NSG 310 - Foundations - Davis Edge for Lecture 11 (Ch 32, 34)

3 (Rationale Option 1: The need for sleep increases, not decreases, because of the physical demands of pregnancy. In addition, pregnant women often have a decreased quality of sleep because a comfortable position may be difficult to assume as the uterus enlarges. Option 2: Adolescents need more, not less, sleep than the average young adult because of accelerated growth and high energy expenditure. Adolescents need 8 to 10 hours of sleep a day. Option 3: Half of all older adults have difficulty sleeping. Insomnia is the most commonly reported issue. Frequent awakening, physical discomfort and pain, and shortened REM sleep associated with aging contribute to a decrease in the quality of sleep. Older adults sleep 5 to 7 hours daily and often take a daytime nap. Option 4: Older adults have a decrease, not increase, in sleep efficiency. The fact that older adults sleep only 5 to 7 hours a day is a result of a decreased need for sleep, not a more efficient sleep time than younger people.)

Question 1. What concept associated with developmental factors and quality of sleep must the nurse understand to best plan patient care? 1. Pregnant women have a decreased need for sleep. 2. Adolescents need less sleep than the average young adult. 3. Aging is associated with an increased risk of sleep disorders. 4. Healthy older adults have more efficient sleep cycles than younger people.

2 (Option 1: Moving patients with a mechanical lift is within the scope of nursing practice and a practitioner's order is unnecessary. Option 2: The longer straps/chains go in the holes for the seat support, which keep the legs and pelvis below the upper body. Appropriate placement of the upper and lower straps/chains creates a bucket seat in which a patient is moved safely. Option 3: This may result in the patient sliding down and out of the sling during the transfer. Nylon, net, or canvas slings are available. Option 4: It does not matter whether the feet or the head exit the bed first as long as functional alignment and safety are maintained.)

Question 20. A nurse must transfer a patient from a bed to a chair using a mechanical lift. What should the nurse do? 1. Ensure that there is a practitioner's order to move the patient using this device 2. Hook the longer straps on the end of the sling closest to the patient's feet 3. Place a sheepskin inside the sling so that it is under the patient 4. Lead with the patient's feet when exiting the bed Rationale

4 (Rationale Option 1: This movement achieves hyperextension. Option 2: This movement achieves adduction. Option 3: This movement achieves external rotation. Option 4: This movement achieves internal rotation.)

Question 8. A nurse is performing range-of-motion exercises for a patient who had a brain attack (cerebrovascular accident) in order to prevent contractures. How should the nurse move the patient's hip when performing internal rotation? 1. Position the leg behind the body. 2. Move the leg laterally across the midline of the body. 3. Turn the leg and foot pointing away from the other leg. 4. Rotate the leg and foot pointing inward toward the other leg.

2 (Rationale Option 1: A confused patient may be at risk for an injury, not a pressure ulcer. Confused patients are capable of moving. Option 2: Paralysis of the lower extremities results in reduced mobility; maintaining one position compresses the capillary beds, which causes tissue hypoxia, resulting in pressure (decubitus) ulcers. Option 3: A patient with hypotension is at risk for falls, not pressure ulcers, because hypotension can cause dizziness and syncope. Option 4: A patient who is disoriented may be at risk for an injury, not a pressure ulcer. Disoriented patients are capable of moving. Test Taking Tip: The word "highest" in the stem sets a priority. Options 1 and 4 are equally plausible. Option 2 is unique because it is the only option that does not end in "-ion.")

Question 1. Which problem will place a patient at the highest risk for developing a pressure (decubitus) ulcer? 1. Confusion 2. Paraplegia 3. Hypotension 4. Disorientation

2, 4 (Rationale Option 1: Ambulation will not prevent blood loss that results in hypovolemia. Option 2: Ambulation promotes intestinal peristalsis that may result in a bowel movement. Option 3: Supporting the incisional site during coughing and deep breathing helps to prevent dehiscence, not complications related to immobility. Option 4: Ambulation promotes deep breathing that helps the alveoli expand. Option 5: The use of sterile technique and hand washing helps prevent infection.)

Question 13. A nurse is assisting a postoperative patient to ambulate. Which postoperative complications will ambulation help prevent? Select all that apply. 1. Hypovolemia 2. Constipation 3. Dehiscence 4. Atelectasis 5. Infection

1 (Rationale Option 1: Nonblanchable erythema refers to redness of intact skin that persists when finger pressure is applied. This is the classic sign of a stage I pressure ulcer. Option 2: Circumoral cyanosis is associated with hypoxia, not pressure ulcers. Option 3: With necrosis, death of cells has occurred. Necrosis occurs in stage III and stage IV pressure ulcers. Option 4: With an abrasion, the superficial layers of the skin are scraped away. This stage II, not stage I, pressure ulcer appears reddened and may exhibit localized serous weeping or bleeding.)

Question 15. Which is the earliest nursing assessment that indicates permanent damage to tissues because of compression of soft tissue between a bony prominence and a mattress? 1. Nonblanchable erythema 2. Circumoral cyanosis 3. Tissue necrosis 4. Skin abrasion

1 (Rationale Option 1: The shoulder, a ball-and-socket joint, flexes by raising the arm from a position by the side of the body forward and upward to a position beside the head. Option 2: Supination occurs when the hand and forearm rotate so that the palm of the hand is facing upward. Option 3: Opposition is the touching of the thumb of the hand to each fingertip of the same hand. Option 4: Hyperextension of the arm occurs by moving an arm from a resting position at the side of the body to a position behind the body.)

Question 16. The nurse raises a patient's arm over the head during range-of-motion exercises. What word should the nurse use when documenting exactly what was done during range-of-motion exercises? 1. Flexion 2. Supination 3. Opposition 4. Hyperextension

3 (Rationale Option 1: A back rub invades personal space and should be administered according to a patient's need and preference; a back rub may be contraindicated in certain clinical situations, such as myocardial infarction or back surgery. Option 2: In an unfamiliar environment, turning the lights off can precipitate confusion or disorientation; a small light provides visual cues if a person awakens at night. Option 3: Usual routines meet self-identified needs and reduce anxiety because they provide a familiar pattern. Option 4: Sleeping medication should not be administered until all nondrug approaches fail to achieve sleep.)

Question 16. What should the nurse do to best promote rest and sleep in the hospital for all patients? 1. Provide a back rub at bed time. 2. Turn the lights off at night. 3. Encourage usual routines. 4. Administer a sedative.

2 (Rationale Option 1: Muscle strain is reduced when moving patients with gravity, not with the added effort needed to move patients against gravity. Option 2: To exert an upward lift the gluteal and leg muscles should be used, rather than the sacrospinal muscles of the back. These larger muscles fatigue less quickly, and their use protects the intervertebral disks. Option 3: Bending from the waist increases the strain on the sacrospinal muscles and intervertebral disks. Option 4: The muscles of the legs are used inefficiently when the knees are kept locked. This increases the strain on the other muscles being used.)

Question 17. A nurse is planning to help move a patient up in bed. What can the nurse do to reduce the risk of self-strain when performing this action? 1. Move the patient up against gravity 2. Use the large muscles of the legs 3. Bend the body from the waist 4. Keep the knees locked

3 (Rationale Option 1: At this time of day, most people are engaged in stimulating activities and generally are not sleepy. Option 2: By this time of the sleep cycle, most people have had sufficient sleep and are beginning to awaken. Option 3: Research has demonstrated that most people experience sleep-vulnerable periods between 2 AM and 6 AM and between 2 PM and 5 PM. Option 4: At this time of day, most people are engaged in stimulating activities, such as preparing and eating dinner.)

Question 19. During which time frame do people tend to be the sleepiest? 1. 12 noon and 2 PM 2. 6 AM and 8 AM 3. 2 AM and 4 AM 4. 6 PM and 8 PM

4 (Rationale Option 1: There is no stage 0 in the classification system for staging pressure ulcers. Option 2: The skin is still intact and there is no undermining in a stage I pressure ulcer. Option 3: Tissue damage is superficial and there is no undermining in a stage II pressure ulcer. Option 4: In a stage III pressure ulcer there is full-thickness skin loss involving damage to subcutaneous tissue that may extend to the fascia and there may or may not be undermining, which is tissue destruction underneath intact skin along wound margins.)

