quiz chapt 4,5,26,23,17

A high school student comes to the nurse's office to discuss her anxiety regarding an upcoming test. Her test-taking anxiety is a(an):

stressor Stress, coping, and adaptation are interrelated. Survival depends upon successful coping responses to ordinary and sometimes extraordinary circumstances and challenges.

The nurse is teaching a client who had a below-the-knee amputation about a temporary prosthetic limb. Which client statement requires further nursing teaching?

"I will tighten the belt when I go to sleep." Further nursing teaching is needed when the client states that the belt should be tightened when going to bed. The belt should be loosened when the client is in bed, and tightened during ambulation. Other statements are accurate and do not require further nursing teaching.

A 45-year-old man is interested in starting an exercise program. The nurse informs him that exercise does not:

decrease appetite. Exercise generally leads to an increased appetite.

A nurse is conducting a home assessment of a 90-year-old male client with a history of several minor strokes that have left him with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.

1. removal of clutter on the floor 2. placing a nightlight in the bathroom and the hallways 3. moving the bedroom to the ground floor

Which client is most at risk for foot difficulties?

45-year-old woman with type 2 diabetes

What is the term for the change that takes place in response to a stressor?

Adaptation When a person is in a threatening situation, immediate and often involuntary responses occur. The change that takes place in response to a stressor is adaptation. Rehabilitation is the action of restoring someone to health or normal life through training and therapy after imprisonment, addiction, or illness. Positive or negative movement is the reactions of the response to the stressor in regards the nature of the actions.

A 56-year-old construction worker is in for his annual physical. As the nurse takes his vital signs, he tells her that his blood pressure may be a little off this morning. He tells the nurse that he is recently unemployed, is quite stressed, and is having a hard time coping. He feels like he needs to numb the pain. What is the nurse most concerned about regarding this client?

Alcohol use Alcohol use is a common altered coping pattern for individuals with poor coping skills. It is legal and easily accessible. Phrases such as "I just cannot cope" and "I need to numb the pain" are common among those who misuse alcohol.

A nurse is caring for a client whose fractured leg is in a cast. Which ambulatory device could the nurse suggest for the client to use at the health care facility?

Axillary crutch The nurse should suggest the use an axillary crutch for the client who has her fractured leg in a cast. This will aid the client to ambulate at the health care facility. Axillary crutches have a bar that fits beneath the axilla. Clients who need brief, temporary assistance with ambulation are likely to use axillary crutches. A cane is used for clients who have weakness on one side of the body. Clients who require considerable support and assistance with balance use a walker. Platform crutches are used by clients who cannot bear weight with their hands and wrists. Many clients with arthritis use them.

A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client?

Client is in supine position with arms in functional position and pillow support under the knees. In the supine position, the client is lying on the back. All other options are incorrect, as prone is lying on the stomach, lateral oblique is a side-lying position, and Sims' position is a semi-prone position that allows for rectal and/or vaginal examination.

The nurse walks into the client's room and finds her sobbing uncontrollably. When the nurse asks what the problem is, the client responds "I am so scared. I have never known anyone who goes into a hospital and comes out alive." On this client's care plan the nurse notes a nursing diagnosis of Ineffective Coping related to stress. What is the best outcome the nurse can expect for this client?

Client will adapt relaxation techniques to reduce stress. Stress management is directed toward reducing and controlling stress and improving coping. The outcome for this diagnosis is that the client needs to adopt coping mechanisms that are effective for dealing with stress, such as relaxation techniques. It is unrealistic to expect a client to be stress free. Avoiding stressful situations and starting an antianxiety agent are not the best answers as outcomes for ineffective coping.

The nurse involved in coordinating a support group for spinal cord injury clients learns that one of the participants in the support group was a college athlete prior to his diving accident. The client informs the group that he earned a scholarship based upon his athletic abilities and not his academic performance, and after the injury, he focused his energies on his studies. He has been on the dean's list for two semesters. What defense mechanism is illustrated in this scenario?

Compensation Compensation is overcoming a perceived weakness by emphasizing a more desirable trait or achieving in a more comfortable area. Sublimation involves a person substituting a socially acceptable goal for one whose normal channel of expression is blocked. Projection is a person's thoughts or impulses attributed to someone else. Reaction formation is the development of conscious attitudes and behavior patterns that are opposite to what he would prefer to do.

