Functional Ability PrepU

The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?

"I have difficulty breathing when walking 30 feet." Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. The client would feel cold and not hot. The client is fatigued and able to sleep often with a decrease in appetite, not an increase.

A client with post-polio syndrome displays fatigue and decreased muscle strength. How should the nurse best respond to the client?

"Intravenous immunoglobulin infusion may help you." There is no specific treatment for post-polio syndrome; however, the infusion of IV immunoglobulin has been shown to help with the physical pain and weakness. Sleeping and relaxation may not assist the client with post-polio syndrome. The syndrome is very common and is most likely related to the past diagnosis of polio.

If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment?

A client with a lower motor neuron lesion would be expected to have decreased muscle tone. Those with upper motor neuron lesion would have hyperactive reflexes, no muscle atrophy, and muscle spasticity.

During assessment of a patient with a hearing loss, the nurse notes a defect in the tympanic membrane. The nurse documents this disturbance as a loss known as:

A defect in the tympanic membrane or interruption of the ossicular chain disrupts normal air conduction, which results in a conductive hearing loss.

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.

ADLs refer to those activities related to personal care, such as bathing, using the toilet, and eating. Cleaning and cooking are independent ADLs--activities that are important for independent living.

An elderly client with chronic osteoarthritis has difficulty ambulating and is seeking a prescription for a walker. How should the nurse categorize the client's disability?

Acquired disabilities may be progression of a chronic disorder, such as arthritis. Developmental disabilities are those disabilities that occur any time from birth to 22 years and may result in impairment of physical or mental health, cognition, speech, language, or self-care. Sensory disabilities affect hearing or vision. Age-related disabilities are conditions from age, not a chronic disease.

The nurse is advising a client with multiple sclerosis on methods to minimize spasticity and contractures. Which of the following techniques would the nurse instruct the client to perform?

Apply warm packs to the affected area.

The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?

Assessment of the movement of the tongue is related to cranial nerve XII, the hypoglossal nerve. Cranial nerve I is the olfactory nerve. Cranial nerve V is the trigeminal nerve responsible for sensation to the face and chewing. Cranial nerve XI is the spinal or accessory nerve responsible for head and shoulder and shoulder movement.

At which of the following spinal cord injury levels does the patient have full head and neck control?

At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.

A client is color blind. The nurse understands that this client has a problem with:

Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isn't involved with color perception.

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

Ischial tuberosity

The diagnosis of multiple sclerosis is based on which test?

Magnetic resonance imaging (MRI)

The nurse has admitted a client who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue?

Pulmonary function studies are performed to determine whether the planned resection will leave sufficient functioning lung tissue. ABG values are assessed to provide a more complete picture of the functional capacity of the lung. Exercise tolerance tests are useful to determine if the client who is a candidate for pneumonectomy can tolerate removal of one of the lungs. Preoperative studies, such as a chest x-ray, are performed to provide a baseline for comparison during the postoperative period and to detect any unsuspected abnormalities.

One of the students asks what the consequences of uncorrected, left-sided heart failure would be. What would be the nursing instructor's best response?

Right-sided heart failure If uncorrected, left-sided heart failure is followed by right-sided heart failure because the circulatory system is a continuous loop. With left-sided congestive heart failure, auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. If the right side of the heart fails to pump efficiently, blood becomes congested in the neck veins, and the nurse may inspect the distention of external jugular vein.

A male client has been unable to return to work for 10 days following chemotherapy as the result of ongoing fatigue and inability to perform usual activities. Laboratory test results are WBCs 2000/mm³, RBCs 3.2 x 10¹²/L, and platelets 85,000/mm³. The nurse notes that the client is anxious. Which of the following is the priority nursing diagnosis?

Risk for infection related to inadequate defenses Physiological needs, such as risk for infection, take priority over the client's other needs.

Which connective tissue disorder is characterized by insoluble collagen being formed and accumulating excessively in the tissues?

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.

Which of the following disorders is characterized by an increased autoantibody production?

Systemic lupus erythematosus (SLE) SLE is an immunoregulatory disturbance that results in increased autoantibody production. 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. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.

A patient was recently diagnosed with a cortical cataract in his left eye. His wife asks the nurse for information about his diagnosis. The nurse explains that:

The cataract should have little or no effect on his vision. A cortical cataract involves the anterior, posterior, or equatorial cortex of the lens. A cataract in the equator or periphery of the cortex does not interfere with the passage of light through the center of the lens and has little effect on vision. Cortical cataracts progress at a highly variable rate. Vision is worse in very bright light.

A male client recovering from a stroke is receiving anticoagulant therapy. Which item will the nurse instruct the client to use for self-care?