Question 19. 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

1 (Rationale Option 1: When in the sitting position, the hips and knees are flexed at 90 degrees and the body's weight is borne by the pelvis, particularly the ischial tuberosities, which are bony protuberances of the lower portion of the ischium. Using a wheelchair results in prolonged sitting unless interventions are implemented to promote local circulation. Option 2: Pressure to the scapulae occurs in all back-lying positions, such as the supine and Fowler positions. Option 3: Pressure to a trochanter occurs in a side-lying, not the sitting, position. Option 4: Pressure to the malleolus (medial and lateral) of the ankle occurs in a side-lying, not a sitting, position.)

Question 2. A patient sits for excessive lengths of time in a wheelchair. Which sites should the nurse assess for skin breakdown in this patient? 1. Ischial tuberosities 2. Bilateral scapulae 3. Trochanters 4. Malleoli

3 (Rationale Option 1: Internal rotation is the act of rolling the leg and foot inward, thereby internally rotating the hip joint. Option 2: Lateral flexion is when the head is tilted as far as possible to one shoulder and then the other shoulder. Option 3: The word "adduction" correctly represents the action of moving an extremity toward the midline of the body and beyond. Option 4: Inversion is when the sole of the foot is turned medially. Test Taking Tip: The words "toward the midline" are the key words/clue in the stem. One could say that the act of moving a body part "toward" another is like "adding" one to another. The first three letters of the word "adduction" in option 3 are "add.")

Question 2. What is the action of moving a patient's lower extremity toward the midline and beyond during range-of-motion exercises called? 1. Internal rotation 2. Lateral flexion 3. Adduction 4. Inversion

4 (Rationale Option 1: The statement regarding the client's serum electrolyte level is not an appropriate outcome for a nursing diagnosis of Risk for Falls Related to Skeletal Muscle Weakness Secondary to Electrolyte Imbalance. Option 2: Promoting oral fluid intake is an intervention and does not pertain to client safety. Option 3: Teaching the client is an intervention and does not pertain to client safety. Option 4: The most appropriate outcome for a client with a nursing diagnosis of Risk for Falls Related to Skeletal Muscle Weakness Secondary to Electrolyte Imbalance is to remain free from injury throughout the hospital stay.)

Question 20. Which outcome would be most appropriate for a nurse to establish when caring for a client who has a nursing diagnosis of Risk for Falls Related to Skeletal Muscle Weakness Secondary to Electrolyte Imbalance? 1. The client's serum electrolyte levels will return to the normal reference range. 2. The nurse will promote oral fluid intake as appropriate. 3. The dietitian will teach the client how to increase dietary potassium intake. 4. The client will remain free from injury throughout the hospital stay.

3 (Rationale Option 1: Although this is important information, it is not the most important factor of the options offered in this question. In addition, the prior admission may have been too long ago to have any current relevance. Option 2: A patient with increased intestinal motility may experience diarrhea, which may place the patient at risk for a fluid and electrolyte imbalance, not a physical injury. Although a person with diarrhea may need to use the toilet more frequently, a bedside commode or bedpan can be used to reduce the risk of falls. Option 3: This is significant information that must be considered because if falls occurred before, then they are likely to occur again. When a risk is identified, additional injury prevention precautions can be implemented. Option 4: Although this is important information, it is not the most important factor of the options offered in this question.)

Question 3. The nurse is assessing a patient who is being admitted to the hospital. Which is the most important information collected by the nurse that indicates whether the patient is at risk for physical injury? 1. Weakness experienced during a prior admission 2. Medication that increases intestinal motility 3. Two recent falls that occurred at home 4. The need for corrective eyeglasses

4 (Rationale Option 1: Nurses should use the longer, stronger muscles of the thighs and buttocks when moving patients to protect their weaker back and arm muscles. Option 2: Nurses should have a wide base of support when moving patients to provide better stability. Option 3: Nurses should use a pulling motion to turn patients because the muscles that flex, rather than extend, the arm are stronger and pulling, rather than pushing, creates less friction and therefore less effort. Option 4: Misaligning the back when moving patients occurs most often when not facing the direction of the move. Twisting (rotation) of the thoracolumbar spine and flexion of the back place the line of gravity outside the base of support, which can cause muscle strain and disabling injuries.)

Question 3. What do nurses sometimes do that increase their risk for injury when moving patients? 1. Use the longer, rather than the shorter, muscles when moving patients 2. Place their feet wide apart when transferring patients 3. Pull rather than push when turning patients 4. Misalign their backs when moving patients

4 (Rationale Option 1: The left arm should be positioned in front of the body, not behind the body. Option 2: Both legs should be slightly flexed in front of the body with the left leg in front of the right leg. Option 3: The right arm should be positioned behind the body in extension with the palm facing toward the ceiling. Option 4: This is correct position of the body when a patient is placed in the Sims' position.)

Question 4. A nurse is repositioning a patient in the right Sims' position. What action should the nurse implement when positioning this patient? 1. Position the left arm behind the body. 2. Rest the right leg on the top of the left leg. 3. Flex the right arm and rest it on a pillow. 4. Turn the body halfway between the lateral and prone position.

3 (Rationale Option 1: Although turning the patient to a new position every 2 hours provides variety and increased comfort, these are not the primary reasons for this intervention. Option 2: Although turning frequently promotes elimination, the upright positions, such as high-Fowler and sitting, have a greater influence on elimination because of the effect of gravity. Option 3: Compression of soft tissue greater than 32 mm Hg prevents capillary circulation and compromises tissue oxygenation in the compressed area. Turning the patient relieves the compression of tissue in dependent areas, particularly those tissues overlying bony prominences. Option 4: Although turning and positioning promotes respiratory functioning, other interventions, such as sitting, deep breathing, coughing, and incentive spirometry, have a greater influence on respiratory status.)

Question 5. An immobilized bed-bound patient is placed on a 2-hour turning and positioning program. What should the nurse explain to the patient as to why this program is important? 1. Support comfort 2. Promote elimination 3. Maintain skin integrity 4. Facilitate respiratory function

3, 4 (Rationale Option 1: Plantar flexion contracture (footdrop) is a localized response to prolonged extension of the ankle. Option 2: Static respiratory secretions provide an excellent media for bacterial growth that can result in hypostatic pneumonia, which is a localized response to immobility. Option 3: Decreased calf muscle activity and pressure of the bed on the legs allow blood to accumulate in the distal veins. The resulting increased hydrostatic pressure moves fluid out of the intravascular compartment into the interstitial compartment, causing edema. Option 4: Atrophy is a decrease in the size of a tissue or an organ as a result of inactivity or decreased function. After 24 to 36 hours of inactivity, muscles begin to lose their contractile strength and begin the process of atrophy. Option 5: Prolonged pressure on skin over a bony prominence interferes with capillary blood flow to the skin, which ultimately can result in the localized response of a pressure ulcer.)

Question 5. Nurses should monitor for which systemic responses in immobilized patients? Select all that apply. 1. Plantar flexion contracture 2. Hypostatic pneumonia 3. Dependent edema 4. Muscle atrophy 5. Pressure ulcer

2 (Rationale Option 1: Although tinnitus can interfere with sleep, it is not the most common problem. Option 2: Bladder fullness causes pressure in the pelvic area that interrupts sleep. Awakening to void during the night is a common occurrence, particularly in older adult men. Option 3: Although hunger can interfere with sleep, it is not the most common problem. A light evening snack or glass of milk prevents hunger. Option 4: Although thirst can interfere with sleep, it is not the most common problem. Thirst is prevented by drinking water as part of the bedtime routine.)

Question 6. A nurse is teaching a patient various techniques to promote sleep. What internal stimulus that most commonly interferes with sleep should the nurse include in the teaching? 1. Ringing in the ears 2. Bladder fullness 3. Hunger 4. Thirst

1 (Rationale Option 1: In the low-Fowler position, the majority of the body's weight is borne by portions of the pelvis: bony protuberances of the lower portion of the ischium (ischial tuberosities) and the triangular bone at the dorsal part of the pelvis (sacrum). Option 2: Plantar flexion (footdrop), not dorsiflexion, contractures can occur in the low-Fowler position. Option 3: This is more likely to occur in the supine, rather than the low-Fowler, position. Option 4: Abduction, rather than adduction, of the legs is more likely to occur in the low-Fowler position.)

