Fundamental Test 5
a nurse in a senior center is couseling a group of older adults about their nutritional needs and considerations. which of the following information should the nurse include. select all that apply 1. older adult are more prone to dehydration than younger adults are 2. older adult need the same amount of most vitamins and minerals as younger adults 3. many older men and women need calcium supplements 4. older adults need more calories than they did when they were younger 5. older adults should consume a diet low in carbohydrates
1, 2, 3
A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement 1. encourage the client to perform antiembolic exercises every 2 hours 2. instruct the client to cough and deep breathe every 4 hours 3. restrict the client's fluid intake 4. reposition the client every 4 hours
1. sequential pressure devices promote venous return in the deep vein of the legs and thus help prevent thrombus formations
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? select all that apply 1. suggest coping skills for the client to use in this situation 2. allow the client to provide input in the treatment plan 3. assist the client with time management, and address the client's priorities 4. provide extensive instruction on the client's treatment regimen 5. encourage the client in the expression of feeling and concerns
2, 3, 5
A patient has hemiplegia as a result of brain attack (cerebralvascular accident) which complication of immobility is a concern to the nurse? 1. dehydration 2. contraction 3. Inconinence 4. hypertension
2. contraction
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. the nurse should recoginze this response as which part of the general adaption syndrome? 1. Exhaustion stage 2. Resistance stage 3. Alarm stage 4. Recovery stage
3. The alarm stage of GAS, the body functions (blood pressure and heart rate) are heightened in order to respond to stressors
A nurse is caring a client who has been sitting in a chair for 1 hour. Which of the following complications is the greatest risk to the client? 1. Decreased subcantaneous fat 2. muscle atrophy 3. pressure injury 4. fecal impaction
3. The greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift his weight every 15 min and reposition the client after 1 hour
A nurse is caring for a client who requires a low residue diet. The nurse should expect to see which of the following foods on the clients meal tray? 1. cooked turkey 2. pureed broccoli 3. vanilla custard 4. lentil soup
3. a low residue diet consists of foods that are low in fiber and easy to digest. Daily product and eggs (custard and yogurt) are appropriate for a low residue diet
A patient has a cast from the hand to above the elbow because of a fractured ulna and radius. After the cast is removed, the nurse teaches the patient active range of motion exercises. Which patient action indicates that further teaching is necessary? 1. move the elbow to the point of resistance 2. keeps the elbow flexed at 90 degrees after the procedure 3. assess the elbow's response after this procedure 4. put the elbow through its full range at least 3 times
2. keeps the elbow flexed at 90 degrees after the procedure
A nurse is caring for a client who is at high risk of aspiration. Which of the following actions should the nurse take? 1. give the client thin liquid 2. instruct the client to tuck their chin when shallowing 3. have the client use a straw 4. encourage the client to lie down and rest after meals
2. tucking the chin when shallowing allows food to pass down the esophagus more easily
A nurse is transferring a patient from bed to wheelchair using a mechanical lift. Which is a basic nursing intervention associated with this procedure? 1. Lock the base lever in the open position when moving the mechanical lift 2. Raise the mechanical lift so that the patient is 6 inches off the mattress 3. Keep the wheels of the mechanical lift lock throughout the procedure 4. Ensure the patient feet are guarded when sitting on the mechanical lift
2. Raise the mechanical lift so that the patient is 6 inches off of the mattress
A nurse is evaluating a client's understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding. 1. "This device will keep me from getting sores on the skin" 2. This device will keep the blood pumping through my bed 3. With this device on, my leg muscles won't get a weak 4. This device is going to keep my joints in good shape
2. Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formations
A nurse is observing a client drawing up and mixing insulin. Which of the following finding should the nurse identify as an indication that psychomoter learning has taken place? 1. The client is able to discuss the appropiate technique 2. the client is able to demonstrate the appropriate technique 3. The client states an understanding of the process 4. the client is able to write the steps on a piece of paper
2. demonstrating the appropriate technique indicates psychomotor learning has taken place
A nurse is caring for a client who is postoperative. which of the following interventions should the nurse take to reduce the risk of thrombus development? select all that apply 1. instruct the client not to perform the valsalva maneuver 2. apply elastic stockings 3. review laboratory values for total protein level 4. place pillows under the client's knees and lower extremities 5. assist the client to change positions often
2. elastic stockings promote venous return and prevent thrombus formations 5. frequent position changes prevent venous stasis
