1430 Review Questions: Comfort, Mobility, Functional Ability

A nurse is assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat emboli? a. Altered mental status b. Reduced bowel sounds c. Swelling of the toes distal to the injury d. Pain with passive movement of the foot distal to the injury

A

27. Of the following nursing goals, which is the most appropriate for a patient who has had a total hip replacement? a. The patient will walk 1000 feet using her walker by the time of discharge. b. The patient will ambulate by the time of discharge. c. The patient will ambulate briskly on the treadmill by the time of discharge. d. The nurse will assist the patient to ambulate in the hall.

A ("The patient will walk 1000 feet using her walker by the time of discharge" is individualized, realistic, and measurable. "The patient will ambulate by the time of discharge" is not measurable because it does not specify the distance. Even though we can see that the patient will ambulate, this does not quantify how far. "Ambulating briskly on a treadmill" is not realistic for this patient. The last option focuses on the nurse, not the patient, and is not measurable.)

36. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. One strategy that the nurse could use is a. A foot cradle. b. A trochanter roll. c. The trapeze bar. d. Hand rolls.

A (A foot cradle may be used in patients with poor peripheral circulation as a means of reducing pressure on the tips of a patient's toes. A trochanter roll prevents external rotation of the hips when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bed frame. It allows the patient to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises.)

12. The nurse is attempting to start an exercise program in a local community as a health promotion project. In explaining the purpose of the project, the nurse explains to community leaders that a. A sedentary lifestyle contributes to the development of health-related problems. b. The recommended frequency of workouts should be twice a day. c. An exercise prescription should incorporate aerobic exercise only. d. The purpose of weight training is to bulk up muscles.

A (A sedentary lifestyle contributes to the development of health-related problems. A holistic approach is taken to develop overall fitness and includes warm-ups, aerobic exercise, resistance training, weight training, and so forth. The recommended frequency of aerobic exercise is 3 to 5 times per week or every other day for approximately 30 minutes. Cross-training is recommended for the patient who prefers to exercise every day. Some patients use weight training to bulk up their muscles. However, the purposes of weight training from a health perspective are to develop tone and strength and to simulate and maintain healthy bone.)

A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care? a. Skeletal traction b. Buck's traction c. Halo traction d. Bryant's traction

B

A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take first to keep the client safe? a. Keep the call light near the client b. Place the client in a room close to the nurses' station c. Encourage the client to ask for assistance d. Remind the client to walk with someone for support

B

A nurse is caring for a client who has MS. Which of the following findings should the nurse expect? a. Fluctuations in blood pressure b. Loss of cognitive function c. Ineffective cough d. Drooping eye lids

B

34. The nurse is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. To help prevent injury secondary to this rotation, the nurse can use a. A trochanter roll. b. The trapeze bar. c. Hand rolls. d. Hand-wrist splints.

A (A trochanter roll prevents external rotation of the hips when the patient is in a supine position. Hand rolls maintain the thumb in slight adduction and in opposition to the fingers. Hand-wrist splints are individually molded for the patient to maintain proper alignment of the thumb and the wrist. The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bed frame. It allows the patient to pull with the upper extremities to raise the trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises.)

6. Alan is a 30-year-old male admitted to the hospital with acute pancreatitis. He is in acute pain described as a 10-10, which is localized to the abdomen, periumbilical area, and some radiation to his back. The abdomen is grossly distended so it is difficult to assess. He is restless and agitated, with elevated pulse and blood pressure. An appropriate pain management plan of care may include a. IV Dilaudid q 4 hours prn, hydrocodone 5-500 PO q 6 hours prn, and acetaminophen. b. Norco 5-500 q 4 hours PO and Benadryl 25 mg PO q 6 hours. c. Phenergan 25 mg IM q 6 hours. d. Tylenol 325 mg q 6 hours.

A (A variety of routes of administration are used to deliver analgesics. A principle of pain management is to use the oral route of administration whenever feasible. All of the first-line analgesics used to manage pain are available in short-acting and long-acting formulations. For patients who have continuous pain, a long-acting analgesic, such as modified-release oral morphine, oxycodone, or hydromorphone, or transdermal fentanyl, is used to treat the persistent baseline pain. A fast-onset, short-acting analgesic (usually the same drug as the long-acting) is used to treat breakthrough pain if it occurs. When the oral route is not possible, such as in patients who cannot swallow or are NPO or nauseated, other routes of administration are used, including intravenous (IV), subcutaneous, transdermal, and rectal. Norco, Benadryl, Phenergan, and Tylenol are not appropriate solo choices for acute pancreatitis with pain reported as 10/10.)