Question 6. A patient prefers to remain in the low-Fowler position the majority of the time. What is the greatest potential problem associated with the low-Fowler position? 1. Pressure on the ischial tuberosities of the pelvis 2. Dorsiflexion contractures of the feet 3. External rotation of the hips 4. Adduction of the legs

4 (Rationale Option 1: When the eyes are closed, the individual may be resting or sleeping. The patient may have the eyes closed when engaged in such activities as praying and imagery. Option 2: Appearing physically at ease with a reduction in muscle tension can occur with both rest and sleep. Option 3: A patient may keep the arms at the side of the body when either resting or sleeping. Option 4: A patient will experience altered levels of consciousness when sleeping, with a lack of response to insignificant environmental noises. A patient at rest will be alert and have no altered level of consciousness.)

Question 1. A nurse has implemented interventions to promote rest and sleep in a postoperative patient. What assessment best indicates that the patient probably is sleeping rather than just resting? 1. Eyes are closed 2. Appears physically at ease 3. Arms are resting at the side of the body 4. Lacks a response to environmental noises

3 (Rationale Option 1: Supination occurs when the hand and forearm rotate so that the palm of the hand is facing upward. Option 2: Adduction occurs when an arm or leg moves toward and/or beyond the midline of the body. Option 3: Dorsal flexion (dorsiflexion) of the joint of the ankle occurs when the toes of the foot point upward and backward toward the anterior portion of the lower leg. Option 4: There is no range of motion called plantar extension. Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg.)

Question 1. A nurse is performing passive range-of-motion exercises for a patient who is in the supine position. Which motion occurs when the nurse bends the patient's ankle so that the toes are pointed toward the ceiling? 1. Supination 2. Adduction 3. Dorsal flexion 4. Plantar extension

3 (Rationale Option 1: Endurance relates to aerobic exercise that improves the body's capacity to consume oxygen for producing energy at the cellular level. Option 2: Strength relates to isometric and isotonic exercises, which contract muscles and promote their development. Option 3: The line of gravity passes through the center of gravity when the body is correctly aligned; this results in the least amount of stress on the muscles, joints, and soft tissues. Bed-bound patients often need assistive devices such as pillows, sandbags, bed cradles, wedges, rolls, and splints to support and maintain the vertebral column and extremities in functional alignment. Option 4: Balance relates to body mechanics and is achieved through a wide base of support and a lowered center of gravity.)

Question 1. Which word is most closely associated with nursing care strategies to maintain functional alignment when patients are bed bound? 1. Endurance 2. Strength 3. Support 4. Balance

3 (Rationale Option 1: This is unsafe. A trochanter roll placed in the small of the back is uncomfortable and produces an excessive lumbar curvature. Option 2: This is contraindicated because it places unnecessary pressure on the popliteal area. Option 3: A trochanter roll is a rolled wedge, pillow, or sandbag placed by the lateral aspect of the leg between the iliac crest and knees to prevent external hip rotation. Option 4: The diameter of a trochanter roll is too wide to maintain the hand in functional alignment.)

Question 10. A nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? 1. Under the small of the back 2. Behind the knees when supine 3. Alongside the ilium to mid-thigh 4. In the palm of the hand with the fingers flexed

3 (Rationale Option 1: Flexion is the decrease in the angle between the bones forming a joint. Option 2: Inversion is turning the sole of the foot medially. Option 3: Adduction of the shoulder occurs when the arm and hand are brought across the midline in the front of the body with the elbow straight. Option 4: Circumduction is movement of a ball-and-socket joint in a full circle.)

Question 10. Identify the range of motion being performed in the following illustration. 1. Flexion 2. Inversion 3. Adduction 4. Circumduction

2 (Rationale Option 1: Although important, this is not as significant as another option. Option 2: The mind (psyche) and body (soma) are interrelated and influence each other; therefore, both must be addressed to promote physical and emotional rest. Option 3: Although uninterrupted sleep promotes restorative sleep because sleep cycles are not interrupted, the length of time needed is individual. Option 4: More metabolic energy is expended during illness.)

Question 10. What is most important for the nurse to do when meeting patients' sleep and rest needs? 1. Teach how sleep and rest promote wellness. 2. Address both the physical and mental components of rest. 3. Encourage at least eight hours of uninterrupted time for sleep. 4. Recognize that less metabolic energy is expended during illness.

2 (Rationale Option 1: The nurse is a secondary source of data. The nurse may not be totally aware of how well the patient slept. Option 2: Patients are primary sources and the only sources able to provide subjective data concerning how they slept. Option 3: Patients should not be held responsible for other patients. Option 4: The health-care provider is a secondary source of information.)

Question 10. Which is the primary source for assessing how a patient slept? 1. Nurse 2. Patient 3. Patient's roommate 4. Health-care provider

2, 3, 4 (Rationale Option 1: Diarrhea related to spastic colonic activity is not associated with hypophosphatemia. Option 2: The client is experiencing hypophosphatemia, which results in muscle weakness. Option 3: The client is experiencing hypophosphatemia, which results in cardiac dysrhythmias. Dysrhythmias are caused by low stores of intracellular energy in the myocardial cells, rendering the contractions weak and ineffective. Option 4: The client is experiencing hypophosphatemia, which results in muscle weakness that may impair the client's physical mobility. Option 5: The client is experiencing hypophosphatemia, which results in muscle weakness that may impair the client's ability to breathe.)

Question 10. Which nursing diagnoses should a nurse assign to a client who is experiencing chronic hypophosphatemia? Select all that apply. 1. Diarrhea Related to Spastic Colonic Activity 2. Risk for Injury Related to Muscle Weakness 3. Decreased Cardiac Output Related to Dysrhythmia 4. Impaired Physical Mobility Related to Skeletal Muscle Weakness 5. Potential for Respiratory Insufficiency Related to Muscle Weakness

1 (Rationale Option 1: A physical examination requires a patient to assume a variety of positions such as supine, side-lying, sitting, and standing. The nurse should inquire about any positions that are uncomfortable or contraindicated because of past or current medical conditions to prevent complications. Option 2: Although this information may be obtained during the course of the physical examination, it is not the priority. Option 3: This is not the priority during a physical examination. This might be done to prevent fragmentation of care and ensure continuity of care. Option 4: Although this might be done, it is not a priority during a physical examination.)

Question 11. The nurse is preparing a patient for a physical examination. What is most important for the nurse to do in this situation? 1. Identify the positions that may be contraindicated for the patient during the examination 2. Explore the patient's attitude toward health-care providers 3. Inquire about the other professionals caring for the patient 4. Ask when the patient last had a physical examination

4 (Rationale Option 1: Flexion is movement that results in a decrease in the angle between the bones forming a joint. Option 2: Adduction is movement that results in drawing an extremity toward the central axis of the body. Option 3: Supination is turning the forearm so that the palm of the hand faces upward. Option 4: Opposition of the thumb occurs when the thumb is touched to the tip of each finger on the same hand.)

Question 11. Which is the range-of-motion exercise being performed in the following illustration? 1. Flexion 2. Adduction 3. Supination 4. Opposition

1 (Rationale Option 1: The state of balance between muscles that serve to contract in opposite directions is impaired with immobility. The fibers of the stronger muscles contract for longer periods than do those of the weaker, opposing muscles. This results in a change in the loose connective tissue to a more dense connective tissue and to fibrotic changes that limit range of motion. Option 2: Contractures occur because of muscle spasticity and shortening, not muscle flaccidity. Option 3: Disuse and muscle wasting cause a reduction in muscle strength at the rate of 5% to 10% a week so that within 2 months more than 50% of a muscle's strength can be lost. This results in muscle atrophy, not contractures. Option 4: This is unrelated to contractures. In unused muscles, catabolism exceeds anabolism and the muscles decrease in size (disuse atrophy).)

