Func. Ability Test 4 PrepU
With which activity would a client experiencing astereognosis need help? A. Chewing and swallowing food B. Identifying an object by touch C. Recognizing faces D. Maintaining bladder continence
Identifying an object by touch Astereognosis is the inability to identify objects by touch. The client would be able to describe the object's characteristics but not recognize it without visual cues.
Which client should the nurse anticipate will be at greatest risk for alteration in quality of life as a result of loss? A. 50-year-old with psychosis in the context of schizophrenia B. 24-year-old diagnosed with borderline personality disorder C. 72-year-old in the late stages of dementia D. 45-year-old with severe depression
45-year-old with severe depression The nurse anticipates that the client at greatest risk for loss affecting their quality of life is the 45-year-old male with depression. Due to the conditions of the other clients, they are not at the greatest risk.
A 60-year-old female client with a history of osteoarthritis in her hip confides to the nurse that "intercourse hurts my hip." Which of the following would be the best option for the nurse to suggest? A. Practicing Kegel exercises B. Using vaginal lubrication C. Taking a narcotic prior to intercourse D. Exploring alternate positions for intercourse
Exploring alternate positions for intercourse Pain, fatigue, stiffness, and loss of range of motion can accompany diseases of the joints and make some positions for intercourse uncomfortable. Couples may find other positions to be more comfortable but may believe they need "permission" to engage in alternative sexual positions. Use of vaginal lubrication is used for conditions that cause decreased vaginal secretions. Taking a narcotic for pain prior to intercourse may effect the client's sexual function. Kegel exercises are used to promote vaginal tone.
A client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure? A. Heart failure occurs when blood pressures drops. B. Hypertension causes the heart's chambers to enlarge and weaken. C. Hypertension in older males regularly leads to heart failure. D. Hypertension causes the heart's chambers to shrink.
Hypertension causes the heart's chambers to enlarge and weaken. Hypertension causes the heart's chambers to enlarge and weaken, making it impossible for the ventricles to eject all the blood they receive.
Which type of fracture occurs when a bone fragment is driven into another bone fragment? A. Impacted B. Transverse C. Oblique D. Spiral
Impacted An impacted fracture is one in which a bone fragment is driven into another bone fragment. An oblique fracture occurs at an angle across the bone. A spiral fracture is one that twists around the shaft of the bone. A transverse fracture is one that is straight across the bone shaft.
A client with multiple myeloma is complaining about pain. What instructions will the nurse give the client to help to reduce pain during activity? A. Limit fluids to prevent going to the bathroom. B. Stay in bed as much as possible. C. Limit activity to once a day. D. Do not lift more than 10 pounds.
Do not lift more than 10 pounds. The client with multiple myeloma needs education about activity instructions, such as lifting no more than 10 pounds and using proper body mechanics. Braces may be needed. The clent should be active and would not be instructed to stay in bed or limit activity, as he or she would become very stiff. Limiting fluids would be contraindicated; the client needs to remain well hydrated.
A nurse is caring for a family whose older parent with dementia is living in their home. The nurse has instructed the family about how to decrease the parent's agitation. The nurse determines that the child of the parent has understood the instructions when stating: A. "I should place my parent in the bedroom with me so I can watch my parent more closely." B. "If I simplify our home environment, my parent may be less agitated." C. "It's important that my parent gets out shopping with me or my spouse." D. "Restraints can help reduce my parent's agitation."
"If I simplify our home environment, my parent may be less agitated." The nurse determines that the child of the parent has understood the nurse's instructions when saying, "If I simplify our home environment, my parent may be less agitated." The goal is to reduce environmental stimuli and adapt the environment to the client. Restraints are used only as a last resort. Continuous surveillance is unrealistic. Taking the client out shopping would add to the already intense and highly confusing stimulation.
The nurse is assessing a 4-year-old child who demonstrates unintelligible speech. The parents are concerned and ask about the cause of the speech problem. What is the most appropriate response by the nurse? A. "Speech problems are often caused by inadequate nutrition." B. "Many speech problems are the result of a hearing deficit." C. "Your child may have a fear of talking that needs to be identified." D. "Your child needs to be exposed to more talking by adults."
"Many speech problems are the result of a hearing deficit." Many speech problems in children are related to hearing problems. When a child is unable to hear sounds or words to repeat them, speech may be delayed or impaired. Although other causes may exist for speech impairment, hearing disorders should be ruled out first.
The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client? A. "Put your arm in this sleeve." B. "Don't put on your shoes yet." C. "Put on your shirt." D. "Put your pants on and zip the zipper."