A client requires crutches but cannot bear any weight with the hands or wrists. What type of crutches would the nurse prepare to assist this client with?

platform crutches

The nurse is caring for an 82-year-old client who has been diagnosed with disuse syndrome. Which assessment data would the nurse anticipate?

weak muscle strength with unsteady gait The consequences of inactivity are referred to as disuse syndrome. Weak muscle strength and unsteady gait are consequences of inactivity. The other options are not related to activity status.

A client with a diagnosis of chronic obstructive pulmonary disease has been experiencing debilitating periods of dyspnea since being admitted to the health care facility. What position is most likely to alleviate this client's shortness of breath?

High Fowler position Fowler position is especially helpful for clients with dyspnea because it causes the abdominal organs to drop away from the diaphragm. Relieving pressure on the diaphragm allows the exchange of a greater volume of air. Positioning the client in the Sims, prone, or lateral oblique position does not promote maximum ventilation.

A nurse is caring for an athlete with torn quadriceps muscles. The physician has prescribed the use of quadriceps setting for rehabilitating the client. How would the quadriceps setting help the client? Select all that apply.

It aids in extending the leg. It enables one to stand. It enables the client to support their body weight. A quadriceps setting aids in extending the leg and enables the client to stand. It also supports the client's body weight. A gluteal setting aids in extending, abducting, and rotating the legs. These functions are essential to walking.

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity?

Pull the shoulder blade forward and out from under the client. Positioning the shoulder blade in this manner removes pressure from the bony prominence. Placing the call light within reach assist with safety but not skin integrity. Covering the client with bed linens assists with keeping the client warm. Assessing the pain does not affect the skin.

The cane's handle should be parallel with the hip. An older adult client with weakness on one side of the body needs to use a cane for walking. How should the nurse determine the correct height of the cane to be used by the client?

The cane's handle should be parallel with the hip. The nurse should ensure that the cane's handle is parallel with the hip, not at waist level. The cane should provide an elbow flexion of approximately 30, not 50. The cane's handle should be slightly bent, not straight, to offer more stability to the client.

A nurse is caring for a client with extensive burns. Which would the nurse have to attach to the client's bed to prevent the bedclothes from touching the client's body?

bed cradle The nurse should provide a bed cradle for a client with extensive burns to prevent the bed linen from touching the client's body. The nurse does not need to provide a footboard, a bed board, or traction for the client. A footboard is used to prevent deformities of the feet as a result of prolonged confinement to bed. A bed board is placed under the mattress to support the body in correct alignment. Traction is used to keep a body part such as the leg in alignment.

The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client data would the nurse check to see if the assistance of another nurse is needed?

client restrictions When attempting to move a client, the nurse would first check the client's chart to see if the client has any physical limitations or restrictions. The nurse would also evaluate the client's condition and determine whether or not the client can help with positioning or understand directions. Lastly, the nurse would evaluate the client's body weight and his or her own strength. Age and food preferences would not affect movement. Clients with restraints still need to be moved and repositioned.

When assessing the physical activity of clients, the nurse would be most concerned about which client?

the middle-age computer programmer

Which statement, made by a senior citizen who has taken a class on stress reduction, would indicate to the nurse the need for further instruction?

"As one grows older, their stress decreases." As a person ages, stress does not decrease; in fact, some people experience increased stressors associated with commonly encountered circumstances, such as experiencing empty-nest syndrome or dealing with the death of a spouse, relatives, or friends.

Which question would be helpful in eliciting data about the effects of stress during a health history?

"How does your body feel when you are upset?" Stress causes many physiologic manifestations and emotional responses. The question "How does your body feel when you are upset" is nonjudgmental and nonthreatening, and encourages the client to talk about the symptoms he has experienced. Asking the client about their alcohol, smoking, and hangovers are targeting their ways of coping with stress.

A Red Cross volunteer has recently returned from assisting families in the Northwest who survived a devastating forest fire. She is having trouble sleeping and has taken up smoking again. Which statement by her leads the nurse to suspect a nursing diagnosis of Caregiver Role Strain related to stress from disaster volunteer activities?

"I can't seem to calm down. I keep seeing those faces and hearing their words every time I close my eyes." This person is exhibiting a physiologic response to stress, while also taking up a negative coping solution to diminish the symptoms. Reliving the events that were stressful is a common complaint when under anxiety. The other statements do not demonstrate the burden of role strain.

A client presents with a flare of lupus. Which statement made by the client would cause the nurse to suspect a stress reaction?