A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. which of the following instructions should the nurse include? select all that apply 1. hold the cane on the right side 2. keep two points of the support on the floor 3. place the cane 38 cm (15 in) in front of the feet before advancing 4. after advancing the cane, move the weaker leg forward 5. advance the stronger leg so that it aligns evenly with the cane
1, 2, 4
A nurse is transferring a patient from the bed to a wheelchair which should the nurse do to quickly assess this patient's tolerance to the change in position. 1. Obtain a blood pressure 2. Monitor for bradycardia 3. Determine if the patient feels dizzy 4. Allow the patient time to adjust to the change in position
1. Obtain the blood pressure
A nurse is caring for a client who has left sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physcial limitation. The client is the primary wage earner in the family. Which of the following describes the client's role problem? 1. role conflict 2. role overload 3. role ambiguity 4. role strain
1. the client is experiencing role conflict because their career is extremely physcial, and they can no longer perform the job duties. however the client is the primary wage earner in the family
A nurse turns a patient's ankle so that the sole of the foot moves medially towards the midline. which word should the nurse use when Documenting exactly what was done during range of motion exercises. 1. Inversion 2. Adduction 3. Plantar flexion 4. Internal rotation
2. Adduction
A nurse in a provider's office is collecting data from the caregiver of a 12 month old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. learning has occurred in which of the following domain? 1.Cognitive 2. affective 3. psychomotor 4. kinesthetic
2. Affective learning has taken place because the client's idea about toilet training changed
A nurse is caring for a client whose partner passed away 4 months ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states, "how could you possibly understand what i am going through?" which of the following response should the nurse make? 1. "it takes time to get over the loss of a loved one" 2. "you are right, I cannot really understand. perhaps you'd like to tell me more about what you're feeling." 3. "Why don't you try something to take your mind off your troubles, like watching a funny movie." 4. "I might not share your exact situation, but i do know what people go through when they deal with a loss."
2. By stating there is a lack of understanding, the nurse is using the therapeutic communication technique of validation, whereby a person shows sensitivity to the meaning behind a behavior. The nurse is also creating a supportive and nonjudgemental environment.
A nurse is evaluating how well a client learned the information presented in an instructional session about following a heart healthy diet. which of the following actions should the nurse take to evalute the client's learning? 1. encourage the client to ask questions 2. ask the client to explain how to select or prepare meals 3. encourage the client to fill out an evalution form about how the nurse presented the information 4. ask weather the client has resources for further instruction of this paper
2. Having the client explain the information in their own words will allow the nurse to evalute what the client remembers and whether the client comprehends the information.
A nurse is providing preoperative education for a client who will undergo a masterectomy the next day. which of the following statements should the nurse identify as an indication that the client is ready to learn? 1. "i don't want my spouse to see my incision" 2. "will you give my plan medicine after the surgery" 3. "Can you tell me about how long the surgery will take"? 4. "My roomate listens to everything i say"
3. asking a concrete question about the surgery indicates that the client is ready to discuss the surgery. The client's new diagnosis of cancer can cause anxiety, fear, or depression. all of which can interfere with the learning process
A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? 1. Prescribing tasks unilaterally 2. delegating care to one member 3. speaking to the primary client privately 4. convening a family meeting
4. an open structure is loose, and convening a family meeting would give all family members input and an opportunity to express their feelings
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. she should explain that which of the following nutrients provide the body with the most energy ? 1. fat 2. protein 3. glycogen 4. carbohydrates
4. carbs are the body's greatest energy source, providing energy for the cells is the primary function they provide glucose, which burn completely and efficiently without end products to excrete. they are also a ready source of energy, and they spare protein from depletion
Which stage pressure ulcer requires the nurse to measure the extent of undermining? 1. stage 0 2. stage I 3. stage II 4. stage III
4. stage III
A nurse is preparing an instructional session for a client about stress incontinence. Which of the following actions should the nurse take first when meeting with the client? 1. Encourage the client to participate actively in learning 2. Select instructional material 3. identify goals the nurse and the client agrees are reasonable 4. determine what the client knows about stress incontinence
4. the first action to take using the nursing process is to assess or collect data from the client. determine how much the client knows about stress incontinence, the accuracy of the knowledge, and what the client needs to learn to manage this problem before instructing the client.
