. the patient will have no further skin breakdown. d. the patient will interact with others.
ANS: C The patient already has a wound, so the goal is focused on no further skin breakdown as a result of the bed rest and immobility. Although nutrition is important to wound healing, it is not the focus of this nursing diagnosis. Ambulating and interacting with others are not goals for this diagnosis.
8. The nurse is correctly assisting the patient in using a cane when the patient demonstrates the following: (Select all that apply.) a. The top of the cane is level with the patient's bent elbow. b. The patient holds the cane on his/her weaker side. c. The patient moves the cane forward first. d. The patient's arm is comfortably bent when walking.
ANS: C, D The top of the cane should be level with the hip joint, and the patient's arm should be comfortably bent when the patient is walking. The patient should hold the cane on his/her stronger side and move the cane forward first, followed by the weaker leg and then the stronger leg. This ensures that another point of support is always on the ground when the weaker leg is bearing weight and gives the patient a wide base of support. A patient using a cane should be encouraged to stand up straight and look forward. Leaning to one side or looking down can jeopardize safety and cause poor posture.
1.) A patient is restricted to bed rest, the nurse needs to educate the patient that it is very important to keep moving still while in bed to prevent atrophy and stiffness. What kind of exercises would the nurse help implement for the bed ridden patient? Select all that apply: a. Anaerobic exercises b. Aerobic exercises c. Isotonic exercises d. Isometric exercises e. Active/passive range of motion
ANS: C, D, E Anaerobic is heavy weight lifting, so it wouldn't be that. Aerobic is rigorous walking or stair climbing so it wouldn't be that.
5. Following hip surgery, a trochanter roll is used to prevent what type of movement? a. Supination b. Pronation c. Internal rotation d. External rotation
ANS: D A trochanter roll is placed along the greater trochanter of the femur (the outer aspect of the leg) to prevent external rotation of the hip when a patient is lying in supine position. A pillow is placed between a patient's legs when logrolling or in the side-lying position to prevent internal rotation. Supination and pronation refer to body positions of face up and face down.
1. Which assessment finding would indicate that a patient has hemiparesis? a. Bilateral lack of movement in the patient's lower extremities b. Complaint of pain when the patient attempts to ambulate c. Loss of sensation in both of the patient's legs d. Weakness of the patient's right arm and leg
ANS: D Hemiparesis results from a neurological brain injury that causes weakness on one side of the body. Bilateral muscle and sensory loss may be due to a spinal cord injury, the level of which determines whether the patient is paraplegic or quadriplegic. Pain with ambulation may be a neurological or musculoskeletal response to a variety of concerns or disorders.
3. What nursing intervention would be the first priority to prevent constipation in an immobile patient? a. Administration of a soap suds enema b. Decreased dietary fiber consumption c. Narcotic analgesic pain relief use d. Increased daily oral fluid intake
ANS: D Increased oral intake and ambulation are the highest priority interventions for the prevention of constipation. Promoting dietary fiber intake and administering ordered stool softeners would be the next most important strategies. The use of narcotic analgesia should be minimized in constipated patients since these types of medications actually decrease gastrointestinal (GI) motility. If none of the previous interventions result in the patient having a bowel movement, a soap suds enema may be ordered.
2. What information should the nurse include when teaching a patient about deep vein thrombosis (DVT) prevention? a. Avoid movement of the extremities to prevent potential deep vein thrombosis formation. b. Encourage use of sequential compression devices (SCDs) during ambulation. c. Utilize an ankle foot orthotic (AFO) or pressure relief orthotic (PRAFO) to stretch ligaments. d. Sit with legs uncrossed to promote circulation and venous blood flow to the heart.
ANS: D Instructing patients to sit without crossing their legs and to ambulate as much as possible are important aspects of patient education in DVT prevention. SCDs must be removed prior to ambulation to prevent patient injury. Orthotics may be helpful in preventing heel pressure and footdrop, but have little effect on DVT prevention.
4. Which patient care activity can be delegated by the registered nurse (RN) to unlicensed assistive personnel (UAP)? a. Completing an admission skin assessment b. Administering an ordered stool softener c. Teaching deep vein thrombosis prophylaxis d. Range of motion exercises
ANS: D Range of motion exercises is the only intervention on this list that legally can be delegated to unlicensed assistive personnel. Completing an initial patient assessment, administering medications, and patient teaching are all roles and responsibilities of the registered nurse.
14. The nurse has delegated to the UAP to assist a patient with ambulating in the hallway with a cane. Which statement by the UAP indicates a need for further education? a. "I should report any complaints of soreness to the nurse." b. "I should watch for indications that the patient has difficulties using the cane." c. "I should let the nurse or PT know if the cane doesn't seem to fit correctly." d. "I should teach the patient how to walk with the cane."
ANS: D Educating patients on how to walk with assistive devices may not be delegated to unlicensed assistive personnel (UAP). UAP should report any of the following: noticeable incorrect usage or fit of assistive devices, complaints of soreness or weakness, difficulties involving balance or strength, or difficulties in performing the procedure or other concerns verbalized by the patient.
13. The nurse is preparing to reposition the patient in bed. What is the first step in this process? a. Position the patient's arms across his/her chest. b. Lower the side rails. c. Grasp the draw sheet. d. Raise the bed to a working height.
ANS: D Raising the bed to a working height is the first step before beginning the procedure. Proper positioning of equipment prevents provider discomfort and reduces the chance of possible injury. Then lower the side rails as appropriate and safe, and ensure that the bed wheels are locked. Then you can have the patient position his/her arms and/or grasp the draw sheet.
15. The nurse correctly teaches the patient to rise from a chair using crutches when the following interventions are used: a. Patient starts from the back of the chair. b. The weak leg is closest to the chair. c. The hand on the strong side holds the handbar of the crutch. d. The strong leg is closest to the chair.