"Put your arm in this sleeve." When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions. "Put your arm in this sleeve" gives one step in the process of getting dressed. "Put on your shirt" involves many steps and should be broken down into the steps of putting on a shirt. "Put your pants on and zip the zipper" should be broken down into steps and given in clear, short sentences. Furthermore, putting on pants and zipping a zipper involves many steps and may be too complicated for the client with dementia to follow. Instructions should be phrased positively as the client may not register the "Don't"; the client may put the shoes on if the nurse states "Don't put on your shoes yet."
A nurse is applying a cast to a 12-year-old boy with a simple fracture of the radius in the arm. What is most important for the nurse to do when she has finished applying the cast? A. Apply a tube of stockinette over the cast B. X-ray the cast to make sure the bones are aligned properly C. Assess the fingers for warmth, pain, and function D. Cut a window in the cast over the wrist
Assess the fingers for warmth, pain, and function Assess fingers or toes carefully for warmth, pain, and function after application of a cast to be certain a compartment syndrome is not developing. Before a cast is applied, not after, a tube of stockinette is stretched over the area, and soft cotton padding is placed over bony prominences. A "window" may be placed in a cast for an open fracture or if an infection is suspected—not to prevent an infection—so that the area can be observed; however, a window is not indicated in this case. The x-ray should be performed before casting, to diagnose the fracture, not afterward.
A 70-year-old client comes to the clinic with the client's daughter for group therapy. The client wants the daughter to do everything with the client, is afraid to be left alone, and is having difficulty making any individual decisions. Interventions for this client would center around the diagnosis of which personality disorder? A. Antisocial B. Narcissistic C. Schizoid D. Dependent
Dependent Dependent personalities lack self-confidence and are unable to function in an independent role. Clients go to great lengths to seek nurturance and support from others. They experience difficulty in making everyday decisions and are preoccupied with fears of being left alone to care for themselves.
The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? A. Gently pressing the bones on the neck B. Moving the head and chin toward the chest C. Moving the head toward both sides D. Lightly tapping the lower portion of the neck to detect sensation
Moving the head and chin toward the chest The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed.
A client brought to the outpatient department by a family member is diagnosed with obsessive-compulsive disorder (OCD). What characteristic of OCD does the nurse expect to find during the assessment of the client? A. Decrease in the level of intelligence. B. Rituals that interfere with occupational function. C. Increase in the amount of time spent with the family. D. Reduced body and mind coordination.
Rituals that interfere with occupational function. The client with OCD is often diagnosed only when the client's obsessions lead to ritualistic behavior that occupies a larger part of the day. This behavior interferes with the occupational functioning of the client. The client with OCD is aware that the irrational thoughts are promoting these behaviors. This client does not have reduced body and mind coordination. Rituals take up a lot of time and leave the client with little time for the family. The client's intellectual functioning is found to be intact during assessment.
When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? A. Self-actualization B. Love and belonging C. Safety and security D. Physiologic E. Self-esteem
Safety and security Physiologic needs are the physical requirements for human survival. Physiologic needs include breathing, water, food, sleep, clothing, shelter, and sex. Once a person's physiologic needs are relatively satisfied, the person's safety needs take precedence and dominate behavior. Safety and security needs include personal security, emotional security, financial security, health and well-being, and safety against accidents or illness and their adverse impacts. After physiologic and safety needs are fulfilled, the third level of human needs is interpersonal and involves feelings of love and belonging. These include relationships with friends, intimacy, and family. Self-esteem needs are ego needs or status needs, such as for getting recognition, status, importance, and respect from others. All humans have a need to feel respected; this includes the need to have self-esteem and self-respect. Self-actualization is what a person's full potential is and the realization of that potential.
Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues? A. Rheumatoid arthritis B. Polymyalgia rheumatic C. Scleroderma D. Systemic lupus erythematosus
Scleroderma Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. SLE is an immunoregulatory disturbance that results in increased autoantibody production. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.
A nurse is caring for an adolescent who lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address? A. Self-esteem needs B. Self-actualization needs C. Safety and security needs D. Love and belonging needs
Self-esteem needs The options listed are stages of Maslow's hierarchy of needs. The adolescent would have issues and concerns in the self-esteem stage. Self-esteem needs would include fear, sadness, loneliness, and accepting self; all would be appropriate with this client. Love and belonging would focus on the sociocultural aspect and would include areas such as relationships with others, communication with others, support systems, being part of a community, and feeling loved by others. Safety and security would focus on the environmental aspect and would include areas such as housing and community/ neighborhood to name a few. Self-actualization needs are in the intellectual and spiritual dimension and would include areas such as thinking, learning, decision making, values, beliefs, and helping others.