The nurse has completed client teaching regarding medication administration. Which client statement best illustrates compliance? 1. Im glad to know about my medications. It makes taking them a lot easier. 2. I already knew most of what you told me. 3. I think you should have waited until I was ready to go home. Maybe Id remember better. 4. If I take my medications as prescribed, Ill feel better.
Rationale 1: Compliance is best illustrated when the person recognizes and accepts the need to learn, then follows through with appropriate behaviors that reflect learning. Learning about the medications helps the client understand why theyre prescribed and improves the possibility for following the prescribed regimen.
At the completion of a teaching session, the nurse wants to evaluate the effectiveness of instruction. In a situation where the client was learning a bandaging technique, which would be the most effective evaluation? 1. Shared by the nurse and client 2. A return demonstration by the client 3. When the nurse is satisfied that the client can complete the technique 4. If the wound heals
Rationale 1: Both the client and the nurse should evaluate the learning experience. The client can tell the nurse what was helpful and provide a demonstration that shows mastery of the skill. The nurse needs to evaluate whether the client has an understanding of the rationale behind the technique.
The nurse is preparing to assist a client to a lateral position to position a bedpan. What action should the nurse take first? 1. Perform hand hygiene. 2. Move the client to the side of the bed. 3. Place the clients arm over the chest. 4. Raise the opposite side rail.
Rationale 1: Even though the intervention being performed is placing the client on a bedpan, the nurse should first perform hand hygiene. This prevents cross-transmission of infection from one client to another. Performing this hygiene in front of the client also increases the clients perception of the quality of care being provided and the nurses concern about infection control.
The client who is unconscious is developing foot drop. What nursing action is indicated? 1. Place high-topped shoes on the client while in bed. 2. Keep the linens on the end of the bed turned back to expose the feet. 3. Use only the prone and Sims positions for client positioning. 4. Use a device to elevate the linens off the feet.
Rationale 1: High-topped shoes will place the clients feet in the anatomical position of dorsal flexion.
The client has a history of postural hypotension. Which activities should the nurse advise this client as likely to cause postural hypotension? Standard Text: Select all that apply. 1. Hot baths 2. Heavy meals 3. Use of a rocking chair 4. Moving in bed 5. Bending down to the floor
Rationale 1: Hot baths can cause venous pooling in the lower extremities. Rationale 2: Heavy meals divert blood to the gastrointestinal organs. Rationale 5: Bending to the floor can cause rapid changes in blood pressure upon standing up again.
he nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should take which action? 1. Include what mobility is impaired. 2. Use Level 1, 2, 3, or 4 to describe immobility. 3. Describe what happens when the client attempts mobility. 4. Add strength assessment data.
Rationale 1: In order to make this broad nursing diagnosis more specific to the client, the nurse should include what mobility is impaired. For example, if the client cannot transfer from bed to chair, a more specific nursing diagnosis is Impaired Transfer Mobility.
A home health client having difficulty keeping his medication schedule organized says There are so many pills and the names are all confusing to me. I dont even understand what theyre for. What should the nurse do? 1. Help the client remember color and size in relationship to dosing time. 2. Write out the generic and trade name of all the pills for the client. 3. Fill a pill bar and tell the client not to worry, and just take the pills according to that system. 4. Have the physician talk to the client about his medications.