Question 12. A nurse is teaching a class to nursing assistants about how to care for patients who are immobile. What should the nurse include about why immobilized people develop contractures? Course Topic: Mobility Concept(s): Mobility; Nursing RolesCognitive Level: Application [Applying] 1. Muscles that flex, adduct, and internally rotate are stronger than weaker opposing muscles 2. Muscular contractures occur because of excessive muscle flaccidity 3. Muscle mass and strength decline at a progressive rate weekly 4. Muscle catabolism exceeds muscle anabolism

4 (Rationale Option 1: Heat lamp treatments will further dry out the wound and can cause burns. Option 2: Topical antibiotics are used only when the ulcer is infected, not to treat eschar. Option 3: Cleansing irrigations are ineffective in removing the thick, fibrin-containing cells of eschar covering the surface of the wound. Option 4: Thick, leather-like, necrotic devitalized tissue (eschar) must be removed surgically or enzymatically before wound healing can occur.)

Question 12. A patient is diagnosed with a stage IV pressure ulcer with eschar. Which medical treatment should the nurse anticipate the physician will order for this patient? 1. Heat lamp treatment three times a day 2. Application of a topical antibiotic 3. Cleansing irrigations twice daily 4. Débridement of the wound

2 (Rationale Option 1: When transferring this patient, the nurse should stand in front of, not next to, the patient. Option 2: Pivoting avoids unnecessary movement by transferring the patient to the chair while the patient supports body weight on the unaffected leg. Option 3: Keeping the patient's feet together narrows the base of support and decreases stability. Option 4: When transferring this patient, the nurse should stand in front of the patient and hold his or her hands on the patient's scapulae.)

Question 13. A health-care provider orders that a patient with one-sided weakness (hemiparesis) be transferred out of bed to a chair twice a day. What should the nurse plan to do? 1. Support the patient on the affected side. 2. Pivot the patient on the unaffected leg. 3. Keep the patient's feet together. 4. Hold the patient by the arms.

1 (Rationale Option 1: Assessing posture will identify whether the patient's center of gravity is in the midline from the middle of the forehead to a midpoint between the feet and, therefore, balanced within the patient's base of support. Option 2: Strength has more to do with the exertion of power, not balance. Option 3: Energy has more to do with endurance, not balance. Option 4: Assessing the respiratory rate before activity establishes a baseline against which to compare the respiratory rate after activity to determine tolerance for activity, not balance.)

Question 13. A nurse is evaluating an ambulating patient's balance. What factor about the patient is most important for the nurse assess? 1. Posture 2. Strength 3. Energy level 4. Respiratory rate

3 (Rationale Option 1: Although a back rub causes vasodilation, which improves circulation and brings oxygen and nutrients to the area, vasodilation does not promote comfort and rest. Option 2: Stimulation of circulation brings oxygen and nutrients to the area, but it does not promote comfort and rest. Option 3: Applying long, smooth strokes while moving the hands up and down the back without losing contact with the skin has a relaxing and sedative effect. Its effect may be related to the gate-control theory of pain relief; rubbing the back stimulates large muscle fiber groups, which close the synaptic gates to pain or uncomfortable stimuli, permitting a perception of relaxation. Option 4: Although a back rub ultimately does increase oxygen and nutrients to the area, oxygen and increased nutrients do not promote comfort and rest.)

Question 13. A nurse is planning to give a patient a back rub to promote comfort and rest. Which is the reason why a back rub promotes comfort and rest? 1. Causes vasodilation 2. Stimulates circulation 3. Relieves muscular tension 4. Increases oxygen to tissues

4 (Rationale Option 1: Washing the hands is not the first thing that the nurse should do before administering a back rub. Option 2: Warming the lotion is not the first thing that the nurse should do before administering a back rub. Option 3: Pulling the curtain for privacy is not the first thing that the nurse should do before administering a back rub. Option 4: The stimulation of a back rub may not be tolerated by some patients. A back rub is contraindicated when a patient has certain conditions, such as impaired skin integrity (e.g., a pressure ulcer, a burn, or an open wound), rib fractures, or a vertebral disorder, or within 48 hours of experiencing the onset of an acute neurological or cardiac problem.)

Question 14. A nurse plans to administer a back rub to a patient. What should the nurse do first before administering the back rub? 1. Wash the hands. 2. Warm the lotion. 3. Pull the curtain for privacy. 4. Identify any contraindications.

1 (Rationale Option 1: Inversion, a gliding movement of the foot, occurs by turning the sole of the foot medially toward the midline of the body. Option 2: Adduction occurs when an arm or leg moves toward and/or beyond the midline of the body. Option 3: Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg. Option 4: Internal rotation of a leg occurs by turning the foot and leg inward so that the toes point toward the other leg.)

Question 14. A nurse turns a patient's ankle so that the sole of the foot moves medially toward the midline. What 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

3 (Rationale Option 1: Remembering dreams is unrelated to adequate sleep. Option 2: Although a person sleeps at night without waking, the length of the sleep or the length of rapid-eye-movement sleep may be insufficient to restore or renew the body. Option 3: The purpose of sleep is to rest and restore the body, which generally is evidenced by renewed strength. Option 4: Seven hours may or may not be enough sleep because each person has unique needs and a biological clock for determining sleeping intervals.)

Question 15. A nurse is assessing a patient who is having difficulty sleeping. What patient response best supports the nurse's conclusion that an adequate night's sleep was attained? 1. Has the ability to remember dreams 2. Sleeps at night without awakening 3. Demonstrates renewed strength 4. Slept seven hours

2 (Rationale Option 1: In the low-Fowler position the hips are slightly flexed. Option 2: While in the high-Fowler position the patient is then positioned leaning forward with arms resting on an over-bed table. In this orthopneic position, the hips are extensively flexed creating an angle less than 90 degrees. Option 3: In the supine position the hips are extended (180 degrees), not flexed. Option 4: In the Sims position, the hip and knee of the upper leg are just slightly flexed.)

Question 15. A nurse is caring for a patient with impaired mobility. Which position contributes most to the formation of a hip flexion contracture? 1. Low-Fowler 2. Orthopneic 3. Supine 4. Sims'

4 (Rationale Option 1: Hyperextension of the condyloid joint of the wrist is accomplished by bending the fingers and hand backward as far as possible. Option 2: Opposition of the thumb, which is a saddle joint, occurs when the thumb touches the top of each finger on the same hand. Option 3: Abduction of the fingers (metacarpophalangeal joints—condyloid) occurs when the fingers of each hand spread apart. Option 4: Flexion of the wrist, a condyloid joint, occurs when the fingers of the hand move toward the inner aspect of the forearm.)

Question 15. A nurse is teaching a family member how to perform range-of-motion exercises of the hand. Which motion occurs when the angle is reduced between the palm of the hand and forearm? Course Topic: Teaching and Learning Concept(s): Family; Mobility; Nursing RolesCognitive Level: Comprehension [Understanding] 1. Hyperextension 2. Opposition 3. Abduction 4. Flexion

4 (Rationale Option 1: A person who chooses not to ambulate still has the ability to assume many different sitting or lying-down positions. Option 2: This is not the most common consequence. Anxiety and ultimately panic that is precipitated by a situation can be prevented by avoiding the situation. Option 3: A person who chooses not to ambulate because of a fear of falling still can socialize. Option 4: Most falls occur when ambulating. Fear of falling results in the conscious choice not to place oneself in a position where a fall can occur. Disuse and muscle wasting cause a reduction of muscle strength at the rate of 5% to 10% per week so that within 2 months of immobility more than 50% of a muscle's strength can be lost. In addition, there is a decreased cardiac reserve. These responses result in decreased physical conditioning.)

Question 16. A nurse in a community center is conversing with a group of older adults who voiced fears about falling. What is the most common consequence associated with older adults' fear of falling that the nurse should discuss with them? 1. Impaired skin integrity 2. Occurrence of panic attacks 3. Self-imposed social isolation 4. Decreased physical conditioning

3 (Rationale Option 1: Hyporesponsiveness, withdrawal, apathy, flat facial expression, and excessive sleepiness are physiological responses associated with a lack of non-rapid-eye-movement (NREM) sleep. Option 2: A depressed immune system is a physiological response to a lack of NREM sleep. Option 3: Rapid-eye-movement (REM) sleep is essential for maintaining mental and emotional equilibrium and, when interrupted, results in irritability, excitability, restlessness, confusion, and suspiciousness. Option 4: Shortened NREM sleep can result in vertigo, which is a physiological response to sleep deprivation.)