The client is taking an anticoagulant, which increases the risk of bleeding. Because of this, the client should be instructed to use an electric razor, which will decrease the risk of causing bleeding while shaving. A loofah sponge is coarse and is often used to exfoliate the skin. The use of this item could scratch the skin and cause bleeding. A long-handle shoe horn would not help prevent the client from bleeding. A hard-bristled toothbrush could scratch the gums and other oral tissue and cause bleeding.

The nurse caring for a client with Ménière's disease needs to assist with what when the client is experiencing an attack?

The client with Ménière's disease requires a great deal of emotional support because of the unpredictability of the attacks and the resulting impairments. During an attack, the nurse administers prescribed drugs, limits movement, and promotes the client's safety. He or she assists the client with activities of daily living because the least amount of motion can produce severe vertigo. The nurse cannot assist with sleeping, coughing. Option D is a distractor for this question.

The nurse at the eye clinic is caring for a patient with suspected glaucoma. What complaint would be significant for a diagnosis of glaucoma?

The presence of halos around lights Glaucoma is often called the "silent thief of sight" because most patients are unaware that they have the disease until they have experienced visual changes and vision loss. The patient may not seek health care until he or she experiences blurred vision or "halos" around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and headache.

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain?

The trigeminal nerve (cranial nerve V) innervates the forehead, cheeks, and jaw, so pain in the face elicited when brushing the teeth would most likely involve this nerve.

When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina?

Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to:

When using an incentive spirometer, the client should be sitting or in the semi-Fowler's position. The client is to inhale, hold the breath for about 3 seconds, and then exhale slowly. Coughing occurs with the use of the incentive spirometer and is encouraged. The client should use the spirometer 10 times every hour while awake.

When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided?

swimming The nurse provides the client and family with the following postoperative instructions: water should not enter the stoma because it will flow from the trachea to the lungs. Therefore, the nurse instructs the client to avoid swimming and to use a handheld shower device when bathing. The nurse also suggests that the client wear a scarf over the stoma to make the opening less obvious. The nurse encourages the client to cough every 2 hours to promote effective gas exchange.

The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include?

"You can use writing or a communication board to communicate." If a total laryngectomy is scheduled, the client must understand that the natural voice will be lost but special training can provide a means for communicating. The client needs to know that until training is started, communication will be possible using the call light, through writing, or using a special communication board. The use of an electronic device is a long-term postoperative goal. The speech therapist will evaluate the client before surgery and establish a method of immediate postoperative communication.

The nurse is caring for a client with a history of bulimia. The client complains of retrosternal pain and dysphagia after forcibly causing herself to vomit after a large meal. The nurse suspects which condition?

Boerhaave syndrome, a spontaneous rupture of the esophagus after forceful vomiting (may occur after eating a large meal), is characterized by retrosternal pain, dysphagia, infection, fever, and severe hypotension. Halitosis (bad breath) is a symptom of pharyngoesophageal pulsion diverticulum, also known as Zenker diverticulum. A periapical abscess (an abscessed tooth) is characterized by dull, gnawing continuous pain, cellulitis, and edema and mobility of the involved tooth.

A nurse has taught a client how to perform quadriceps-setting exercises. The nurse determines that the client has understood the instructions when he demonstrates which of the following?

Pushes the popliteal area against the mattress while raising the heel

A client comes to the clinic for evaluation because of complaints of dizziness and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain?

Cerebellum Findings such as ataxic or staggering gait, dizziness, marked muscle incoordination, and nystagmus suggest a cerebellar tumor. A frontal lobe tumor frequently produces personality, emotional, and behavioral changes. A tumor in the motor cortex produces seizure-like movements localized on one side of the body. Occipital lobe tumors produce visual manifestations.

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following?

Client does not reach the toilet before experiencing voiding. Functional incontinence is incontinence in clients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and cannot reach and use the toilet before soiling themselves. Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Urge incontinence is the involuntary elimination of urine associated with a strong perceived need to void. Stress incontinence is associated with weakened perineal muscles that permit leakage of urine when intraabdominal pressure is increased, such as with coughing or sneezing.

Which of the following type of fracture is associated with osteoporosis?

Compression fractures are caused by compression of vertebrae and are associated frequently with osteoporosis. Stress fractures occur with repeated bone trauma from athletic activities, most frequently involving the tibia and metatarsals. An oblique fracture runs across the bone at a diagonal angle of 45 to 60 degrees. A simple fracture (closed fracture) is one that does not cause a break in the skin.

This type of disability represents one that occurs any time from birth to 22 years and results in impairment of physical or mental health, cognition, speech, language, or self-care.

