foundations exam 1 qs

the nurse is reviewing the data of a patient with severe join pain, which question asked by the nurse helps assess joint mobility

"does your joint pain worsen if you walk" "have you noticed any swelling of the joints"

the RN is teaching a nursing student about interventions performed to prevent deep vein thrombosis in an immobilized patient. which statement made by the nursing student indicates a need for correction

"i will massage the legs"

the nurse is teaching a patient diagnosed with arthritis of the knees about physical activity and lifestyle changes. which statement by the patient indicates correct understanding of the teaching

"i will perform exercises in a pool"

arrange the steps of a nurse following guidelines to initiate an exercise program for a patient in sequential order.

1. assess fitness level 2. design the fitness program 3. assemble equipment 4. get started using the exercise routine 5. monitor progress

which order of steps is correct for safely using a fire extinguisher in the home

1. pulling the pin to unlock the handle 2. aiming low at the base of the fire 3. squeezing the handle 4. sweeping the unit from side to side

which order of safety measures would the nurse follow in the event of a fire in a hospital area

1. rescuing and removing all patients 2. activating the alarm 3. closing doors an windows and turning off electrical equipment 4. extinguishing the fire with an appropriate extinguisher

which patient is at risk for poor hygiene practices?

a patient diagnosed with dementia, a patient experiencing acute psychosis, a patient who had a cerebrovascular accident, a patient who suffered from a traumatic brain injury

which movement is assessed in the frontal plane when the nurse observes the mobility of the joint?

adduction

the patient with hemiparesis needs passive ROM exercises to promote musculoskeletal health. which precaution would be taken to ensure effective ROM exercises?

carry out movements slowly and smoothly, never force a joint beyond its capacity, perform exercises using head-to-toe sequence

while assessing a patient, the nurse finds complete elongation of the deltoid muscle even in a normal position. how does the nurse interpret this observation?

normal finding

the nurse is assessing four patients. which patient does the nurse suspect to be at increased risk of pulmonary embolism because of immobility?

patient with enlarged calf circumference

which component of health belief model (HBM) describes a patient who is concerned about developing diabetes because a parent and grandparent have diabetes?

perceived susceptibility to the disease

which safety precaution would be followed by a patient infected with hepatitis A

practicing hand hygiene

the nurse is caring for a patient with muscle weakness. the patient is provided with skid-proof footwear. which safety measure is implemented in this situation?

preventing falls from slipping on the floor

which level of need to Maslow is being addressed when the nurse discusses with the elderly couple about removing the throw rugs and low footstool and improving the lighting in the home?

safety and security

the nurse is caring for a retired patient who has had a stroke. the nurse needs to assist the family in adapting to the condition and helping rehabilitate the patient. the nurse would collaborate with which interprofessional team members?

speech therapist, occupational therapist, physical therapist

nonblanchable erythema

stage 1

ruptured blisters

stage 2

full-thickness skin loss into subcutaneous tissue

stage 3

no exposure of bone with full-thickness skin loss

stage 3

exposure of muscle

stage 4

which condition is a serious reportable event included in the national quality forum (NQF) list

surgery performed on the wrong site

the nurse reviews discharge instructions with a patient who has osteoporosis. which statement by the patient indicates that the patient understands the instructions?

" i will stop smoking as soon as possible"

an older patient tells the nurse, "my skin is dry and flaky. I take a bath every day. how can I prevent my skin from being so itchy?" which recommendation does the nurse make?

"decrease the frequency of bathing with soap."

which condition does the nurse suspect when a patient who has been on best rest several days attempts to walk with assistance and becomes dizzy and nauseated, with an elevation in his pulse rate from 85 beats per minute to 110 beat per minute?

orthostatic hypotension

which patient would be suspected to have an electrolyte imbalance?

person exposed to heat for an extended period

according the american hospital association, a red wristband is given for which category?

allergies

which element is part of the chain of injection

an infectious agent, the source of pathogen growth, a susceptible host

which factors contributes to an increase in falls in older patients

anticonvulsants, high bed position

a patient has her nurse call system on and looks frightened when the nurse enters the room. the patient has been on bed rest for 3 days after a fractured femur. she says, " it hurts when I try to breathe, and I can't catch my breathe" which action would the nurse take immediately

assess vital signs, perform a respiratory assessment, and be prepared to start oxygen

the nurse is assisting a patient to bathe at the sink. during the procedure, the patient experiences fatigue, rapid breathing, and tachycardia. which action does the nurse take first?

assist the patient into a sitting or lying position

which factor is the greatest risk of injury for an adolescent

automobile accidents, suicide, and substance abuse

which phrase best explains the term proprioception?

awareness of the position of the body and its parts

the nurse understands the increased risk of musculoskeletal injuries due to activities such as lifting objects, pushing beds, and bathing and feeding patients. which measure would the nurse adopt to prevent injury

bend at the knees, maintain an erect trunk and bent knees, get assistance when moving patients, keep the weight to be lifted as close to the body as possible

a patient has been locked in a poorly ventilated room containing a furnace. which conditions is likely to be observed in the patient after a period of time?

carbon monoxide poisoning

the family member of an adult patient reports that the patient is a long-term smoker. which health risk factor does the nurse anticipate?

cardiovascular disease

which action does the nurse take to prevent skin breakdown in a drowsy patient who is incontinent of stools?

checking frequently for soiling

which health promotion strategy would be classified as passive?

clean water laws

which infection control practice would the nurse implement for a patient who is hospitalized for treatment of an infection with a multidrug- resistant organism?