Rationale 1: Learning is facilitated by material that is logically organized and proceeds from the simple to the complex. This helps the learner comprehend new information, apply it to previous learning, and form new understandings. Naming the pills by color and size and dosing time helps the client move from that level to learning what each medication is for and why he is taking it simple to complex.
A home health nurse is working with a client who has pulmonary fibrosis. Of the following teaching priorities, which will take the highest priority? 1. Client will be able to set up and administer a nebulizer treatment by the end of the day. 2. Client will have increased activity level by the end of the week. 3. Client will be able to do activities of daily living (ADLs) without shortness of breath in 3 days. 4. Client will have a positive attitude about the diagnosis by the end of the month.
Rationale 1: Learning outcomes state the client behavior and are ranked according to priority. Nurses can use theoretical frameworks such as Maslows hierarchy of needs to establish priorities. In this case, the physiological need of learning how to administer medication takes priority over activity and attitudinal needs.
A school nurse is putting together a program for adolescents about positive lifestyle choices. What should the nurse keep in mind when preparing content to present to this age group? Standard Text: Select all that apply. 1. Based on learning outcomes 2. Current 3. Adjusted to the adolescent client 4. Based on sources available within the school system 5. Consistent with the teaching topics
Rationale 1: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be based on learning outcomes. Rationale 2: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be current. Rationale 3: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be adjusted to the learners age. Rationale 5: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be consistent with the information that the nurse is teaching.
The nurse has documented that the client has orthostatic hypotension. Which assessment finding would support this assessment? 1. Decrease in blood pressure when moving from supine to standing 2. Decrease in heart rate when moving from supine to sitting 3. Pale color in the legs when lying in bed 4. Complaints of dizziness when first sitting up
Rationale 1: Orthostatic hypotension occurs when the normal vasoconstriction reflex in the legs is dormant and the clients central blood pressure drops when moving from supine to sitting or to standing.
The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client? 1. Institute an exercise plan that includes weight-bearing activities. 2. Increase the amount of calcium in the clients diet. 3. Protect the clients bones with strict bed rest. 4. Provide the client with assisted range-of-motion exercising twice daily.
Rationale 1: Osteoporosis is a demineralization of the bone in which calcium leaves the bone matrix. One causative factor is lack of weight-bearing activity. Weight bearing helps to move calcium back into the bones, thereby strengthening them. A standard intervention for those attempting to prevent or reverse osteoporosis is beginning an exercise plan that includes weight-bearing activities.
The nursing diagnosis Readiness for Enhanced Knowledge (Nutrition) related to desire to improve nutritional intake has been formulated for a client who has decided to change his eating habits to be more nutritionally sound. What would be an appropriate outcome for this client? 1. Client will understand the importance of eating healthy. 2. Client will be able to lose weight. 3. Client will list foods that are nutritionally sound, low fat, and high fiber. 4. Client will appreciate the value of using the Food Guide Pyramid.
Rationale 3: Learning outcomes, like client outcomes, must be specific and observable so they can be measured.
The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? 1. Place a turn sheet on the bed. 2. Always use two personnel to move the client. 3. Stand at the head of the bed to pull the client up. 4. Slide the client toward the head of the bed. 5. Encourage the client to assist as possible.
Rationale 1: Placing a turn sheet on the bed will help overcome inertia and friction during moving. Rationale 2: Using two personnel will allow a lift and move rather than pulling or sliding the client over linens. Rationale 5: Encouraging the client to assist as much as possible will lighten the workload.
A nursing student is presenting a teaching project to the class using each of Blooms domains. The student has several activities included in the project. Which activity is an example of the affective domain? 1. Each member of the class must identify two attitudinal changes that have occurred in their lives since beginning their nursing education. 2. All members must list the technical skills theyve learned. 3. Members must demonstrate a favorite nursing skill at the end of the class period. 4. Members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class.
Rationale 1: The affective domain of Blooms theory of learning is also known as the feeling domain. It includes emotional responses to tasks such as feelings, emotions, interests, attitudes, and appreciations.