Which diagnostic measure is most accurate in detecting neural tube defects? A. Presence of high maternal levels of albumin after 12th week of gestation B. Flat plate of the lower abdomen after the 23rd week of gestation C. Significant level of alpha-fetoprotein present in amniotic fluid D. Amniocentesis for lecithin-sphingomyelin (L/S) ratio
Significant level of alpha-fetoprotein present in amniotic fluid Screening for significant levels of alpha-fetoprotein is 90% effective in detecting neural tube defects. Prenatal screening includes a combination of maternal serum and amniotic fluid levels, amniocentesis, amniography, and ultrasonography and has been relatively successful in diagnosing the defect. Flat plate X-rays of the abdomen, L/S ratio, and maternal serum albumin levels aren't diagnostic for the defect.
Which would be an appropriate intervention to help a client regain, maintain, or improve psychological well-being? A. Teach problem solving, stress reduction, coping, and proper interpersonal communication skills. B. Provide 24-hour mental health care counseling to a client and family. C. Teach the client and family ways to avoid detection of mental illness to prevent stigma in the community. D. Bring medication to a client on a daily basis to ensure the client takes medication.
Teach problem solving, stress reduction, coping, and proper interpersonal communication skills. A general intervention directed toward achieving the goals of psychiatric home care nursing includes: helping clients and family members or caregivers learn skills of problem solving, stress reduction, coping, and proper interpersonal communication; helping clients and family members or caregivers understand mental illness and how to monitor signs of relapse, medication effects, and medication side effects; providing respite and community resources to family members and caregivers; and coordinating and integrating clients' medical, social, spiritual, vocational, and other community-based services, as well as teaching clients and families to do so.
Which term indicates an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage? A. Joint effusion B. Tophi C. Subchondral bone D. Pannus
Tophi Tophi, when problematic, are surgically excised. Subchondral bone refers to a bony plate that supports the articular cartilage. Pannus refers to newly formed synovial tissue infiltrated with inflammatory cells. Joint effusion refers to the escape of fluid from the blood vessels or lymphatic vessels into the joint cavity.
A client experiencing a manic phase of bipolar disorder sustained cuts on the body from falling through a store window. The nurse is preparing to start an intravenous needle insertion. How should the nurse explain the procedure to the client? A. Ignoring the client's statement of, "I don't want this." B. Using clear and simple terms C. Interrupting the client's ravings D. Giving specific details about the procedure and what is going to happen next
Using clear and simple terms When communicating with clients who have psychiatric or mental health disabilities, the nurses uses clear and simple communication. The nurse needs to listen to the client and wait for the client to finish speaking. The client makes independent decisions, and the nurse does not ignore the client's refusal.
When developing a care plan for an older adult, a nurse should consider which challenges that clients in this age-group face? A. adjusting to retirement, deaths of family members, and decreased physical strength B. developing leisure activities, preparing for retirement, and resolving empty-nest crises C. selecting vocation, becoming financially independent, and managing a home D. managing a home, developing leisure activities, and preparing for retirement
adjusting to retirement, deaths of family members, and decreased physical strength Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges faced in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty-nest crises.
A client who is blind is said to be experiencing: A. sensory deficit. B. sensory overstimulation. C. sensory overload. D. sensory deprivation.
sensory deficit. Impaired or absent functioning in one or more senses, such as blindness, is termed sensory deficit. Sensory overload is excessive stimulation of one or more of the senses. Sensory deprivation is insufficient stimulation of one or more of the senses. Sensory overstimulation is not a common term used in health care.
The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: A. uses the sides of the walker to rise from a chair. B. places the walker far in front when walking. C. steps into the walker when walking. D. leans over the walker when walking.
steps into the walker when walking. A walker is mechanical aid that enhances the client's balance and ability to bear weight. Education is usually done by physical medicine or physical therapy, but the nurse should continue to assess the client's ability to use the walker properly. The client should step into the walker when walking rather than walking behind it. When the client is rising from a seated position, the arms of the chair, not the walker, should be used for support. The client should be cautioned to avoid pushing the walker out too far in front. Also, the client should avoid leaning over the walker but should instead stay upright while moving.
A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate? A. "Dementia is a terrible disease of the elderly." B. "Depression may manifest as dementia in elderly clients." C. "Drug interactions are the most common cause of dementia in the elderly." D. "The most common cause of dementia in the elderly is Alzheimer's disease."
"The most common cause of dementia in the elderly is Alzheimer's disease." The nurse should inform the family member that Alzheimer's disease is the most common cause of dementia in elderly clients. Dementia is a clinical manifestation, not a disease process. Although drug interactions and overmedication are causes of dementia, these causes aren't as common as Alzheimer's disease. Depression is common in elderly clients, but it doesn't cause dementia.
Which of the following is the role of the nurse toward a patient who is to undergo eye examinations and tests? A. Determining if further action is warranted B. Conducting various tests to determine the function and the structure of the eyes C. Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss D. Advising the patient on the diet and exercise regimen to be followed
Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss Although nurses may not be directly involved in caring for patients who are undergoing eye examinations and tests, it is essential that they ensure that patients receive eye care to preserve their eye function and/or prevent further visual loss. The nurse is not involved in conducting the various tests to determine the status of the eyes and in determining if further action is warranted. Patients who are to undergo eye examinations and tests are not required to modify their diet and exercise regimen.
A client with a delusional disorder has been undergoing individual psychotherapy. The therapy would be deemed ultimately successful when the client meets which outcome? A. The client will identify situations that evoke anxiety. B. The client will describe problems relating to others. C. The client will differentiate between reality and fantasy. D. The client will identify alternatives to present coping patterns.
The client will differentiate between reality and fantasy. The ultimate goal of all forms of treatment for clients with delusional disorders is to foster the ability to distinguish between fantasy and reality. Promoting healthy coping, anxiety awareness, and healthy relationships are therapeutic outcomes, but the priority in treatment is the delusional thinking itself.
A client has sought treatment because of the overwhelming anxiety the client experiences regarding the safety of the client's young children. The client admits that the client will not normally let the client's children leave the client's sight for fear that they will be abducted, abused, or injured. The client is unable to function at work as a result of this anxiety. The nurse would recognize that this client experiences which condition? A. Anticipatory anxiety B. Derealization C. Signal anxiety D. Fear
Anticipatory anxiety Anticipatory anxiety exists in the context of phobia. People with phobias develop anticipatory anxiety even when thinking about possibly encountering the dreaded phobic situation (i.e., danger to the client's children). The anticipatory anxiety in this case is so severe that the client is unable to function in certain situations leading to hardship. Signal anxiety refers to the natural anxiety mechanism that communicates danger or motivation for needed change. Fear refers to feeling afraid or threatened by a clearly identifiable external stimulus that presents a danger to a person. Derealization refers to a stage in the experience of anxiety when a person senses that things are not real.
A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse? A. Alzheimer's disease affects memory so the client doesn't need an explanation before procedures are performed. B. Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment. C. As long as the client receives the ordered medication, special care measures aren't necessary. D. The nursing staff should rely on the family to assist with care because family members know the client best.
Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment. The charge nurse should inform the new nurse that clients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. Maintaining a safe environment takes top priority. Families are an important part of the client care team; however, they shouldn't be relied upon to deliver care. Family members may take turns sitting with the hospitalized client to help maintain client safety. All procedures should be explained in simple terms that the client can understand. Medications should be administered as ordered; however, they don't typically improve symptoms. Instead, they slow disease progression.
A nurse is caring for a toddler admitted for long-term treatment of a chronic illness. Which action should the nurse take to promote normal childhood growth and development? A. Maintain a diet high in carbohydrates and low in fats. B. Consult with a play therapist about activities in which the child can participate. C. Allow the child to sleep for at least 12 hours per night. D. Make sure the child is continuously isolated because of the chronic illness and risk of infection.
Consult with a play therapist about activities in which the child can participate. Play is an important part of a child's growth and development. A nurse should facilitate play even when a child has a chronic illness. Consulting a play therapist is one way of facilitating such play. Although it's important for children to get adequate sleep, it isn't necessary for a toddler to get 12 hours' sleep per night. A child with a chronic illness may need to be temporarily isolated, but he should still have interaction with family members. A diet high in carbohydrates and low in fat isn't indicated for every toddler with a chronic illness.
A client is having an increasing amount of difficulty caring for oneself in the home alone. The client states to the nurse, "I need more help. What am I going to do?" Which action would be the most appropriate for the nurse to take? A. Have the home health aide increase visits for bathing the client. B. Have the occupational therapist assess for the client's need for adaptive devices. C. Have the social worker visit the client to discuss care options. D. Have the physical therapist help the client with rehabilitation.
Have the social worker visit the client to discuss care options. Services to manage health care needs in the home can involve a team of interdisciplinary professionals, including social workers. The social worker is able to broadly identify resources to meet the client's needs. As no specific needs are indicated in this case, such as the need for rehabilitation, bathing, or adaptive devices, it would be more appropriate for the nurse to refer the client to the social worker than to a physical therapist, home health aide, or occupational therapist.
A client has a nursing diagnosis of "Feeding self-care deficit related to right-sided weakness. Which of the following would be the most appropriate expected outcome for this client? A. The client will demonstrate an interest in eating during the evening snack. B. The client will not lose any weight throughout the hospital stay. C. The client will demonstrate an ability to feed himself with a spoon at the morning meal. D. The client will have a staff member open all packages prior to all meals.
The client will demonstrate an ability to feed himself with a spoon at the morning meal. Outcomes are expressed in terms of client behavior and have a time period in which they are to be achieved. The outcome is associated with the nursing diagnosis. In this case, the diagnosis reflects a self-feeding problem caused by weakness. Therefore, being able to feed oneself would be a client behavior the nurse would expect to see achieved.