ANS: D The patient's strongest leg should be close to the chair. The patient's hand on the weak side holds the handbar of the crutches, and the hand on the patient's strong side holds onto the armrest of the chair. The patient moves to the front edge of the chair.
6. What nursing intervention would be most effective in preventing flaccidity in a hospitalized patient? a. Early ambulation after surgery b. Administering calcium with vitamin D c. Coughing and deep breathing exercises d. Referring the patient to occupational therapy
Answer: a Ambulation is the most effective intervention to promote maintenance of muscle tone and prevent flaccidity. Calcium with vitamin D helps prevent osteoporosis. Coughing and deep breathing is important for the prevention of pneumonia associated with immobility, and occupational therapy is typically ordered to help patients regain their ability to complete activities of daily living (ADLs) independently.
8. Which discovery found during an admission assessment of a patient transferred from a long-term care facility does the nurse recognize as the result of immobility? a. Bilateral elbow contractures b. Increased muscle tone c. Decreased cardiac workload d. Orthostatic hypertension
Answer: a Joint contractures may begin within hours of immobility and cause irreparable damage to joint flexibility. Muscle tone decreases, and cardiac workload increases with immobility. Pooling of blood in the lower extremities and quickly changing position may cause a rapid drop, rather than increase, in blood pressure, known as orthostatic hypotension.
5. A nurse is providing patient education on the prevention of osteoporosis. Which important fact should the nurse include in the teaching care plan? a. Calcium should be taken with vitamin D to increase calcium absorption. b. African American women are more prone to developing osteoporosis than are Asian American women. c. Increased phosphorus metabolism may lead to bone fragility. d. Aerobic exercise is more advantageous than weight-bearing exercise in preventing osteoporosis.
Answer: a Vitamin D is required for calcium metabolism. Asian American women are more prone to osteoporosis than African American women. Phosphorus deficiency may lead to malformation of bones. Weight-bearing exercise is more beneficial than aerobic exercise in the prevention of osteoporosis.
2. After instruction, which action by a patient who can bear weight on both feet indicates an understanding of the proper use of crutches? a. Adjusting the crutches so that they rest directly under the axilla b. Moving the opposing crutch and leg together for a two-point crutch walk c. Using a four-point crutch walk when not weight bearing on the left leg d. Placing the crutches 28 inches forward and then swinging both legs forward when using a three-point crutch walk
Answer: b Moving the opposing crutch and leg together provides needed stability for patients who can bear partial weight on each foot. Crutches must rest at minimum of two to three finger widths below the axilla to prevent brachial nerve damage. The four-point crutch walk is used by only patients who can bear weight on both legs. Crutches should be advanced no more than 6 to 8 inches, and a three-point crutch walk is not a swing-through gait.
10. After application of sequential compression devices (SCDs) on a patient, what assessment finding is essential for the nurse to include in documentation? a. Warmth of bilateral upper extremities b. Lower extremity circulatory status c. Circumoral cyanosis d. Bowel sounds
Answer: b The nurse must document the date and time of initiating SCD placement and the results of a skin, circulatory, and neurologic assessment of the lower extremities. SCDs do not affect the upper extremities, cardiac or respiratory status leading to circumoral cyanosis, or bowel sounds.
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: c According to safe patient handling algorithms, a full-body sling with the assistance of the nurse and UAP 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.
9. Which nursing diagnosis label is most appropriate for a patient who is experiencing sensory deprivation due to a lack of interaction with others? a. Impaired Verbal Communication b. Sedentary Lifestyle c. Social Isolation d. Disturbed Personal Identity
Answer: c Social isolation is experienced by patients who are unable to be in contact with other people. Patients with impaired verbal communication have difficulty speaking. A sedentary lifestyle may constitute an appropriate nursing diagnosis for patients who have a low physical activity level. Patients who exhibit serious psychological issues concerning identity may suffer from disturbed personal identity.
4. Which area of the central nervous system has most likely sustained damage if a patient exhibits a lack of coordination and an unsteady gait after a traumatic head injury? a. Medulla oblongata b. Articular disk c. Brainstem d. Cerebellum
Answer: d Injury to the cerebellum directly affects a patient's ability to ambulate and control movement. The medulla oblongata regulates heart rate, breathing, blood pressure, and reflexive actions such as vomiting. The articular disk is fibrous connective tissue in the temporomandibular joint, which facilitates jaw movement. The brainstem connects the spinal cord to the hemispheres of the brain.
7. Identify all nursing interventions that are necessary when caring for a quadriplegic patient injured 2 years earlier in a motor vehicle accident. (Select all that apply.) a. Monitoring respiratory status and breathing difficulties b. Assisting with feeding and ADLs c. Developing a care plan with the patient's power of attorney d. Using mechanical lifts to assist with transferring the patient e. Placing a gait belt around the patient's waist before ambulation
Answers: a, b, d Quadriplegia is the result of a high spinal cord injury that affects a patient's ability to breathe without mechanical assistance and severely limits the patient's ability to move all extremities. Most quadriplegics are confined to a wheelchair and unable to ambulate even with assistance. Mechanical lifts should be used to safely transfer this type of patient. Quadriplegic patients should be given the opportunity to direct their care and fully participate in setting care plan goals.
3. What bony prominences are at greatest risk for skin breakdown on a patient who is restricted to bed rest and placed in the side-lying position? (Select all that apply.) a. Sternum b. Ears c. Elbows d. Hips e. Coccyx
Answers: b, c, d The patient's ears, elbows, and hips are in contact with the bed surface in the side-lying position. Breakdown on the sternum would be a potential risk if the patient were in prone position. The coccyx experiences the most pressure when a patient is sitting or in the supine position.