The nurse has completed a teaching session for a client with a tracheostomy. Documentation of the session should include what information? Standard Text: Select all that apply. 1. Diagnosed learning needs 2. Supplies required 3. Client outcomes 4. Need for additional teaching 5. Topics taught
Rationale 1: The parts of the teaching process that should be documented in the clients chart include diagnosed learning needs Rationale 3: The parts of the teaching process that should be documented in the clients chart include client outcomes. Rationale 4: The parts of the teaching process that should be documented in the clients chart include need for additional teaching. Rationale 5: The parts of the teaching process that should be documented in the clients chart include topics taught.
The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed is parallel to the stretcher and 1. slightly higher. 2. slightly lower. 3. at the same height. 4. at least 2 inches lower.
Rationale 1: When transferring a client from bed to gurney, the bed should be parallel to the stretcher and slightly higher. It is easier for the client to move down a slant to the new surface than to move up to a higher surface or to an even surface.
The nurse is assisting a newly delivered mother in ambulating to the nursery to see the baby. The client complains of light-headedness and begins to faint. What is the nurses most important action? 1. Ensure the clients modesty as she falls. 2. Be certain the client does not hit the head on anything. 3. Call for immediate assistance. 4. Check the vital signs and for excessive vaginal bleeding.
Rationale 2: All of these actions are important, but the priority is ensuring the client does not strike her head on anything when falling. The nurse should ease the client down while supporting her body against the nurse, protecting the head and laying it gently on the floor.
A nurse is working with the family of a child who is hospitalized with asthma. The family members speak little English, and the child is being sent home on nebulizer treatments as well as an inhaler. In addition to enlisting an interpreter to help with the language barrier, the nurse should 1. provide written instructions before discharge. 2. address any healing beliefs the family has. 3. make sure the child comes back for the follow-up appointment. 4. make sure the parents can set up the treatments for their child.
Rationale 2: If the prescribed treatment conflicts with the client/familys cultural healing beliefs, the client may not be compliant with the recommended treatments. To be effective, nurses must deal directly with any conflicts and differing values held by the client.
A nurse is working in a neonatal intensive care unit, teaching parents how to care for their tiny babies while they are still in the hospital. Which statement by a parent reflects a readiness to learn? 1. Im so afraid Ill hurt my baby with all these tubes. 2. I want to make sure my spouse is here, in case I dont hear everything thats said. 3. When my baby is just a little bigger, Ill be able to handle him. 4. Youll give us written instructions before we go home, correct?
Rationale 2: Readiness to learn is the demonstration of behaviors or cues that reflect a learners motivation, desire, and ability to learn at a specific time. The client who wants the spouse involved is demonstrating motivation and willingness, but also wants support from the spouse as well.
A client being discharged after a myocardial infarction has been prescribed several new medications and a low-fat diet. The client states: Im never going to understand what to do, when to do it, and why I should be doing all these things. Which nursing diagnosis should the nurse formulate for this client? 1. Health-Seeking Behavior related to desire to prevent heart problems 2. Deficient Knowledge (diet and medication regimen) related to inexperience 3. Noncompliance related to situational factors 4. Risk for Myocardial Infarction related to deficient knowledge
Rationale 2: The NANDA label Deficient Knowledge is used when the client is seeking health information or when the nurse has identified a learning need, as in this case. The area of deficiency (diet and medication regimen) should always be included in the diagnosis.
The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching? Standard Text: Select all that apply. 1. Hold the cane on the weaker side of the body. 2. Move the cane forward while the body weight is between both legs. 3. The length of the cane should permit the elbow to be fully extended. 4. Move the weaker leg forward while the weight is between the cane and the stronger leg. 5. Move the stronger leg forward while the weight is between the cane and the weaker leg.
Rationale 2: The cane should be moved forward while the body weight is borne by both legs. Rationale 4: The weaker leg is moved forward while the weight is borne by the cane and stronger leg. Rationale 5: The stronger leg is moved forward while the weight is borne by the cane and weak leg.