20. The nurse is caring for an elderly patient with the diagnosis of urinary tract infection (UTI). The patient is confused and agitated. It is important for the nurse to realize that confusion in the elderly is a. Not a normal expectation. b. Purely psychological in origin. c. Not a common manifestation with UTIs. d. Acceptable and needs no further assessment.

A (Acute confusion in older adults is not normal; a thorough nursing assessment is the priority. Abrupt changes in personality often have a physiological cause such as surgery, a medication reaction, a pulmonary embolus, or an acute infection. For example, the primary symptom of compromised older patients with an acute urinary tract infection or fever is confusion. Identifying confusion is an important component of the nurse's assessment.)

45. The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique to keep the spinal column in straight alignment. Which of the following is the proper technique for logrolling? a. Obtain assistance from at least two or three other people. b. Have the patient reach for the opposite side rail when turning. c. Move the top part of the patient's torso, then the bottom part. d. Do not use pillows after turning because the softness causes misalignment.

A (At least three to four people are needed to perform this skill safely. Have the patient cross arms on chest to prevent injury to the arms. Move the patient as one unit in a smooth, continuous motion on the count of three. Gently lean the patient as a unit back toward pillows for support.)

7. The nurse is preparing to reposition a patient. Before doing so, the nurse must a. Assess the weight to be lifted and the assistance needed. b. Attempt to manually lift the patient alone before asking for assistance. c. Attempt a manual lift only when lifting most or all of the patient's weight. d. Not use the agency lift team if a mechanical lift is available.

A (Before lifting, assess the weight to be lifted and determine the assistance needed and the resources available. Manual lifting is the last resort, and it is used when the task at hand does not involve lifting most or all of the patient's weight. Use safe patient handling equipment in conjunction with agency lift teams to reduce the risk of injury to the patient and members of the health care team.)

26. The patient is being admitted to the neurological unit with the diagnosis of stroke. The nurse should begin discharge planning a. At the time of admission. b. The day before the patient is to be discharged. c. As soon as the patient's discharge destination is known. d. When outpatient therapy will no longer be needed.

A (Discharge planning begins when a patient enters the health care system. In anticipation of the patient's discharge from an institution, the nurse makes appropriate referrals or consults a case manager or a discharge planner to ensure that the patient's needs will be met at home. Referrals to home care or outpatient therapy are often needed.)

8. Isotonic, isometric, and resistive isometric are three categories of exercise. They are classified according to the type of muscle contraction involved. Of the following exercises, which are considered isotonic? a. Bicycling, swimming, walking, jogging, dancing b. Tightening or tensing of muscles without moving body parts c. Push-ups, hip lifting, pushing feet against a footboard on the bed d. Quadriceps set exercises and contraction of the gluteal muscles

A (Examples of isotonic exercises are walking, swimming, dance aerobics, jogging, bicycling, and moving arms and legs with light resistance. Isometric exercises involve tightening or tensing of muscles without moving body parts. Examples include quadriceps set exercises and contraction of the gluteal muscles. Examples of resistive isometric exercises are push-ups and hip lifting, as well as placing a footboard on the foot of the bed for patients to push against with their feet.)

2. The nurse is assessing a patients functional performance. What assessment parameters will be most important in this assessment? a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment b. Height, weight, body mass index (BMI), vital signs assessment c. Sleep assessment, energy assessment, memory assessment, concentration assessment d. Healthy individual, volunteers at church, works part time, takes care of family and house

A (Functional impairment, disability, or handicap refers to varying degrees of an individuals inability to perform the tasks required to complete normal life activities without assistance. Height, weight, BMI, and vital signs are physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance.)

1. What is meant by "concentric tension" of muscles? a. Increased muscle contraction results in movement. b. The speed and direction of movement are controlled. c. Tension causes no shortening or active movement. d. Tension does not result in isotonic contraction.

A (In concentric tension, increased muscle contraction causes muscle shortening, resulting in movement. Eccentric tension helps control the speed and direction of movement. Concentric and eccentric muscle actions are necessary for active movement and are referred to as dynamic or isotonic contraction. Isometric contraction (static contraction) causes an increase in muscle tension or muscle work but no shortening or active movement of the muscle.)

2. A 19-year-old male has sustained a transaction of C-7 in an MVA rendering him a quadriplegic. He describes his pain as burning, sharp, and shooting. This is characteristic of a. neuropathic pain. b. ghost pain. c. mixed pain syndrome. d. nociceptive pain.