"I just had a baby 3 weeks ago."

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?

"I will use conditioner so that the lice eggs will slide off my hair." Hair conditioner coats the hairs and protects the nits. The nurse must intervene to teach the client to only use the pediculicide shampoo; not conditioner. Eggs may attach to hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces, and lice can be spread by direct contact.

Four daughters of a client diagnosed with brain death after a myocardial infarction are trying to come to terms with this stressor. Which statement from one of the daughters shows the nurse that they are coping effectively with their mother's situation?

"Is it okay if I ask our pastor to come and say a prayer with us in Mom's room?" Family coping can be influenced by shared values and culture, economics, environment, past events, and religion. Blaming, projection, and denial can be unhealthy ways to defend against a stressor. An effective way to help these daughters cope with grieving and loss might be seeking out the support of a respected member of their religious community.

The nurse teaches a client about the use of yoga as a stress management intervention. Which client statement indicates to the nurse that learning has taken place?

"It reduces physical and emotional tension through postural changes and focused concentration." Stating that yoga reduces physical and emotional tension through postural changes and focused concentration is correct because yoga reduces stress, increases relaxation, and promotes greater flexibility. Stating that yoga eases tense muscles by clearing the mind of stressful thoughts refers to progressive relaxation, not yoga. Stating that yoga alters a negative physiologic response through the power of suggestion is incorrect, as this is referring to the placebo effect. Using the mind to visualize calming, pleasurable, and positive experiences is called imagery, not yoga.

Which client statement, after a presentation about drug use, indicates to the nurse a correct understanding of the information presented?

"Mixing alcohol and tranquilizers may cause physical impairment and drug dependency." Stating that the mixing of alcohol and tranquilizers may cause physical impairment and drug dependency indicates to the nurse that learning has taken place, because the client's awareness of the health risks that are associated with the combination may prevent the client from using drugs. The combination of alcohol and tranquilizers can lead to drug dependency instead of individuals weaning off drugs. The combination of alcohol and tranquilizers decreased brain activity, resulting in decreasing (not increasing) arousal.

The nurse is providing step-by-step instructions to a client who is learning how to climb stairs while using crutches. Arrange the following instructions in the correct order.

"Place both crutches under your left arm." "Grasp the stair railing with your right arm." "Place your unaffected leg on the first stair tread." "Transfer your weight to the unaffected leg." "Move up onto the stair tread." "Move your crutches and the affected leg up onto the stair tread."

Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?

"These brown spots are senile lentigines and are common when you get older."

The emergency department nurse suspects that an older adult client who fell and broke her hip is using a defense mechanism when the client states:

"They must have given me the wrong medication at the drug store. I don't have trouble with my eyesight." Defense mechanisms are psychological tools individuals use to deal with high levels of anxiety from stressors. Clients under extreme stress may self-protect by using denial and rationalization; they may convince themselves that the problem didn't happen or was not caused by them, or that it must have resulted from someone else's mistake. Additionally, the denial may be nonacceptance of the developmental stressors of aging.

To avoid postural hypotension, which teaching will the nurse provide to the client?

Dangle feet before moving from a reclining position. Teaching the client dangle before moving from a reclining position can help normalize blood pressure. Other interventions listed do not decrease the risk for postural hypotension.

A 22-year-old college student recently engaged in sexual intercourse with a new partner. When a nurse tells her that she is pregnant, she tells the nurse "that's not possible, I got my period last week". This is an example of what defense mechanism?

Denial

Aleah is a 22-year-old college student who recently engaged in sexual intercourse with a new partner. When the nurse tells her that she is pregnant, she states, "That's not possible, I got my period last week." This is an example of what defense mechanism?

Denial Aleah is exhibiting denial by refusing to accept something as is.

The nurse is performing a routine assessment of a male client who has an artificial arm as a result of a small plane crash many years earlier. How should the nurse best understand this client's health?

Despite the loss of his limb, the client may consider himself to be healthy. Individuals who live with chronic conditions, such as the loss of a limb, may accommodate their condition fully and consider themselves to be healthy and well. This is not a certainty, however, and the passage of time does not guarantee such acceptance.

A nurse is caring for a client who is in the remission state of leukemia. The client expresses anxiety about the recurrence of leukemia and states feels depressed when thinking about the outcome of leukemia. Which aspect of health is the client talking about?