A community health nurse runs a clinic that provides health screening to mainly Mexican American and Native American clients. The nurse wants to have a class on smoking cessation for interested adults of this group. In order to adjust to their time orientation, what is the best action of the nurse? 1. Make sure that the classes are held at specific times. 2. Begin classes when a group of clients are gathered. 3. Mail letters ahead of time to make sure clients are informed about the upcoming class. 4. Make posters and place them in areas of the community frequented by these groups.
Rationale 2: The nurse must be quite flexible, treat the cultures beliefs with respect, and not expect that cultural practices will change to reflect the nurses needs.
The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse? 1. Percuss for flatness over the liver. 2. Palpate for bladder fullness. 3. Use the p.r.n. order to medicate the client with an antacid. 4. Inspect the sacral area for edema.
Rationale 2: The nurse should palpate for bladder fullness that could cause this discomfort.
The nurse is caring for a client experiencing dyspnea. In which position should the nurse place this client? 1. High Fowlers position with two pillows behind the head 2. Orthopneic position across the overbed table 3. Prone position with knees flexed and arms extended 4. Sims position with both legs flexed
Rationale 2: The orthopneic position across the overbed table facilitates respiration by allowing maximum chest expansion.
A client is practicing using an incentive spirometer after surgery. The nurse has explained the use, demonstrated how it works, and also given the rationale for the client to continue to use this device. When mastering the use of this device, the client will demonstrate learning in which of Blooms domains? 1. Cognitive 2. Psychomotor 3. Affective 4. Imitation
Rationale 2: The psychomotor domain is the skill domain and includes motor skills, such as being able to use an incentive spirometer.
The nurse is assisting in logrolling a client recovering from spinal surgery. Why should the nurse place a pillow between the clients legs when turning? 1. Stabilizes the spine 2. Prevents hip contractures 3. Supports the upper leg 4. Keeps the legs parallel and aligned 5. Prevents adduction of the upper leg
Rationale 3: A pillow between the clients legs when logrolling supports the upper leg when the client is turned. Rationale 4: A pillow between the clients legs when logrolling keeps the legs parallel and aligned. Rationale 5: A pillow between the clients legs when logrolling prevents adduction of the upper leg.
What is the priority action of the nurse prior to transferring a client from bed to wheelchair? 1. Place the bed in its lowest position. 2. Place the wheelchair parallel to the bed. 3. Lock the brakes on the bed. 4. Place a transfer belt on the client.
Rationale 3: Although all of these activities address important safety issues, the most important is to lock the wheels on the bed. If the wheels are not locked and the bed moves out from under the client, none of the other safety actions will likely prevent a fall or near fall.
A nurse is planning a community health education project that deals with organ donation, and the target audience is a group of adults. When following andragogy concepts, the nurse should make sure that the teaching includes which information? 1. Past statistics about organ donors 2. Written pamphlets 3. Directions about how to become an organ donor 4. Information on how this group can influence their children
Rationale 3: An adult is more oriented to learning when the material is useful immediately, not sometime in the future. For this audience, giving clear directions on how to become an organ donor would be more helpful than past information and future activities such as influencing their children.
The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? 1. The UAP 2. A licensed practical (vocational) nurse 3. A registered nurse 4. It makes no difference
Rationale 3: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. The registered nurse must assess and evaluate the clients response to the ambulation. Once the client has successfully ambulated, any nursing staff member can assist. The registered nurse should make assistive personnel aware of potential untoward effects of ambulation and of what to report to the nurse.
While assisting the client with a bath, the nurse encourages full range of motion in all the clients joints. Which activity would best support range of motion in the hand and arm? 1. Give the client a washcloth to wash the face. 2. Move the wash basin farther toward the foot of the bed so the client must reach for it. 3. Have the client brush the hair and teeth. 4. Move each of the clients hand and arm joints through passive range of motion.