A (Neuropathic pain results from the abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Simply put, neuropathic pain is pathologic. Examples of neuropathic pain include postherpetic neuralgia, diabetic neuropathy, phantom pain, and post stroke pain syndrome. Patients with neuropathic pain use very distinctive words to describe their pain, such as burning, sharp, and shooting. Ghost pain is pain associated with loss of a limb or digit. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain. Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting.)

12. The nurse is caring for a patient who has been diagnosed with a stroke. As part of her ongoing care, the nurse should a. Encourage the patient to perform as many self-care activities as possible. b. Provide a complete bed bath to promote patient comfort. c. Place the patient on bed rest to prevent fatigue. d. Understand that the patient will not eat owing to a decreased energy need.

A (Nurses should encourage the patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient's immobility by providing unnecessary help with activities such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. Anorexia and insufficient assistance with eating lead to malnutrition.)

28. The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment? a. Increasingly higher doses of opioid are needed to control pain. b. The patient needed a substantial dose of naloxone (Narcan). c. The patient asks for pain medication close to the time it is due around the clock. d. The patient no longer experiences sedation from the usual dose of opioid.

A (Opioid tolerance occurs when a patient needs higher doses of an opioid to control pain. Naloxone (Narcan) is an opioid antagonist that is given to reverse the effects of opioid overdose. Taking pain medications regularly around the clock is an effective way to control pain. The pain medication for this patient is most likely effectively managing the patient's pain because the patient is not asking for the medication before it is due. A patient no longer experiencing a side effect of an opioid does not indicate opioid tolerance.)

A nurse is reinforcing teaching with a client who has Parkinson's disease and has a new prescription for bromocriptine. Which of the following instructions should the nurse include in the teaching? a. Rise slowly when standing b. Expect urine to become dark colored c. Avoid foods containing tyramine d. Report any skin discoloration

A (Orthostatic hypotension is a common adverse effect of bromocriptine, a dopamine receptor agonist. Therefore, rising slowly when standing up will decrease the risk of dizziness and lightheadedness)

3. Controlling pain is important to promoting wellness. Unrelieved pain has been associated with a. prolonged stress response and a cascade of harmful effects system-wide. b. large tidal volumes and decreased lung capacity. c. decreased tumor growth and longevity. d. decreased carbohydrate, protein, and fat destruction.

A (Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, which can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbohydrate, protein, and fat are not associated with pain or stress response.)

5. The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when she states, Patients with impaired bed mobility a. have an increased risk for pressure ulcers. b. like to have extra visitors. c. need to have a mechanical soft diet. d. are prone to constipation.

A (Patients who cannot move themselves in bed are more susceptible to pressure ulcers because they cannot relieve the pressure they feel. Extra visitors or diet consistency do not have any bearing on mobility. Constipation should not be a by-product of immobility if a bowel regimen is instituted.)

4. The nurse is providing care to a patient who is bedridden. To prevent fatigue, the nurse raises the height of the bed. The nurse understands that balance is maintained by raising the bed to a. Prevent a shift in the nurse's base of support. b. Narrow the base of support. c. Allow the nurse to bring his or her feet close together. d. Shift the center of gravity further away from the base of support.

A (Raising the height of the bed when performing a procedure prevents bending too far at the waist and causing a shift in the base of support. Balance is maintained by maintaining proper body alignment and posture through two simple techniques. First, widen the base of support by separating the feet to a comfortable distance. Second, increase balance by bringing the center of gravity closer to the base of support.)

2. A structural curvature of the spine associated with vertebral rotation is known as a. Scoliosis. b. Osteogenesis. c. Osteomalacia. d. Arthritis.

A (Scoliosis is a structural curvature of the spine associated with vertebral rotation. Osteogenesis imperfecta is an inherited disorder that makes bones porous, short, bowed, and deformed. Osteomalacia is an uncommon metabolic disease characterized by inadequate and delayed mineralization, resulting in compact and spongy bone. Arthritis is an inflammatory joint disease characterized by inflammation or destruction of the synovial membrane and articular cartilage, and by systemic signs of inflammation.)

8. A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? a. Relaxation and guided imagery b. Transcutaneous electrical nerve stimulation (TENS) c. Herbal supplements with analgesic effects d. Pudendal block

A (Some cultures prefer nonpharmacological measures for pain control. In the case of a patient in labor, relaxation with guided imagery is often an effective supplement for pain management because it provides women with a sense of control over their pain. Relaxation and guided imagery can be used during any phase of health or illness. TENS units are typically used to manage postsurgical and procedural pain. Herbal supplements need to be evaluated for safety during pregnancy. Additionally, some patients consider herbal supplements to be another form of medication, and they are not typically used to control acute pain. A pudendal block is a type of regional anesthesia; use of it does not respect the patient's wishes for nonpharmacological pain control.)