Developmental disabilities occur any time from birth to 22 years and result in impairment of physical or mental health, cognition, speech, language, or self-care. Examples are spina bifida, cerebral palsy, and Down syndrome. An example of an acquired disability is a traumatic brain injury. An age-related disability is hearing loss or osteoporosis. An acute nontraumatic disorder is a stroke.

A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with left-sided stroke?

Expressive aphasia, defects in the right visual fields, problems with abstract thinking are symptoms of left hemispheric stroke. Impulsive behavior, poor judgment, deficits in left visual fields are symptoms of right hemispheric stroke.

Which of the following refers to fixation of a joint?

Fixation of a joint, called ankylosis, eliminates friction, but at the drastic cost of immobility. Inflammation is manifested in the joints as synovitis. Pannus has a destructive effect on the adjacent cartilage and bone. Articulations are joints.

A client with a spinal cord injury is prescribed to be transferred out of bed to a chair. Which action will the nurse take to prepare the client to be in a seated position?

Gradually raise the head of the bed to 90 degrees. Some conditions, such as spinal cord injury (SCI), that require extended periods in the recumbent position prevent the client from assuming an upright position at the bedside. When getting a client with a SCI out of bed, the nurse will gradually raise the head of the bed to a 90-degree angle; this often takes 10 to 15 minutes. Raising the head of the bed 45 degrees is not sufficient to prepare the client to be in a seated position. The client should not be brought to a seated position by supporting the back and shoulders, as this does not provide the necessary support nor the slow, gradual transition from recumbent to sitting upright than is required in clients with SCI. Raising the upper body while swinging the legs over the side of the bed will not prepare the client to be in a seated position, as this is too fast of a transition to upright for a client with SCI.

A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?

In a partial laryngectomy, a portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing. During a supraglottic laryngectomy, a tracheostomy is left in place until the glottic airway is established. Hemilaryngectomy is done by splitting the thyroid cartilage of the larynx in the midline of the neck, and the portion of the vocal cord is removed with the tumor. During a total laryngectomy, a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea.

Which of the following maybe the first and only physical sign of symptomatic osteoarthritis (OA)?

Limited passive movement can be the first and only physical sign of symptomatic OA. Physical assessment of the musculoskeletal system reveals joint enlargement, joint instability, and limb shortening.

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia.

The nurse is performing an assessment of the visual fields for a patient with glaucoma. When assessing the visual fields in acute glaucoma, what would the nurse expect to find?

Marked blurring of vision Glaucoma is often called the "silent thief of sight" because most patients are unaware that they have the disease until they have experienced visual changes and vision loss. The patient may not seek health care until he or she experiences blurred vision or "halos" around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and headache.

Which joint is most commonly affected in gout?

Metatarsophalangeal

A patient with a history of hypothyroidism is admitted to the intensive care unit unconscious and with a temperature of 95.2ºF. A family member informs the nurse that the patient has not taken thyroid medication in over 2 months. What does the nurse suspect that these findings indicate?

Myxedema coma is a rare life-threatening condition. It is the decompensated state of severe hypothyroidism in which the patient is hypothermic and unconscious (Ross, 2012a). This condition may develop with undiagnosed hypothyroidism and may be precipitated by infection or other systemic disease or by use of sedatives or opioid analgesic agents. Patients may also experience myxedema coma if they forget to take their thyroid replacement medication.

An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate?

Refractive changes, such as presbyopia, occur in older adults where the lens cannot readily accommodate aging. In such cases, the client is observed holding reading materials at an increasing distance to focus properly. In case of a cataract, the client should report increased glare, decreased vision, and changes in color perception. Macular degeneration affects the central vision. Myopia is the inability to see things at a distance clearly.

The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?

There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement.

A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate, I can't control it and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?

Urge incontinence occurs when the client experiences the sensation to void but cannot control voiding in time to reach a toilet. Stress incontinence occurs when the client has an involuntary loss of urine that results from a sudden increase in intra-abdominal pressure. Overflow incontinence occurs when the client experiences an involuntary loss of urine related to an over distended bladder; the client voids small amounts frequently and dribbles. Functional incontinence occurs when the client has function of the lower urinary tract but cannot identify the need to void or ambulate to the toilet.

The nurse is discussing life management with the client with rheumatoid arthritis in a health clinic. What assessment finding indicates the client is having difficulty implementing self-care?

increased fatigue Fatigue is common with rheumatoid arthritis. Finding a balance between activity and rest is an essential part of the therapeutic regimen. The client is reporting being able to do ADLs and decreased joint pain. The client's weight gain of 2 pounds does not correlate with self-care problems.