chapter 64 1

The nurse is performing a skin assessment on a bedbound patient who was positioned in a semi-Fowler's position. The nurse notices erythema over the sacrum and repositions the patient to a left recumbent position. The nurse anticipates resolution of the erythema will occur in less than which of the following timeframes? a) 45 minutes b) 1 hour c) 30 minutes d) 15 minutes

1 hour

What diet can the nurse recommend to a patient with hypoproteinemia that spares protein? a) A diet high in fats b) A diet high in minerals c) A diet high in carbohydrates d) A diet high in vitamins

A diet high in carbohydrates

The nurse assessing a patient on a rehabilitation units notices that the patient experiences pain when his right arm is moved away from the midline of his body. The nurse documents pain on which of the following movements? a) Extension b) Flexion c) Abduction d) Adduction

Abduction

A nurse is working with a patient to establish a bowel training program. Based on the nurse's understanding of bowel function, the nurse would suggest planning for bowel evacuation at which time? a) After breakfast b) Before bed c) Around lunchtime d) Upon arising

After breakfast

The nurse is evaluating the lab values of a patient whose nursing diagnosis is "risk for impaired skin integrity." Which of the following lab values places the patient at greatest risk? a) Hematocrit: 43.5 b) Albumen: 1.5 g/dL c) Potassium: 3.0 d) Hemoglobin: 10.5

Albumen: 1.5 g/dL

The nurse is using a measurement tool to determine a patient's level of independence in activities of daily living, such as continence, toileting, transfers, and ambulation. What would be the appropriate tool for the nurse to use? a) Barthel Index b) The Braden Scale c) Patient evaluation conference system d) The Pulses Profile

Barthel Index

A nurse is assessing a client who will be discharged home after rehabilitation for a stroke. The nurse is questioning the client about his instrumental activities of daily living (IADLs). Which of the following would the nurse address? a) Cooking b) Bathing c) Dressing d) Grooming

Cooking Instrumental activities of daily living (IADLs) include cooking, cleaning, shopping, doing laundry, managing personal finances, developing social and recreational skills, and handling emergencies. Bathing, grooming, and dressing are activities of daily living (ADLs)

A nurse is caring for a patient who is documented to have orthostatic hypotension. The nurse anticipates finding which of the following symptoms upon assessment? a) Dizziness b) Bradycardia c) Dry skin d) Hypertension

Dizziness

The nurse is assisting a patient to sit up on the side of the bed in preparation for standing. The patient has been on strict bedrest for more than a week. While assuming the sitting position, the patient begins to report feeling dizzy and nauseated. The patient is pale and diaphoretic. Which of the following would the nurse do next? a) Encourage the patient to take deep breaths. b) Have the patient lie back down. c) Obtain a transfer board to ease the change. d) Have the patient stand up immediately.

Have the patient lie back down.

The nurse is creating a bowel evacuation program for a paraplegic patient. When should the nurse plan for administration of a suppository? a) Just before breakfast b) 1 hour before dinner c) 30 minutes after lunch d) Right before bed

Just before breakfast

Which nursing intervention can help a client maintain healthy skin? a) Avoiding bathing the client with mild soap b) Removing adhesive tape quickly from the skin c) Keeping the client well hydrated d) Recommending wearing tight-fitting clothes in hot weather

Keeping the client well hydrated

Which nutritional deficiency may delay wound healing? a) Lack of vitamin E b) Lack of calcium c) Lack of vitamin D d) Lack of vitamin C

Lack of vitamin C

Which nutritional deficiency may delay wound healing? a) Lack of vitamin C b) Lack of vitamin E c) Lack of calcium d) Lack of vitamin D

Lack of vitamin C Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing.

Which disciplines should be consulted when caring for a client with a stage III heel ulcer? a) Nutrition support and orthotics b) Occupational therapy and infectious disease c) Plastic surgery and cardiology d) Physical therapy and respiratory therapy

Nutrition support and orthotics

Which therapeutic exercise is done by the nurse without assistance from the patient? a) Resistive b) Active c) Passive d) Isometric

Passive

A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair? a) Zinc sulfate b) Water c) Vitamin C d) Protein

Protein

The nurse is evaluating the serum albumin of a patient newly admitted on the rehabilitation unit. The nurse determines that the serum albumin is low, indicating that the patients level of which of the following is deficient? a) Phosphorous b) Potassium c) Protein d) Calcium

Protein

The nurse is working with the physical therapist to create a multidisciplinary plan of care for a patient in a rehabilitation unit. The therapist suggests that the patient would benefit from the use of light weights during shoulder exercises. The nurse incorporates this onto the plan of care as which of the following types of exercise? a) Active-assistance b) Isometric c) Resistive d) Passive

Resistive

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk? a) Prothrombin time b) Serum albumin c) Sedimentation rate d) Serum glucose

Serum albumin

To prevent footdrop, what is the best way for the nurse to position the patient? a) To keep the feet at right angles to the leg b) In a semisitting position in bed c) In a sitting position with legs hanging off the side of the bed d) In a side-lying position

To keep the feet at right angles to the leg

A client is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility? a) Raising the head of the bed to maximize the client's lung inflation b) Decreasing fluid intake to ease dependent edema c) Turning the client every 2 hours and providing a low-air-loss mattress d) Bathing and feeding the client to decrease energy expenditure

Turning the client every 2 hours and providing a low-air-loss mattress

Rotation of the forearm so that the palm of the hand is down is termed a) supination. b) pronation. c) eversion. d) inversion.

pronation

A spinal cord injury patient has no awareness of the need to void. This type of incontinence is termed a) stress incontinence. b) reflex (neurogenic) incontinence. c) functional incontinence. d) toilet incontinence.

reflex (neurogenic) incontinence. Explanation: Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void.

A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply. a) Toileting b) Cleaning c) Bathing d) Eating e) Cooking

• Toileting • Bathing • Eating