Emotional health Anxiety and depression are components of emotional health. The client is not feeling emotionally well because she is worried about the disease outcomes. Presently, the client is in remission and thus is physically healthy. The client does not mention anything about social interactions and spiritual health.

A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, a problem that was accompanied by a random blood glucose reading of 575 mg/dLm (31.91 mmol/L), vomiting, and shortness of breath. This client has experienced which phenomena?

Exacerbation This client has experienced a significant exacerbation of his chronic disease (diabetes mellitus), which has manifested as an acute threat to their health. Morbidity is an epidemiological statistic of the frequency of a disease. The client's problem does not have an infectious etiology. A risk factor is any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury.

Older, continent clients who are hospitalized should receive a full bed bath with soap and water every day.

False

The nurse understands that an idiopathic illness is a condition whose cause is unexplained. Which is an example of idiopathic illness?

Fever of undetermined origin Fever of undetermined origin is an example of idiopathic illness because the cause is unknown. Juvenile rheumatoid arthritis is a rheumatic disorder. Inflammatory bowel disorder is due to imbalance in immunological responses of the body. Patent ductus arteriosus is a congenital anomaly of the heart due to abnormal fetal development.

A nurse working on an oncology floor often sits with her clients in a calm, quiet, dimly lit environment and describes a walk along the ocean's shore. The nurse provides details of the walk and verbally paints a picture for the client. What best defines this form of stress management?

Guided imagery Guided imagery involves creating a mental image based upon a verbal description offered by another individual. Biofeedback is a method of gaining mental control of the autonomic nervous system and regulating body responses. Meditation involves relaxing major muscle groups and repeating a word silently during exhalation. Anticipatory guidance focuses on physiologically preparing a person for an unfamiliar or painful event.

A nursing student asks the instructor about the leading cause of death. What would the instructor identify as the most common cause of death in clients?

Heart disease Diseases of the heart represent the leading cause of death in the United States, accounting for 26% of all deaths in 2006. Cancer was second, stroke was third, and diabetes was sixth during that same period.

The client is under immediate stress. The nurse assesses which sign as an effect of the sympathetic system?

Heart rate of 102 beats/min. When stressed, the client's sympathetic system is activated, which causes an increase in heart rate. The sympathetic system also stimulates release of glycogen, which increases blood glucose levels and dilates skeletal muscle blood vessels. This would most likely cause warm skin and not cool and clammy. The parasympathetic system, which functions under normal conditions and at rest, stimulates secretion of digestive juices and the smooth muscle of the digestive tract, thus leading to increased peristalsis.

If a nurse assessed the vital signs of a person who was in the initial alarm reaction stage (shock phase) of the GAS, what would be the expected findings?

Hypertension The alarm reaction is initiated when a person perceives a specific stressor and various defense mechanisms are activated. The initial or shock phase is characterized by increased energy, oxygen intake, increased respiratory rate, cardiac output, blood pressure, and mental alertness.

Which are considered internal stressors? Select all that apply.

Illness Fear Hormonal change A stressor is anything that is perceived as challenging, threatening, or demanding. Stressors may be internal (e.g., an illness, a hormonal change, or fear) or external (e.g., loud noise or cold temperature).

A client is being admitted to a health care facility for abdominal pain of undetermined origin. The client states, "I've never been hospitalized before. What is going to happen to me?" The nurse notes the client's respirations are 28 breaths/minute, heart rate is 102 beats/minute, blood pressure is 120/86. The client's muscles are tense. What actions would the nurse take to reduce the client's anxiety? Select all that apply.

Introduce self to client by name and title. Provide information about diet, activity, and diagnostic tests. Discuss past experiences involving the health care system with the client. Ask the client about available support systems and enlist his or her support

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?

Launder gowns, linens, and towels separate from other clients items.

Which client would be at greatest risk for injury to the skin and mucous membranes?

Man 77 years of age with diabetes Resistance to injury of the skin and mucous membranes varies among people. Factors influencing resistance include the person's age, the amount of underlying tissue, and illness conditions. In this question, the older man with diabetes would be most at risk. Diabetes and high blood glucose puts a client as a higher risk of infection. Hemorrhoids are swollen veins in the lowest part of the rectum and anus and are not associated with injury. Asthma is a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe.

The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action?

Move the client to edge of the bed opposite the side that client will be turning. When turning a client in bed, the nurse would use a friction-reducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Pushing the client to the opposite side of the bed is not good for back safety. Consult a Safe Patient Handling Algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client.