contact precautions

the nurse is caring for a patient whose calcium intake must increase because of high-risk factors for osteoporosis. which menu would the nurse recommend

cream of broccoli soup with the whole wheat crackers and tapioca for dessert

deep maroon, nonblanchable area

deep tissue pressure injury

which finding may indicate metabolic change as a result of immobility

delayed wound healing

which finding is a serious reportable event included in the national quality forum (NQF) list?

disability associated with electric shock at a health care agency

the nurse is assessing a patient who reports joint pain. which type of range of motion assessed by the nurse involved sagittal plane movement?

extension, dorsiflexion

which data indicates to the nurse that a patient may have difficulty performing activities of self-care independently?

frequent shortness of breath, postoperative incisional pain, confusion

which health condition is likely to be observed in people working in cold conditions?

frostbite, hypothermia

which position change will require the nurse to implement precautions to prevent orthostatic hypotension in a patient reporting dizziness, lightheadedness, and nausea?

horizontal to vertical

which assessment finding indicates atelectasis that may result from immobility?

hypoventilation

because of the changes in the inflammatory and immune processes due to aging, the nurse would expect an older adult with pneumonia to experience which type of response?

increased fatigue

the nurse suspects deep vein thrombosis in a patient. which factor os Virchow's triad may lead to this condition

increased platelet activity

while assessing a patient for join mobility, the nurse notices that the patient is unable to dorsiflex the foot., which condition does the nurse suspect in the patient?

joint contracture

which is a desired outcome for a patient diagnosed with osteoporosis?

maintain independence with activities of daily living (ADLs)

an older adult who was in a car accident and fractured their femur has been immobilized for 5 days. which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time?

risk of inability to tolerate activity

which safety precaution would be taken for the patient with muscle weakness while walking?

rubber-soled shoes

which risk factor for cerebrovascular disease is considered modifiable

smoking five times a day, sedentary lifestyle, high sodium and saturated fat in diet

which datum indicates that additional assistance is needed to transfer a patient from the bed to the stretcher

the patient received an injection of morphine 30 mins ago for pain

which device should the nurse use to prevent external rotation of the hips when the patient is in a supine position?

trochanter roll

a patient with postural hypotension is hospitalized. which safety measure would the nurse implement during ambulation?

use of gait belt

after caring for a patient with diarrhea, which procedure would the nurse employ to clean visibly soiled hands?

wash with soap and water

a patient whose height is 167 cm ( 5'5 ) and weight is 75 kg ( 165 lbs ) takes medication to manage arthritis. which tertiary prevention intervention would a nurse suggest?

weight reduction, continuing medication, physical exercise

regarding home care considerations for patients with infections, which statement made by the nursing student indicates the need for further learning

"I should ensure that teach-back about sterile asepsis has occurred"

the nurse is evaluating a patient was diagnosed with osteoporosis 3 months ago. the patient has limited mobility and has been taught measures to limit risks associated with osteoporosis. which statement made by the patient indicates an effective outcome of teaching?

"i am using a cane to walk when i am alone" "i reduced drinking coffee to 1 cup per day" "i added spinach to my daily diet because i am lactose intolerant"

the registered nurse is teaching a nursing student about the interventions performed in immobilized patients whoa re at risk of impaired skin integrity. which statement made by the nursing student indicates the need for further learning?

"i should reposition the patient frequently when he or she is awake"

the nurse is teaching a parent about toddler care. which instruction provided by the nurse indicates effective teaching

"immunize with all recommended vaccines"

which statement can be applied to the purpose of evaluating the nutrition of an older patient immobilized from dystonia?

"improved nutrition increases the patient's ability to perform reconditioning exercises" "there is a direct relation between the success of older adults' rehabilitation, risk for falls, and their nutritional status" "a nutritional assessment should be performed before developing the plan of care for an older adult experiencing immobility" "anorexia and insufficient assistance with eating lead to malnutrition, contributing to known problems associated with mobility"

the RN is teaching a nursing student about safety for equipment-related accidents. which statement by the nursing student indicates the need for further learning?

"make regular safety check of equipment"

what group is at the highest risk of lead poisoning?

infants

the is assessing a patient with impaired mobility. the nurse observes poor coordination and muscle weakness. which risk would the nurse anticipate in the patient?

injury

health care professionals have increased risk of musculoskeletal injuries, because their occupation involves lifting and transferring patients. how can the nurse reduce the risk of musculoskeletal injuries when lifting any person or object?

keep trunk erect and bend the knees

the senior is discussing with student nurses the serious reportable events included on the NQF list. which environmental event would be discussed?

patient death caused by burns from agency equipment, patient death associated with falls, patient death caused by electrocution

which level of prevention describes the nurse administering influenza vaccines to senior citizens at a health fair?

primary

which movement is assessed based on the line that divides the body into upper and lower regions when the nurse is observing the mobility of the joint?

pronation

a patient with which documented finding would be provided with a yellow wristband according to the AHA

risk of falls

to ensure safe use of oxygen in the home by a patient, which teaching point would the nurse include?

smoking is prohibited around oxygen, don'y use electrical equipment around oxygen, special precautions may be required when traveling with oxygen

according to the national quality forum, which event is considered a care-management event?

stage III pressure injury acquired after admission to a health care agency

the nurse suspects the client is experiencing _________. the nurse will notify the healthcare provider and prepare to _______ and _______________________

wound infection; culture the wound; administer the prescribed antibiotic

the nurse is preparing a dietary plan for a patient who has osteoporosis. which food would the nurse recommend to increase the patient's calcium level?

yogurt, cheese, green vegetables

which patient is at higher risk of motor vehicle accidents according to the CDC

16-year-old adolescent

which amount of the patient's weight is the nurse required to lift to validate using an assistive device in a patient who is fully dependent?

35

the incidence of suicidal tendency is highest in which age group?

adolescents