Question 16. A nurse is caring for a patient who is having difficulty sleeping. Which patient response indicates to the nurse that the patient is not obtaining adequate rapid-eye-movement (REM) sleep? Course Topic: Pain, Comfort, Rest, and Sleep Concept(s): Sleep, Rest, and ActivityCognitive Level: Analysis [Analyzing] 1. Hyporesponsiveness 2. Immunosuppression 3. Irritability 4. Vertigo

1 (Rationale Option 1: An occupational therapist is the most appropriate professional to help this patient regain, acquire, improve, and maintain abilities related to activities of daily living, such as eating, dressing, bathing, grooming activities, cooking, and so on. Option 2: A medical technician works in a laboratory testing body fluid; activities may include evaluating blood levels of medication, crossmatching blood for blood transfusions, and examining tissues of the body. Option 3: A physical therapist is involved with preventing and limiting physical impairment and restoring function, strength, and coordination associated with mobility, not helping a patient cope with performing activities of daily living. Option 4: A primary nurse may be involved in coordinating the efforts of nursing team members with those of other health-care professionals involved in helping a patient recover from an illness. A primary nurse provides nursing care.)

Question 16. A patient experienced a brain attack (cerebrovascular accident) that resulted in a left hemiparesis. Which health-care professional is most appropriate to teach this patient how to recover and maintain abilities associated with activities of daily living? 1. Occupational therapist 2. Medical technician 3. Physical therapist 4. Primary nurse

2 (Rationale Option 1: Hypoxia is associated with obstructive sleep apnea because episodes of upper airway obstruction occur 50 to 600 times a night. Option 2: Melatonin, the "hormone of darkness," regulates the circadian phases of sleep. Environmental triggers called synchronizers adjust the sleep-wake cycle to a 24-hour solar day. Intensive care units have bright lights and increased sensory input that cause disorientation to day and night and interrupt sleep. Interrupted sleep results in lability of mood, irritability, excitability, suspiciousness, confusion, and delirium. Option 3: Lethargy and fatigue are early signs of sleep deprivation, not ICU psychosis. Option 4: Sleep deprivation may cause impaired memory, confusion, illusions, and visual or auditory hallucinations, not dementia.)

Question 17. A patient has been in the intensive care unit (ICU) for 3 days. For which common adaptation indicating ICU psychosis associated with sleep deprivation should the nurse assess the patient? 1. Hypoxia 2. Delirium 3. Lethargy 4. Dementia

3 (Rationale Option 1: The percentage of older adults below the designated poverty level is less than 9.8% and is declining. Option 2: Although older adults may take more time to process and respond to information, only 5% to 7% of adults older than 65 years of age experience dementia. Option 3: Studies report that one-third of older adults 75 years of age and older experience at least one fall each year; falls have become the leading cause of injury deaths for older adults. Option 4: Approximately only 4.5% of adults 65 years or older live in a nursing home; 91% of adults 65 years or older live alone or with a spouse.are and supports the plans of care established by professionals in other health-care disciplines.)

Question 17. The home care nurse is coordinating the delivery of health-care services to an older adult in the home. The nurse considers the factor that most affects health-care delivery to the older adult population is that older adults: Course Topic: Health Care Delivery Concept(s): Assessment; Critical Thinking; Mobility; Promoting Health; SafetyCognitive Level: Comprehension [Understanding] 1. Live below the economic poverty level, requiring financial assistance 2. Suffer from significant cognitive deficits as they age 3. Tend to fall, requiring expensive hospital services 4. Need the services of long-term care institutions

4 (Rationale Option 1: Eversion, a gliding movement of the foot, occurs by turning the sole of the foot away from the midline of the body. Option 2: Circumduction is a range of motion that is performed with a ball-and-socket joint. It occurs when an extended extremity moves forward, up, back, and down in a full circle. Option 3: Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg. Option 4: External rotation occurs when the entire leg is rolled outward from the body so that the toes point away from the opposite leg.)

Question 17. The nurse moves a patient's leg through range of motion demonstrated in the figure. What word should the nurse use when documenting exactly what was done during range-of-motion exercises? 1. Eversion 2. Circumduction 3. Plantar flexion 4. External rotation

3 (Rationale Option 1: Although uninterrupted sleep is advantageous for restorative sleep, the number of hours required depends on the individual. Option 2: In older adults, the length of stage IV sleep is markedly decreased; they awaken more frequently, and it takes them longer to go back to sleep. Option 3: Fear of loss of control, the unknown, and potential death results in the struggle to stay awake, which interferes with the ability to relax sufficiently to fall asleep. Option 4: Bed rest does not decrease the need for sleep. The body still needs stage IV restorative sleep. Often the physiological problems requiring the bed rest increase the need for sleep.)

Question 17. What concept associated with sleep should the nurse consider to best plan nursing care for a hospitalized patient? 1. People require eight hours of uninterrupted sleep to meet energy needs 2. Frequency of nighttime awakenings decreases with age 3. Fear can contribute to the need to stay awake 4. Bed rest decreases the need for sleep

2 (Rationale Option 1: Top sheets tucked in along the sides of the bed still exert pressure on the upper surface of the feet, which may promote plantar flexion. The sides of top sheets, mitered at the foot of the bed, hang feely off the side of the bed. Option 2: Making a vertical or horizontal toe pleat at the foot of the bed over the patient's feet leaves room for the feet to move freely and avoids exerting pressure on the upper surface of the feet, thus minimizing plantar flexion. Option 3: The weight of the top sheets still exerts pressure on the upper surface of the feet, promoting plantar flexion. Option 4: Trochanter rolls prevent external hip rotation, not plantar flexion.)

Question 18. A nurse is making an occupied bed. What should the nurse do to prevent plantar flexion? 1. Tuck in the top linens on just the sides of the bed 2. Place a toe pleat in the top linens over the feet 3. Let the top linens hang off the end of the bed 4. Use trochanter rolls to position the feet

1 (Rationale Option 1: Range-of-motion exercises maximally stretch all muscle groups; this prevents shortening of muscles, which can result in contractures. Option 2: Although movement of joints experienced during activity will contribute to preventing contractures, it will not move all joints through their full range; also, prolonged sitting can cause flexion contractures of the hips and knees. Option 3: Although supporting joints contributes to maintaining functional alignment, which helps prevent contractures, it is not the best intervention. Option 4: Turning and repositioning a patient every 2 hours will reduce pressure, not prevent contractures. Test Taking Tip: The word "best" in the stem sets a priority. Option 1 is unique because it is the only option that contains capital letters (ROM).)

Question 18. A patient, who had a brain attack, has hemiparesis. What should the nurse do to best prevent this patient from developing contractures? 1. Teach the patient to perform range-of-motion exercises. 2. Transfer the patient to a chair 2 times a day. 3. Support the patient's joints with pillows. 4. Reposition the patient every 2 hours.

1 (Rationale Option 1: Sleep deprivation occurs with frequent interruptions of sleep because the sleeper returns to stage I rather than to the stage that was interrupted. There is a greater loss of stage III and IV non-rapid-eye-movement (NREM) sleep, which is essential for restorative sleep. Option 2: Although early awakenings often do occur in hospital settings, it is not the most common cause of sleep deprivation in the hospital. Option 3: Restless legs syndrome, an intrinsic sleep disorder, is not the most common cause of sleep deprivation in the hospital. Option 4: Only 1% to 4% of the population have sleep apnea.)

Question 18. Which most common cause of sleep deprivation in the hospital should the nurse consider when planning care? 1. Fragmented sleep 2. Early awakening 3. Restless legs 4. Sleep apnea

3 (Rationale Option 1: Extension is straightening the finger joints. Option 2: Adduction is bringing the fingers in alignment next to one another. Option 3: Opposition is the correct term to describe touching the thumb to the tip of each finger of the same hand Option 4: Circumduction is a circular motion of the hip or shoulder joint.)

Question 18. Which range-of-motion exercise is being performed when the nurse touches the patient's thumb to the small fifth finger on the same hand? 1. Extension 2. Adduction 3. Opposition 4. Circumduction

2 (Rationale Option 1: Footboards should be avoided to prevent plantar flexion contractures and undue pressure on the soles of the feet. Wearing high-top sneakers when in bed helps maintain the ankles in functional alignment and prevents plantar flexion contractures (footdrop). Option 2: The pillow supports the upper leg in functional alignment and prevents skin-to-skin contact. Option 3: Two pillows will cause flexion of the neck when in the semi-Fowler position; one pillow supports the head in functional alignment. Option 4: This is appropriate when positioning the patient in the right, not left, Sims' position. It prevents undue pressure on the ball and socket joint of the shoulder.)