Which health problem is most clearly suggestive of a history of inadequate dental care?

Periodontitis

A student has been assigned to provide morning care to a client. The plan of care includes information that the client requires partial care. What will the student do?

Provide supplies and assist with hard-to-reach areas.

A nurse teaches a client deep-breathing exercises to help control his anxiety. This is considered what type of stress management technique?

Relaxation Deep breathing and progressive muscle relaxation are two helpful relaxation activities. They should be practiced 3 or 4 times at each session. A person practicing meditation sits comfortably with closed eyes, relaxes the major muscle groups, and repeats the selected word silently with each exhalation. Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. In guided imagery, a person creates a mental image, concentrates on the image, and becomes less responsive to stimuli (including pain).

A dancer has suffered a fall injury, which will prevent participation in a much-anticipated event. The fall is classified as what?

Stressor

A group of nursing students is learning about the body's response to stress. Which system is responsible for initiating the fight-or-flight response to stress?

Sympathetic nervous system

A nurse is performing a comprehensive assessment of a new resident of a long-term care home. When asked about ways in which the resident manages stress, the client admits he drinks "five or six stiff martinis each afternoon." How will heavy alcohol use affect the client's stress management?

The client may ultimately experience more stress Excessive or chronic substance abuse can lead to physical impairment, drug dependence, and legal problems creating more stressors than those for which they were originally intended to relieve.

On a previous clinic visit a month ago, the overweight client reported shortness of breath with activity and constipation. The client was diagnosed as having osteoporosis and noted to have an elevated triglyceride level. The primary care provider prescribed an exercise program. The nurse is assessing for the effects of exercise. What are the expected outcomes for this client? Select all that apply.

The client reports no shortness of breath with activity. The client reports regular and formed bowel movements. The client's weight is maintained or lessened. Effects of an exercise program include improved work of breathing (no shortness of breath with activity), improved bowel elimination (regular and formed bowel movements), and weight controlled at the current weight, or ideally lessened. The client's blood triglyceride level should decrease with an effective exercise program. The client should experience increased joint mobility and less joint pain.

A client has been brought to the health care facility with accident-related injuries. During the initial interview, the client becomes agitated, upset and is unable to answer any more of the nurse's questions. What does the nurse conclude about the condition of the client?

The client's mind is preparing for a fight-or-flight response as he relates the incident. The client is currently in the alarm stage, where the stimulating neurotransmitters and neurohormones are released, which prepare the client for a fight-or-flight response. The brain, at this time, receives more oxygen to sharpen the senses and coordination. The brain also sends more chemicals to the bloodstream, which helps the client to keep alert for an extended period of time.

Which data requires the nurse to plan care for a sequela for a client who is postoperative for a coronary artery bypass grafting (CABG) and who experienced decrease oxygen saturation and hypotension during the surgical procedure?

The client's urine output decreases with elevations noted to both blood urea nitrogen (BUN) and creatinine levels noted the day after surgery. The client with decreased urine output and elevated BUN and creatinine levels indicate acute kidney injury caused by the sudden drop of oxygen and blood pressure during surgery. The other client data is expected following a CABG.

A client is to begin ambulating with the use of a T-handle cane. The nurse determines that the cane is at the proper height based on which observation?

The handle is parallel with the client's hip.

A recent nursing graduate has been making a concerted effort to ensure that clients receive holistic nursing care. Which action best demonstrates the principle of holism?

The nurse attempts to meet the physical, social, emotional, and spiritual health needs of clients Holism is the sum of physical, emotional, social, and spiritual health and it determines how "whole" or well a person feels. A nurse does not necessarily need to prioritize a client's high-level needs in order to promote holism. Equal care that disregards client acuity and individualities is not consistent with the principle of holism. Seeking input from clients is consistent with holism, but this activity is not necessarily evidence of holistic care.

The nurse has completed a change of a client's beding while the client is seated in a wheelchair. When removing the bedding, what action best maintains the principles of infection control?

The nurse should avoid contact with the soiled bedding as much as possible, and should avoid placing it on surfaces where it could transmit microorganisms. Such surfaces include the floor and chairs.

A nurse is trying to assess a client's stress type; however, the client is very depressed and quiet and does not reply to the nurse's questions. The nurse is unable to maintain her calm while repeating the questions. Where is the nurse going wrong in assessing the client?

The nurse should demonstrate confidence and expertise. Some general interventions appropriate during the care of the client who is suffering from stress include remaining calm during the discussions with the client, being available to the client, responding promptly to the client's signal for assistance, and encouraging family interaction. However, taking the help of a senior physician or giving the client a sedative would not help in assessing the client. The nurse has to assess the client's type of stress.

A college student fell and sprained his right ankle. The student health physician recommends the student use crutches to facilitate healing. What would the nurse teach the student?

The support of the body should be the hands and arms

The nurse is caring for a client with a previous knee injury that is healing. Which crutch-walking gait will the nurse teach?

Three-point partial weight-bearing Three-point partial weight-bearing is appropriate for a client who has a previous injury that is healing. Other choices are inappropriate.

A nurse places a client in the position shown in the accompanying photo. What position is the client assuming?

Trendelenburg In the Trendelenburg position, the head is lower than the feet.

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement is correct regarding logrolling?

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight alignment when the client is being turned. The nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement. The nurse should avoid twisting the client's head, spine, shoulders, knees, or hips while logrolling. A chair is not used with logrolling.

An older adult resident of a long-term care facility has recurring problems with dry skin. Which strategy should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness?

Use a nonsoap cleaning agent. Soap cleans the skin, but while it removes dirt from the surface, it affects the lipids that are present on the skin, and the skin pH. This contributes to drier skin, damaging the barrier function of the skin. The substitution of a nonsoap, emollient cleaning agent is an easy way to prevent drying and damage to the skin. An organic soap is not necessarily less drying to the skin. It would be inappropriate to forego the use of any cleaning products whatsoever. Providing a bed bath rather than a tub bath will not necessarily minimize dry skin.

A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply.

Use of a tub/shower seat may be necessary if balance problems are present. Water temperature should be monitored carefully due to decreased temperature sensation. Use a long-handled shower brush or attachment to help with limited mobility.

Which type of mobility aid would be most appropriate for a client who has poor balance?

a cane with four prongs on the end (quad cane)

Which nursing intervention is an example of tertiary preventive care?

assisting with speech therapy for a client with a traumatic brain injury Tertiary prevention begins after the illness and is used to help rehabilitate clients. Speech therapy is an example of tertiary preventive care. The administration of immunizations and teaching stress reduction classes are examples of primary preventive care. Blood pressure screening is an example of secondary preventive care.

A teenage girl is discussing her recent breakup with her boyfriend. She tells the nurse she just stays in bed all day and cannot seem to feel any better. She says she is only relieved of the pain while sleeping. The nurse identifies this coping strategy as:

avoidance coping.

A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP)?

back massage A back massage can be delegated to a UAP. Assessments and wound care must be done by the RN.

When a client is lifted or held by a nurse, the additional weight becomes a part of the nurse's weight and should be:

balanced over the center of gravity. Maintaining balance involves keeping the spine in vertical alignment, the feet positioned for a broad base of balance, and the body weight close to the center of gravity.

A young mother tells the nurse, "I can't stop smoking. That is what I do to make myself feel better." What is the term used to describe this behavior?

coping mechanism

A nurse is teaching a client using crutches to follow this pattern: one crutch, opposite foot, other crutch, remaining foot. What type of gait is the nurse instructing about?

four point

A debilitated client needs help to improve muscle tone and strength. What type of exercise would the nurse be most likely to assist with for this client?

isometric Isometric exercises are used to promote muscle tone and strength. Tone means the ability of muscles to respond when stimulated; strength means the power to perform. Both tone and strength are inherent in maintaining mobility.

A 79-year-old client reports brittle fingernails. What may be the cause of the client's problem?

lack of keratin on nails The client's fingernails could be brittle due to lack of keratin on nails. Fingernails and toenails are made of keratin, which in concentrated amounts gives them their tough texture. Skin is not made of keratin. Lack of skin or presence of dry skin near the nails does not affect the texture of the nails.

A nurse is providing care for a client whose treatment is being funded by Medicaid. The nurse should be aware that this client most likely qualified for this program on the basis of:

low income. Medicaid is a state-administered program designed to meet the needs of low-income residents. Military service, older age and chronic illnesses are not normally criteria that qualify an individual for enrollment in Medicaid.

The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure?

lying flat The nurse would position the bed so that the client is lying flat on the back and then raise the bed to a comfortable working height. This facilitates moving the client to the side in order to perform the turn in bed. If the client was prone, the client will need to moved to their back. Sitting up is another position a client can be moved into.