6. The nurse is assessing a patients functional abilities and asks the patient, How would you rate your ability to prepare a balanced meal? How would you rate your ability to balance a checkbook? How would you rate your ability to keep track of your appointments? Which tool would be indicated for the best results of this patients perception of their abilities? a. Functional Activities Questionnaire (FAQ) b. Mini Mental Status Exam (MMSE) c. 24hFAQ d. Performance-based functional measurement

A (The FAQ is an example of a self-report tool which provides information about the patients perception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ is used to assess functional ability in postoperative patients. Performance-based tools involve actual observation of a standardized task, completion of which is judged by objective criteria.)

22. The patient who is experiencing an alteration in mobility often has one or more nursing diagnoses. The nurse would use the diagnosis of Impaired physical mobility for a patient who is a. Not completely immobile. b. Completely immobile. c. At risk for multisystem problems. d. At risk for single-system involvement.

A (The diagnosis of Impaired physical mobility applies to the patient who has some limitation but is not completely immobile. The diagnosis of Risk for disuse syndrome applies to the patient who is immobile and at risk for multisystem problems because of inactivity. Beyond these diagnoses, the list of potential diagnoses is extensive because immobility affects multiple body systems.)

20. The patient weighs 450 lbs (204.5 kg) and complains of shortness of breath with any exertion. His health care provider has recommended that he begin an exercise program. He states that he can hardly get out of bed and just cannot do anything around the house. To focus on the cause of the patient's complaints, the nurse devises which of the following nursing diagnoses? a. Activity intolerance related to excessive weight b. Activity intolerance related to bed rest c. Impaired gas exchange related to shortness of breath d. Imbalanced nutrition: less than body requirements

A (The diagnostic label directs nursing interventions. This requires the correct selection of related factors. For example, Activity intolerance related to excess weight gain requires very different interventions than if the related factor is prolonged bed rest. In this case, the intolerance is related to the patient's excessive weight. He is not on bed rest, although he claims that it is difficult for him to get out of bed. Shortness of breath is a symptom, not a cause, of Impaired gas exchange, making this nursing diagnosis ineffective. The patient certainly has an imbalance of nutrition, but it is more than body requirements.)

3. Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain? a. "Meditation controls pain by blocking pain impulses from coming through the gate." b. "Meditation will help me sleep through the pain because it opens the gate." c. "Meditation stops the occurrence of pain stimuli." d. "Meditation alters the chemical composition of pain neuroregulators, which closes the gate."

A (The gate theory states that pain impulses cause pain when they get through gates that are open. Pain is blocked when the gates are closed. Nonpharmacologic pain relief measures, such as meditation, work by closing the gates, which keeps pain impulses from coming through. Meditation does not open pain gates or stop pain from occurring. Meditation also does not have an effect on pain neuroregulators.)

29. A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about? a. Patient drinks 1 to 2 glasses of wine every night. b. Patient smokes 2 packs of cigarettes a day. c. Patient occasionally smokes marijuana. d. Patient takes antianxiety medications.

A (The major adverse effect of acetaminophen is hepatotoxicity. Because both alcohol and acetaminophen are metabolized by the liver, when taken together, they can cause liver damage. Smoking cigarettes and smoking marijuana are not healthy behaviors, but their effects on health are not affected by acetaminophen. Antianxiety medications can be taken with acetaminophen.)

21. The patient is being admitted for elective knee surgery. While the nurse is admitting the patient, she will a. Begin to develop a discharge plan. b. Plan to wait until after the surgery to plan for discharge. c. Place a generalized discharge plan in the record for later use. d. Address immediate needs of the patient only and address other needs later.

A (The nurse needs to begin discharge planning when the patient enters the health care system. The nurse cannot wait until after surgery to begin to plan for discharge. In addition, the discharge plan is always individualized to the patient and directed at meeting the actual and/or potential needs of the patient.)

A nurse is performing health screenings at a health fair. which of the following clients are at risk for osteoporosis? Select all that apply a. A 40 year old who takes prednisone for asthma b. A 30 year old who jogs 3 miles/day c. A 45 year old who take phenytoin for seizures d. A 65 year old who has a sedentary lifestyle e. A 70 year old who has smoked for 50 years

A, C, D, E

38. When preparing a plan of care for an immobilized patient, the nurse should a. Use established expected outcomes to evaluate the patient's response to care. b. Display an air of professional superiority when interventions are not successful. c. Never vary from interventions that have been successful for other patients. d. Use objective data only in determining whether interventions have been successful.

A (The nurse should use established expected outcomes to evaluate the patient's response to care. The nurse should use creativity when designing new interventions to improve the patient's mobility status and should display humility when identifying those interventions that were not successful. Ask if the patient's expectations of care are being met and use objective data to determine the success of interventions.)

18. The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controlling the patient's pain during dressing changes? a. The patient's need for analgesic medication decreases during the dressing changes. b. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10. c. The patient's facial expressions are stoic during the procedure. d. The patient can tolerate more pain, so dressing changes can be performed more frequently.

A (The purpose of guided imagery is to allow the patient to alter the perception of pain. Guided imagery works in conjunction with analgesic medications, potentiating their effects. If the patient needs less pain medication during dressing changes, then guided imagery is helping to manage the patient's pain. A rating of 6 on a 0 to 10 scale indicates that the patient is having moderate pain and shows that this patient is not experiencing pain relief at this time. A person who is stoic is not showing feelings, which makes it difficult to know whether or not the patient is experiencing pain. The ability to change dressings more frequently is not a way to evaluate the effectiveness of guided imagery.)

2. The nurse is caring for a patient with the diagnosis of Impaired physical mobility. The nurse needs to be alert for which of the following potential complications? (Select all that apply.) a. Pulmonary emboli b. Pneumonia c. Impaired skin integrity d. Somnolence e. Increased socialization

A, B, C (Immobility leads to complications such as pulmonary emboli or pneumonia. Other possible diagnoses include impaired skin integrity. Insomnia and social isolation are more common complications than somnolence or increased socialization.)

2. When assessing the activity tolerance of a patient, the nurse would evaluate which of the following? (Select all that apply.) a. Skeletal abnormalities b. Emotional factors c. Age d. Pregnancy status e. Race

A, B, C, D (Factors influencing activity tolerance include physiological factors such as skeletal abnormalities, emotional factors such as anxiety/depression, developmental factors such as age and gender, and pregnancy status. Race is not a factor because people of all races are faced with similar factors that affect their activity tolerance.)

A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? Select all that apply a. Impulse control difficulty b. Left hemoplegia c. Loss of depth perception d. Aphasia e. Lack of situational awareness

A, B, C, E

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? Select all that apply. a. Have suction equipment available for use b. Feed the client thickened liquids c. Place food on the unaffected side of the clients mouth d. Assign an assistive personnel to feed the client slowly E. Teach the client to swallow with her neck flexed

A, B, C, E

A nurse is planning discharge teaching on home safety for an older adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? Select all that apply a. Remove throw rugs in walkways b. Use prescribed assistive devices c. Remove clutter from the environment d. Walk with caution on icy surfaces e. Maintain lighting of doorway areas

A, B, C, E

A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include? Select all that apply a. Apply heat to joints to alleviate pain b. Ice inflamed joints following activity c. Install an elevated toilet seat d. Take tub baths e. Complete high-energy activities in the morning

A, B, C, E

A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? Select all that apply a. Check continuous passive motion devices b. Palpate dorsal pedal pulses c. Place a pillow behind the knee d. Elevate heels off the bed e. Apply heat therapy to incision

A, B, D

A nurse is beginning a physical assessment of a client who has a new diagnosis of MS. Which of the following findings should the nurse expect? Select all that apply. a. Areas of paresthesia b. Involuntary eye movements c. Alopecia d. Increased salivation e. Ataxia

A, B, E

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? Select all that apply a. Speak to the client at a slower rate b. Assist the client to use flash cards with pictures c. Speak to the client in a loud voice d. Complete sentences that the client cannot finish E. Give instructions one step at a time

A, B, E

3. The nurse is caring for a patient who has had a recent stroke and is paralyzed on his left side. He has no respiratory or cardiac issues, but he cannot walk. He becomes extremely frustrated when he cannot button his shirt and cannot feed himself because he was left-handed. He has shown no signs of dysphagia, but he has been eating very little and has lost 2 lbs. He asks the nurse, "How can I go home like this? I'm not getting better. I can't ask my wife to take care of me like a baby." Of the following list of health care team members, which member would the nurse need to consult? (Select all that apply.) a. Physical therapy b. Occupational therapy c. Respiratory therapy d. Cardiac rehabilitation e. Psychology services

A, B, E (Physical therapists are a resource for planning ROM or strengthening exercises, and occupational therapists are a resource for planning ADLs that patients need to modify or re-learn. Referral to a mental health advanced practice nurse, a licensed social worker, or a physiologist to assist with coping or other psychosocial issues is also wise. Because the patient exhibits good cardiac and respiratory function, respiratory therapy and cardiac rehabilitation probably are not needed at this time)

1. