Fundamentals Week 3

A nurse is caring for a client who states, "My doctor said I should have an EMG. What is that?" Which of the following responses should the nurse make?

"It is a test that determines if there is nerve damage affecting a muscle."

A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make? *****

"SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin."

A nurse is reviewing the process of how a refraction assessment is performed with a client. Which of the following statements should the nurse make? *****

"This test is performed using lenses of various prescription strengths."

A nurse is caring for a client who is scheduled for an otoacoustic emissions (OAE) test. The client asks what to expect during the test. Which of the following responses should the nurse make? ****

"You will have a small probe placed in your ear canal during the test."

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include? *****

1. A stable center of gravity increases stability and balance 2. A wide base lowers the center of gravity 3. Proper body alignment involves tightening the abdomen

A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics? ****

1. Stand as close to the object as possible 2. Keep abdominal muscles contracted and lower the back straight 3. Look straight ahead with shoulders raised up 4. Bend hips slightly and squat5. Push up from the knees when lifting the object

A nurse is preparing an in-service for a group of staff members about types of tests used to diagnose sensory impairments. Which of the following information should the nurse include?

A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles.

A charge nurse is discussing hearing tests with a newly licensed nurse. Which of the following information should the charge nurse include?

A tuning fork is placed against the client's mastoid bone during the Rinne test.

A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching? (Select all that apply.)****

A walking cane A walker

A nurse is reviewing the medial record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia? ****

Alzheimer's disease

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Ask the client to read a Snellen chart

A nurse is assessing a client for hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss? (Select all that apply.)

Asks for questions to be repeated Withdraws from social activities Describes sounds as being muffled

A nurse in a long-term care facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing?

Atrophy

A nurse is reviewing discharge instructions with a client who has macular degeneration. Which of the following information should the nurse include in the instructions?

Availability of aids to enhance vision

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage?

Damage into the skin layer

A nurse is caring for a client who had stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions?

Deep vein thrombosis

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? (Select all that apply.)

Difficulty maintaining attention Agitation Hallucinations Rambling speech

A nurse is assessing a client whose family is concerned that the client has developed dementia. Which of the following findings should the nurse identify as a manifestation of dementia? *****

Difficulty problem-solving

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following?

Diminished awareness of body position and balance

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse use to enhance communication with the client? (Select all that apply.) *****

Ensure the client wears their hearing aids.Use a sign language interpreter.Communicate using paper and pen.Face the client when speaking.

A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?

Foot drop

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?

Fowler's

A nurse is teaching a group of older adult clients about the sensory system. The nurse should include that the aging process is most likely to cause which of the following changes?

Hearing loss

A nurse is performing a focused assessment to an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing and age-related change to their musculoskeletal system?

Increased curvature of the thoracic spine

A nurse is providing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include? (Select all that apply.)

Inspect the feet every day. Wear closed-toe shoes. Manage glucose levels.

A nurse is providing care for a client who has a sensory deficit. Which of the following actions is the nurse's priority for the client? ****

Keep the client's environment free from clutter.

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include?

Kyphosis is a rounded upper back with the pelvis tilted forward.

A nurse is preparing to transfer a client from a bed to a wheel chair. Which of the following actions by the nurse demonstrates proper use of body mechanics?

Looking at the client face-to-face when transferring the client

A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic? (Select all that apply.)

Loop diuretics NSAIDS Aminoglycoside antibiotics

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?

Mechanical Lift

A nurse is caring for a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client?******

Mechanical lift

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture? **********

Muscles

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include? *****

Muscles assist with thermoregulation in the body

A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client? ***

Occupational Therapist

A nurse is caring for a middle adult client who asks about expected age-related changes. Which of the following sensory changes should the nurse include as an age-related change? ****

Presbyopia

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage? ******

Prone

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take? *****

Remind the client to use incentive spirometer

A nurse is preparing a poster presentation about sensory alterations. Which of the following information should the nurse include about sensory deprivation?

Risk factors for sensory deprivation include experiencing total vision or hearing loss.

A nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks?

Sit on the edge of the bed for 1 min

A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following can decrease with age? (Select all that apply.)

Sour Bitter Salty

A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include?****

Tendons connect muscle to bone.

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches? ****

The client has the crutches resting 5 cm (2 in) below their axilla

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint?

The contraction of a muscle results in flexion of a joint.

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include?***

The top of the walker should be at the level of your wrist

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?*****

The use of ergonomics increases job satisfactions

A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL?******

Toileting

A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss? (Select all that apply.)

Trauma to the outer ear Inflammation Cerumen buildup Otitis media

A nurse is preparing to collect data about cranial nerve function for a client. Which of the following actions should the nurse take to collect data about cranial never VIII?

whisper something in one ear while occluding the other ear