Rationale 3: Brushing the hair and teeth includes more of the joints of the hands and the arms than does washing the face
A client who is legally blind requires vitamin B12 injections every 2 weeks and insists on self-administration. What is the best way for the nurse to assist this client? 1. Teach the spouse to draw up the medication, then the client can give the injection. 2. Make sure that the injection is scheduled during a visit, so the nurse can supervise. 3. Prefill syringes with the correct dose, so the client can use them for self-administration. 4. Schedule the clients clinic appointments in accordance with the dosing schedule, then give the injection when the client is at the clinic.
Rationale 3: Clients who have visual impairment may need the assistance of a support person or creative care in order to remain compliant with their treatment. Because the client insists on self-administration, prefilling syringes (and keeping them away from light and heat) would be a plausible solution. The client is concerned with independence, and allowing the client to maintain that would be quite important.
The nurse is instructing a client on self-administration of insulin. Which statement regarding feedback will be most beneficial to the client? 1. You know, there are children who can learn to do this. 2. Maybe it would be better if we taught your spouse to help you with this. 3. Next time, dart the needle in your skin, instead of pushing it in. 4. If you dont learn this, you cant be discharged.
Rationale 3: Feedback should be meaningful to the learner and should support the desired behavior through praise, positively worded corrections, and suggestions of alternative methods.
A nurse is presenting teaching sessions to a group of residents in a home for long-term physical rehabilitation. Which client exhibits the highest motivation? 1. An individual who has been struggling with following nursing directives regarding discharge goals 2. The client who has just moved in and is already waiting for discharge 3. A client who is excited to learn about his new prosthesis 4. A client who has been there the longest and is a great coach for newcomers
Rationale 3: Motivation is the desire to learn and influences how quickly and to what extent a person learns. It is generally greatest when a person recognizes a need and believes the need will be met through learning. The client who is excited to learn about his prosthesis understands that learning about it will help take his recovery to a high level.
The nurse is going to be working with a client who has a permanent colostomy and is ready to go home within the next several days. When organizing the teaching/learning experience, the nurse should 1. start from the beginning and proceed through all material. 2. break up sessions into shortened time periods. 3. discover what the learner knows before proceeding with further teaching. 4. make sure the clients spouse is present before the teaching session begins.
Rationale 3: Nurses should save time in constructing their own teaching sessions and should follow basic guidelines when sequencing the learning experience. The nurse should find out what the learner knows, and then proceed to the unknown. This gives the learner confidence. This information can be elicited either by asking questions or by having the client take a pretest or fill out a form.
The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this clients plan of care? 1. Frequent position changes to reverse the contractures 2. Exercises to strengthen flexor muscles 3. Range-of-motion exercises to prevent worsening of contractures 4. Weight-bearing activities to stimulate joint relaxation
Rationale 3: Once contractures occur they are irreversible except by surgical intervention. The best nursing intervention is to keep the contractures from getting tighter (or worse) by providing range-of-motion exercises.
The nurse is providing range-of-motion exercising to the clients elbow when the client complains of pain. What action should the nurse take? 1. Stop immediately and report the pain to the clients physician. 2. Discontinue the treatment and document the results in the medical record. 3. Reduce the movement of the joint just until the point of slight resistance. 4. Continue to exercise the joint as before to loosen the stiffness.
Rationale 3: Range-of-motion exercising should never cause discomfort. In this case, the best action is to reduce the movement of the joint just until the point of slight resistance is felt and evaluate the pain response at that level. If there is no pain, the exercise can be continued.
The clients chief complaint is, I just cant get around like I used to. I have to stop halfway up the stairs to the bedroom, and just walking to the bathroom makes me so tired. Which nursing diagnosis is most likely appropriate for this client? Activity Intolerance: 1. Level 1. 2. Level 2. 3. Level 3. 4. Level 4.
Rationale 3: The NANDA diagnosis Activity Intolerance is further individualized to the clients level of intolerance. Level 3 (this clients level) indicates ability to walk no more than 50 feet on level ground without stopping and inability to climb one flight of stairs without stopping.
During a prenatal visit, the nurse is instructing a newly pregnant client in regard to exercise. What advice is best for the nurse to give this client? 1. Pregnant clients can exercise if exercise was a part of their life prior to pregnancy. 2. Due to the stress of a growing fetus, exercise should be limited to no more than 10 minutes per day. 3. Healthy pregnant women should exercise at least 30 minutes on most if not all days. 4. The pregnant womans exercise should actually increase above normal recommended levels to prevent water weight gain.
Rationale 3: The current recommendation of the American College of Obstetricians and Gynecologists is for healthy pregnant women to get as much exercise as the general population (30 minutes on most if not all days). This is a change from the previous recommendation that pregnant women can exercise.
When planning care, the nurse should identify which client as needing logrolling for position changes? 1. A client with documented pneumonia 2. The client who has had abdominal surgery 3. The client who fell from a house, sustaining a fractured tibia 4. A client who has a severe headache from hypertensive crisis
Rationale 3: The logrolling technique is used in moving any client who may have sustained a spinal injury. Of these clients, the most concern is for the client who fell from a house.
The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? 1. Toward the nearest corner of the head of the bed 2. Toward the side of the bed 3. Toward the far corner of the foot of the bed 4. Directly toward the client
Rationale 3: The nurse should face the far corner of the foot of the bed because this is the direction in which movement will occur.
The bed-bound client complains of pain and burning in the right calf area. What action should be taken by the nurse? 1. Deeply palpate the area for rebound tenderness. 2. Percuss over the area for change in tone. 3. Measure the calf and compare to the opposite calf. 4. Medicate the client for pain and reassess in 30 minutes.
Rationale 3: The nurse should measure the calf and compare it to the opposite calf. The client may be developing a deep vein thrombosis or thrombophlebitis.
The nurse is instructing a client on self-administration of a subcutaneous injection. The nurse is using which theoretical construct of learning? 1. Thorndikes behaviorism 2. Skinners positive reinforcement 3. Pavlovs conditioning response 4. Banduras imitation
Rationale 4: Bandura claims that most learning comes from observation and instruction. Imitation is the process by which individuals copy or reproduce what they have observed.
The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. Which technique should the nurse use to protect the back? 1. Place the feet together to provide a strong base of support. 2. Flex the knees to lower the center of gravity. 3. Face the box, pick it up, and rotate the upper body toward the table. 4. Hold the box as close to the body as possible.
Rationale 4: In order to pick up this box as safely as possible, the nurse should hold the box as close to the body as possible.
A client with an incision necessitating a complex dressing change is being discharged and will require continued dressings at home. Which statement by the client indicates a need to postpone teaching? 1. Its going to take time for me to understand this whole thing. 2. Lets make sure my spouse is around before you start explaining. 3. I wish my doctor would have explained this more in depth. 4. Im feeling nauseous, but go ahead and start anyway.
Rationale 4: Learning can be inhibited by physiologic events such as illness, pain, or sensory deficits. The client must be able to concentrate and apply adequate energy to the learning or the learning itself will be impaired. If the client is experiencing nausea, the nurse should first try to reduce this symptom before beginning the teaching session.
A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the clients motivation to learn? 1. Demonstrating the finger stick on the nurse 2. Offering to do the procedure for the client each time it is scheduled 3. Teaching the clients support system how to perform the procedure 4. Encouraging the clients participation each time the procedure is performed
Rationale 4: Nurses can increase a clients motivation in several ways, including encouragement of self-direction and independence.
The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? 1. Nurses must wear back belts when lifting clients. 2. All nursing personnel must attend annual body mechanics education. 3. In order to prevent injury, nurses must strive to become physically fit. 4. No solo lifting of clients is permitted in the facility.
Rationale 4: The only option that has any influence on frequency of back injury is a practice prohibiting solo lifting.
The nurse is working with a group of older clients through a community senior citizens center. Utilizing an understanding of health literacy, the nurse will make sure that 1. information given to this group is written at a third-grade level. 2. teaching includes a variety of approaches. 3. information includes pictures. 4. there is ample time for teaching.
Rationale 4: When working with the older population, the nurse must realize that increased time for teaching is necessary because processing of information is slower. Health literacy skills are often limited in older adults.