Question 19. A nurse is instructing a nursing assistant how to position an immobile patient. What should the nurse teach the nursing assistant to do? 1. Place the patient's feet against a footboard when in the spine position. 2. Position a pillow between the patient's legs when in the side-lying position. 3. Place two pillows under the patient's head when in the semi-Fowler position. 4. Position the patient's right arm in extension with the palm facing the ceiling when in the left Sims' position.

2 (Rationale Option 1: Although this should be done, it is not the first nursing action implemented by the nurse. Option 2: Assessment is the first step of the nursing process. Before a patient engages in range-of-motion exercises, the nurse should identify any factors that should be taken into consideration before teaching or providing these exercises, such as the presence of contractures, pain, weakness, or impaired cognition. Option 3: Although this should be done, it is not the first thing that the nurse should do. Option 4: Although this may be arranged, it is not the first thing that the nurse should do.)

Question 19. A nurse is planning to assist a patient with active assistive range-of-motion exercises. What should the nurse do first? 1. Encourage the patient to be as independent as possible when doing range-of-motion exercises. 2. Identify any restrictions regarding the type or extent of range-of-motion exercises. 3. Explain what range-of-motion exercises are and why they are being done. 4. Schedule range-of-motion exercise to occur during the patient's bath.

1 (Rationale Option 1: Anxiety increases norepinephrine blood levels through stimulation of the sympathetic nervous system, which results in prolonged sleep onset. Option 2: Patients with anxiety still reach the depth of stage IV non-rapid-eye-movement (NREM) sleep. Option 3: Stage IV, not stage II, of NREM sleep is affected. Option 4: The duration of sleep is affected indirectly, not directly, because of the prolonged onset of sleep.)

Question 19. A patient is experiencing anxiety. Which aspect of sleep should the nurse expect will be affected as a result of the anxiety? 1. Onset 2. Depth 3. Stage II 4. Duration

4 (Rationale Option 1: Although the extent of weakness should be assessed, it is not the priority. Option 2: Although the presence of flaccidity should be assessed, it is not the priority. Option 3: Although the degree of atrophy should be assessed, it is not the priority. Option 4: If the patient is experiencing pain, there will be reluctance to move. An analgesic administered before beginning these exercises will promote acceptance and tolerance of the exercises.)

Question 2. A nurse must administer passive range-of-motion exercises to a patient. For which clinical finding should the nurse assess the patient before beginning? 1. Weakness 2. Flaccidity 3. Atrophy 4. Pain

3 (Rationale Option 1: Rapid-eye-movement (REM) sleep is essential for maintaining mental and emotional equilibrium and, when interrupted, results in anxiety, irritability, excitability, restlessness, confusion, and suspiciousness. Option 2: Interrupted REM, not non-rapid-eye-movement (NREM), sleep is associated with hyperactivity, excitability, and restlessness. Option 3: During NREM sleep, growth hormone is consistently secreted, which provides for protein synthesis, anabolism, and tissue repair. Option 4: Interrupted REM, not NREM, sleep is associated with excitability, emotional lability, and suspiciousness. Interrupted NREM sleep is associated with apathy, withdrawal, and hyporesponsiveness.)

Question 2. A patient is experiencing interrupted sleep. For which response associated with shortened non-rapid-eye-movement (NREM) sleep should the nurse assess the patient? 1. Anxiety 2. Hyperactivity 3. Delayed healing 4. Aggressive behavior

4 (Rationale Option 1: Back massage is the therapeutic manipulation of muscles and tissues that relaxes tense muscles, relieves muscle spasms, and induces rest or sleep. However, it may be contraindicated, and some people do not like a back rub or consider it an invasion of their personal space. Option 2: Music can be relaxing or stimulating depending on the music and the individual. Option 3: Although milk contains the amino acid L-tryptophan that promotes sleep, many people do not like milk or avoid fluids before bedtime to limit nocturia. Option 4: Following routines provides consistency and comfort in an unfamiliar environment. Bedtime rituals meet basic physiological needs and usually include physically and emotionally relaxing behaviors.)

Question 2. What is the most effective nursing intervention to promote sleep that is appropriate for a patient in any situation? 1. Providing a back rub 2. Playing relaxing music 3. Offering a glass of warm milk 4. Following a routine at bedtime

1 (Rationale Option 1: Chronic fatigue syndrome is a condition characterized by the onset of disabling fatigue after an initial viral-like illness. The fatigue is so overwhelming and consuming it interferes with the activities of daily living. Option 2: Chronic fatigue syndrome does not impair mobility. Impaired physical mobility is the state in which an individual experiences limitation of physical movement but is not immobile. Option 3: The fatigue of chronic fatigue syndrome may be unrelated to social isolation, which is a state in which an individual experiences or perceives a desire for increased involvement with others but is unable to make that contact. Option 4: Although fatigue is related to impaired gas exchange, the fatigue caused by hypoxia is unrelated to chronic fatigue syndrome, which is a very different condition.)

Question 20. A patient is diagnosed with chronic fatigue syndrome. It is most important that the nurse explore the extent of the patient's: 1. Ability to provide self-care 2. Physical mobility 3. Social isolation 4. Gas exchange

4 (Rationale Option 1: This protects only the heels, not the other dependent areas of the body. Option 2: Air-filled rings usually are made of plastic, which tends to promote sweating. Air rings rarely are used because they are designed for just the sacral area and often they increase, not decrease, pressure. Option 3: Air mattresses usually are made of plastic, which tends to promote sweating. Option 4: The soft tuffs of sheepskin allow air to circulate, thereby promoting the evaporation of moisture that can precipitate skin breakdown.)

Question 20. A patient with an order for bed rest has diaphoresis. What should the nurse use to best limit the negative effects of perspiration on dependent skin surfaces of this patient? 1. Ventilated heel protectors 2. Air-filled rings 3. Air mattress 4. Sheepskin

2 (Rationale Option 1: Although meeting the basic physiological need to feel warm is appropriate, a hospital's environment generally is warm, so a top sheet and spread are adequate. Option 2: Noise is a serious deterrent to sleep in a hospital. The nurse should limit environmental noise (e.g., distributing fluids, providing treatments, rolling drug and linen carts) and staff communication noise. Option 3: This is unsafe. Dim the lights or put a night light on to provide enough illumination for safe ambulation to the bathroom. Option 4: Although this provides privacy, it does not limit the environmental factors that usually interfere with sleeping in a hospital.)

Question 20. Which is the most important nursing intervention that supports a patient's ability to sleep in the hospital setting? 1. Providing an extra blanket 2. Limiting unnecessary noise on the unit 3. Shutting off lights in the patient's room 4. Pulling curtains around the bed at night

2 (Rationale Option 1: This is desirable. Performing range of motion beyond resistance may injure muscles and joints and should be avoided. Option 2: This is undesirable because it contributes to a flexion contracture. Functional alignment is preferred because it minimizes stress and strain on muscles tendons, ligaments, and joints. Option 3: Response to range of motion must be evaluated and compared with the assessment performed before the procedure. Option 4: Sequential contraction of muscles tends to be more efficient in facilitating full range of motion.)

Question 3. 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. Moves the elbow to the point of resistance 2. Keeps the elbow flexed after the procedure 3. Assesses the elbow's response after the procedure 4. Puts the elbow through its full range at least three times

2 (Rationale Option 1: Opioids are prescribed to treat moderate to severe pain and should facilitate, not cause a disturbance in, rest and sleep. Option 2: The pharmacological action of diuretics causes an increase in the excretion of water and various electrolytes from the body. Because of this action, the patient may void more frequently, interfering with rest. Most often, diuretics are given in the morning in an effort to minimize nocturia, which can interfere with sleep. Option 3: The pharmacological action of corticosteroids should not interfere with sleep or rest. Option 4: The pharmacological action of antihypertensives should not interfere with sleep or rest.)

Question 3. Which classification of medication is most likely to cause a patient to experience a disturbance in rest and sleep that the nurse should consider when planning the patient's care? 1. Opioids 2. Diuretics 3. Corticosteroids 4. Antihypertensives

1 (Rationale Option 1: An expectation of an outcome of behavior usually becomes a self-fulfilling prophecy. Bedtime rituals include activities that promote comfort and relaxation (e.g., music, reading, praying) and hygienic practices that meet basic physiological needs (e.g., bathing, brushing the teeth, toileting). Option 2: Alcohol hastens the onset of sleep. Option 3: The need for sleep varies and depends on factors such as age, activity level, and health. Option 4: The healthy older adult spends more time in bed, spends less time asleep, awakens more often, stays awake longer, and naps more often. Rapid-eye-movement (REM) sleep and stage IV non-rapid-eye-movement (NREM) sleep are reduced, resulting in less restorative sleep. Naps lead to desynchronization of the sleep-wake cycle.)

Question 4. A nurse is teaching a community health education class about rest and sleep. Which concept related to sleep should the nurse include? 1. Bedtime routines are associated with an expectation of sleep 2. Alcohol intake interferes with one's ability to fall asleep 3. Sleep needs remain consistent throughout the life span 4. Total time in bed gradually decreases as one ages

2 (Rationale Option 1: Dehydration is not a response to immobility. Option 2: Contractures result from permanent shortening of muscles, tendons, and ligaments. Routine range-of-motion exercises and maintaining the body in functional alignment can prevent contractures. Option 3: The decreased tone of the urinary bladder and the inability to assume the usual voiding position in bed promotes urinary retention, rather than urinary incontinence. Option 4: With immobility, the increased heart rate reduces the diastolic pressure. In addition, there is a decrease in blood pressure related to postural changes from lying to sitting or standing (orthostatic hypotension). This situation is manageable with a priority on maintaining patient safety.)

Question 4. A patient has hemiplegia as a result of a brain attack (cerebrovascular accident). Which complication of immobility is of most concern to the nurse? 1. Dehydration 2. Contractures 3. Incontinence 4. Hypertension

1 (Rationale Option 1: This open-ended question requires patients to explore the topic of sleep as it relates specifically to their own experiences. Option 2: This direct question gathers information about only one aspect of sleep. Option 3: This direct question precipitates just a yes or no response. Option 4: This direct question precipitates just a yes or no response about only one aspect of sleep.)

Question 4. A patient is being admitted to the hospital and the nurse is performing a complete assessment. Which is the most therapeutic open-ended question the nurse can ask about the quality of the patient's sleep? 1. "How would you describe your sleep?" 2. "Do you consider your sleep to be restless or restful?" 3. "Is the number of hours you sleep at night good for you?" 4. "Does your bed partner complain about your sleep behaviors?"

4 (Rationale Option 1: The risk for infection is a concern in the physiological, not the psychosocial, domain. Option 2: Data do not support the concern that the patient will cause self-harm. The data related to the risk for self-harm is an expression of a desire to harm oneself, commit suicide, or die. Option 3: The risk for constipation is a concern in the physiological, not the psychosocial, domain. Option 4: People who are unable to care for themselves independently often perceive a lack of control over events. The nurse should be alert to the presence of data that support powerlessness.)

Question 4. Which might a patient be at risk for in the psychosocial domain when the nursing assessment indicates that the patient is almost completely paralyzed? 1. Infection 2. Self-harm 3. Constipation 4. Powerlessness

1, 4, 5 (Rationale Option 1: Organizing care into blocks of time minimizes the need to interrupt rest or sleep in order to complete a task. Option 2: Touching pleasant objects is an intervention to prevent sensory deficit, not overload. Option 3: The patient should not be awakened or rest interrupted to engage the patient in conversation. This is an intervention that is used to prevent sensory deficit, not overload. Option 4: Pain is a contributing factor to interrupted rest and sleep. The patient in pain should receive care that addresses the patient's pain appropriately. Option 5: Sounds that are not understood can be frightening. When a person is frightened, she or he patient often is afraid to sleep, which contributes to sensory overload. When sounds are understood, the patient can organize them mentally, and the sounds are less confusing and more easily overlooked and disregarded.)

Question 5. A nurse is caring for a patient who is in the intensive care unit. Which action should the nurse implement to prevent sensory overload? Select all that apply. 1. Organize care into blocks of time. 2. Provide objects that are pleasant to touch. 3. Maintain frequent meaningful interaction. 4. Medicate for pain immediately when it occurs. 5. Explain the meaning of sounds in the environment.

1 (Rationale Option 1: Gastric secretions increase during rapid-eye-movement (REM) sleep. The semi-Fowler position limits gastroesophageal reflux because gravity allows the abdominal organs to drop, which reduces pressure on the stomach and results in less stomach contents flowing upward into the esophagus. Option 2: This is a horizontal position that increases the pressure of the abdominal organs against the stomach and increases gastric reflux. Option 3: This is a horizontal position that increases the pressure of the abdominal organs against the stomach and increases gastric reflux. Option 4: This is a horizontal position halfway between lateral and prone. Direct pressure exerted on the stomach, particularly in the left Sims position, promotes gastric reflux.)

Question 5. A patient is experiencing discomfort associated with gastroesophageal reflux. In which position should the nurse teach the patient to sleep? 1. Semi-Fowler 2. Right lateral 3. Prone 4. Sims

2 (Rationale Option 1: Pressure of a pillow or the hands held against the abdomen supports an abdominal surgical incision, not log-rolling. Option 2: Log-rolling turns a patient while keeping the vertebral column, including the head and neck, in straight alignment to prevent twisting (rotation) that can injure the spinal cord. Option 3: This patient does not need to be log-rolled. The entire leg from hip to ankle should be supported when turning a patient with a long leg cast. Option 4: This patient does not need to be log-rolled. The side of the body with hemiparesis or hemiplegia must be supported.)

Question 5. Which condition requires the nurse to use the log-rolling technique when repositioning a patient? 1. Abdominal surgery 2. Spinal cord trauma 3. Long leg cast 4. Brain attack

4 (Rationale Option 1: The lights, noise, and activity in the hospital environment can interfere with napping during the day. However, naps when they do occur usually are short and rarely reach stage IV restorative sleep. Option 2: Hospitalized patients can follow their usual bedtime rituals. Option 3: Most medications are administered by 10:00 PM to 11:00 PM and should not interfere with sleep. Option 4: Patients frequently find hospital beds unfamiliar and uncomfortable. In addition, therapeutic regimens restrict movement or require patients to assume sleeping positions other than their preference. Studies support the fact that finding a comfortable position is the most common factor that interferes with sleep as reported by hospitalized patients.)

Question 6. A nurse is planning care to support a patient's ability to sleep. Which factor from among the options presented most commonly interferes with the sleep of hospitalized patients? Course Topic: Pain, Comfort, Rest, and Sleep Concept(s): Sleep, Rest, and ActivityCognitive Level: Comprehension [Understanding] 1. Napping during the day 2. Disrupted bedtime rituals 3. Medication administration 4. Difficulty finding a comfortable position

4 (Rationale Option 1: The width of the base depends on the configuration of the bed, objects in the room, and the ultimate destination. The base usually is locked open when lifting or lowering the patient and locked closed when moving the lift. Option 2: This is unsafe. The lift should raise the patient high enough to clear the surface of the bed. Option 3: The wheels must be unlocked to move the lift from under the bed to its ultimate destination. Option 4: The legs dangle from the sling and therefore may drag across the linens or hit other objects if not protected.)

Question 6. A nurse is transferring a patient from the bed to a 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 six inches off the mattress 3. Keep the wheels of the mechanical lift locked throughout the procedure 4. Ensure the patient's feet are protected when on the mechanical lift

3 (Rationale Option 1: This goal is not measurable as stated. Understanding is not measurable unless parameters are identified. Option 2: This is a nursing intervention, not a patient goal. Option 3: This is a patient-centered goal and measurable. Option 4: This is a nursing intervention, not a patient goal.)