A nurse is ambulating a client who has had a stroke. The client has paresis on the right side of the upper body. Where would the nurse stand to walk the client?

on the weak side When a client has weakness or paralysis on one side, the nurse stands on the weaker side and stabilizes the client by putting one arm around the client's waist. The client's weak arm is supported in the axillary area

A kindergarten student is sent to the school nurse because they have been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of:

pediculosis. - LICE

A client that is a single parent of two small children is working two part-time jobs. The client comes into the clinic for an appointment looking disheveled and fatigued. Which health promotion activities would this client benefit from? Select all that apply.

reduction of stressors perfection reduction Assertiveness, not aggressiveness, is a preferred health promotion strategy. CBT is a treatment, not health promotion. Medications are also a treatment.

During a counseling session a client states, "I just try to forget about my spouse hitting me." Which coping mechanism should the nurse document based on this client's statement?

repression Repression is the coping mechanism that this client is using, in which the client has removed the experience of being abused from conscious memory. Reaction formation is a coping mechanism that sees an individual acting just the opposite of one's feelings. Rationalization is relieving oneself of personal accountability by attributing responsibility to someone or something else. Regression is behaving in a manner that is characteristic of a much younger age.

Which behaviors represent effective coping mechanisms? Select all that apply.

setting limits with family members who upset you learning relaxation techniques taking a vacation Coping mechanisms can have positive or negative effects on a client's well-being. All of these examples represent coping, either effective or ineffective.

A client is on a stress management program. She states that she is open to trying a guided meditation class. When helping her get started, a nurse tells her that which of the following is not important?

soft music Music may be helpful for some, but is not essential for meditation.

A middle-age woman's father has passed away, and her mother requires physical and emotional help due to disabilities. The woman is married and raising two children, along with working full time. All of the factors described are:

stressors. Stress is defined as any event or set of events (a stressor) that causes a response. Everyday triggers associated with work or social relationships, and uncommon events such as natural disasters, physical trauma, injuries, illnesses, divorce, death of a loved one, or loss of a job are commonly recognized stressors.

The nurse is preparing a plan of care for a client with nutritional deficits. Which is the priority intervention for this client?

teaching about intake of food and vitamins Priority management according to Maslow's hierarchy starts at physiological needs and includes the need for oxygen, food, water, rest, and elimination. Therefore, teaching the client about intake of food and vitamins is most appropriate for the client who has nutritional deficits. Teaching about weight loss programs, teaching about binge eating, and acknowledging the client's weight problem are examples of other needs that are not the priority.

The nurse at the student health center is seeing a group of nursing students who are interested in reducing their stress level. The nurse identifies guided imagery as an appropriate intervention. What does guided imagery involve?

the mindful use of a word, phrase, or visual image which allows oneself to be distracted and temporarily escape from stressful situations Guided imagery is the mindful use of a word, phrase, or visual image for the purpose of distracting oneself from distressing situations or consciously taking time to relax or re-energize. Progressive tensing and relaxing of muscles describes progressive muscle relaxation. Using positive self-image to increase workouts in the gym is not an identified technique. Relaxing with music is not guided imagery.

Chronic illness may be characterized by periods of remission. Remission is best defined as:

the presence of a disease with the absence of symptoms. Remission is defined as the presence of a disease, but the person does not experience the symptoms. Exacerbation is the reappearance of symptoms of a disease. Disease is a pathologic change in the structure of function of the body or mind. Illness is the response of a person to a disease.

After teaching a client how to perform a four-point crutch gait, the nurse determines that the teaching was successful when the client first moves the left crutch and then follows with:

the right foot. With a four-point gait, the client moves one crutch—in this case, the left crutch. Then the client would move the opposite foot—in this case, the right foot. Then the client would move the right crutch, followed by the left foot.

Before a long-term care resident goes to sleep at night, the client's dentures are placed in a denture cup with clean water. What rationale supports placing dentures in water?

to prevent drying and warping of plastic If a client removes dentures while sleeping, they should be stored in water in a disposable denture cup to prevent drying and warping of plastic materials. If the dentures warp, then the client will experience discomfort in eating. Dentures do not need to be stored in saline as tap water is sufficient. The storage container does not ensure the dentures will not be thrown away and nurses should be diligent to prevent this from occurring.