Question 6. A patient with impaired mobility is to be discharged within a week from the hospital. Which is the best example of a discharge goal for this patient? The patient will: 1. Understand range-of-motion exercises 2. Be taught range-of-motion exercises 3. Transfer independently to a chair 4. Be kept clean and dry

4 (Rationale Option 1: Somnambulism, sleepwalking, is a parasomnia that occurs during stages III and IV non-rapid-eye-movement (NREM) sleep. Option 2: Snoring relates to obstructive sleep apnea, which is a periodic cessation of air flow during inspiration that results in arousal from sleep. Option 3: Nocturnal enuresis, bedwetting, is a parasomnia that occurs when moving from stages III to IV of NREM sleep. Option 4: Bruxism, clenching and grinding of the teeth, is a parasomnia that occurs during stage II NREM sleep. Usually, it does not interfere with sleep for the affected individual but rather the sleeper's partner.)

Question 6. Which patient statement indicates that the patient is experiencing bruxism? 1. "I walk around in my sleep almost every night, but I don't remember it." 2. "I annoy the whole family with the loud snoring noises I make at night." 3. "I occasionally urinate in bed when I am sleeping, and it's embarrassing." 4. "I am told by my wife that I make a lot of noise grinding my teeth when I sleep."

3 (Rationale Option 1: This is a waddling gait associated with developmental dysphagia of the hip or due to the enlarged abdomen associated with pregnancy. Option 2: This is a steppage gait. It is associated with foot drop and Guillain-Barré syndrome. Option 3: This is a propulsive cogwheel gait. It is associated with Parkinson's disease. Option 4: This is a spastic gait. It is associated with cerebral palsy. Test Taking Tip: Identify the option with an obscure clang association. The word propulsive in the stem and the word acceleration are an obscure clang association. Both words have the same meaning. Examine options with clang associations carefully. More often than not, an option with a clang association is the correct answer.)

Question 7. A nurse identifies that a patient is walking with a propulsive cogwheel gait. Which patient behavior observed by the nurse supports this conclusion? 1. Rolling motion in which the opposite hip drops when taking a stride 2. Exaggerated lifting of the leg to avoid dragging the toes 3. Small, shuffling steps with involuntary acceleration 4. Stiff dragging of the foot when walking

1 (Rationale Option 1: An increase in falls is associated with older adults receiving Xanax. Xanax, a benzodiazepine, depresses the central nervous system, which may cause impaired coordination, drowsiness, fatigue, confusion, and tremors. Option 2: The blood pressure decreases, not increases, in response to Xanax because it may cause central nervous system depression. Option 3: This is not the priority at this time. Receiving Xanax longer than 2 weeks may lead to dependence. Option 4: Xanax should be discontinued slowly, not immediately, to prevent signs and symptoms of withdrawal.)

Question 7. A nurse is caring for an older adult who just had alprazolam (Xanax) prescribed for anxiety that has been interrupting sleep. What nursing action is most important at this time when caring for this patient? 1. Institute fall precautions. 2. Assess for elevated blood pressure. 3. Monitor for clinical indicators of dependence. 4. Discontinue immediately if the patient experiences drowsiness.

4 (Rationale Option 1: The right leg should be supported on a pillow in front of the left leg. Option 2: This excessive flexion can result in contractures of the hip and knee if permitted to remain in this position extensively. Option 3: The ankles should be maintained at 90 degrees. Option 4: In the left lateral (side-lying) position, the left arm is positioned in front of the body with the shoulder pulled forward (protracted). This reduces the pressure on the joint in the shoulder and the acromial process.)

Question 7. A nurse is repositioning a patient to the left lateral position. What action should the nurse implement when positioning this patient? 1. Rest the right leg on top of the left leg 2. Maintain knee flexion at ninety degrees 3. Place the ankles in plantar flexion 4. Left shoulder protracted

2 (Rationale Option 1: Deep breathing prevents atelectasis and hypostatic pneumonia, not pressure ulcers which this question is about. Option 2: Range-of-motion exercises help prevent contractures, not pressure ulcers. Option 3: Although sheepskin reduces friction and limits pressure, its main purpose is to allow air to circulate under the patient to minimize moisture and maceration of skin. Option 4: Turning a patient relieves pressure on the capillary beds of the dependent areas of the body, particularly the skin overlying bony prominences, which reestablishes blood flow to the area.)

Question 7. Which nursing action is most effective in relation to the concept Immobility can lead to occlusion of blood vessels in areas where bony prominences rest on a mattress? 1. Encouraging the patient to breathe deeply 10 times per hour 2. Performing range-of-motion exercises twice a day 3. Placing a sheepskin pad under the sacrum 4. Repositioning the patient every 2 hours

2 (Rationale Option 1: Demineralization of bone is a systemic response to immobility. Without the stress of weight-bearing activity, the bones begin to demineralize and the urine becomes more alkaline. Calcium salts precipitate out as crystals to form calculi. Option 2: A contracture is a localized response to immobility. When muscle fibers are not able to shorten or lengthen, eventually a permanent shortening of the muscles, tendons, and ligaments occurs. Option 3: Thrombophlebitis results from the systemic responses of impaired venous return and hypercoagulability in conjunction with injury to a vessel wall. Option 4: Immobility can cause the systemic response of demineralization of bone (disuse osteoporosis) that eventually can result in bone fractures.)

Question 8. A patient has been experiencing prolonged immobility because of a brain attack resulting in a coma. For which local response should the nurse monitor the patient? 1. Renal calculi 2. Contractures 3. Thrombophlebitis 4. Pathological fracture

2 (Rationale Option 1: NREM sleep deficiency precipitates physiological deficiencies, such as fatigue and lethargy. Option 2: REM sleep deficiency precipitates cognitive, emotional, and behavioral changes that include irritability and confusion. Also, the person may experience anxiety, apathy, an inability to concentrate, combativeness, disorientation, delusions, hallucinations, and/or paranoia. Option 3: NREM sleep deficiency precipitates physiological deficiencies, such as tremors and an increased sensitivity to pain. Option 4: NREM sleep deficiency precipitates physiological deficiencies, such as immunosuppression and delayed wound healing.)

Question 9. A nurse identifies that a patient has been awakening frequently during the night and comes to the conclusion that the patient is experiencing REM sleep deprivation. Which clinical manifestations identified by the nurse support this conclusion? 1. Fatigue and lethargy 2. Irritability and confusion 3. Tremors and increased sensitivity to pain 4. Immunosuppression and delayed wound healing

1 (Rationale Option 1: Resting the head on one pillow prevents right lateral flexion of the neck and positions the patient's head in functional alignment. Option 2: The right arm should be flexed at the elbow and the shoulder externally rotated. The right arm should rest on the mattress without a pillow. Option 3: A trochanter roll is unnecessary. The right hip and leg are positioned against the mattress. A trochanter roll is used to prevent external rotation of the hip when the patient is in a supine position. Option 4: The left hip and knee should be flexed slightly in front of the right leg and positioned on enough pillows to maintain functional alignment of the left hip, knee, and ankle. Test Taking Tip: Identify the unique option. Option 1 is the only option that includes the head rather than an extremity.)

Question 9. A nurse is repositioning a patient in the right lateral position. What action should the nurse implement when positioning this patient? 1. Rest the head on one pillow. 2. Extend the right arm and rest it on a pillow. 3. Support the right hip to the knee with a trochanter roll. 4. Flex the left hip and knee and rest the leg on the right leg.

3 (Rationale Option 1: Grinding the teeth while sleeping is bruxism. It may include repetitive clenching of teeth; it can erode tooth enamel, loosen teeth, and cause pain in the jaw. Option 2: Snoring is a clinical indicator of obstructive sleep apnea, not narcolepsy. Option 3: Abruptly falling asleep unexpectedly is a clinical indicator of narcolepsy. Additional clinical indicators include slurred speech and abrupt bilateral loss of muscle tone (cataplexy). The patient may report weakness of the knees and/or an inability to move during the onset of a sleep attack or when waking up (sleep paralysis) and vivid or bizarre dreams while falling asleep. Option 4: Episodic walking around while asleep with minimal awareness of the environment is sleepwalking (somnambulism), not narcolepsy.)

Question 9. Which statement indicates that the patient is experiencing narcolepsy? 1. "I grind my teeth at night to the point that my jaw is sore in the morning." 2. "My family says that I snore so loud that I keep everyone awake at night." 3. "I unexpectedly fall asleep for several minutes in the middle of the day at work." 4. "My mother says that I walk around in my sleep at night, but I don't remember anything."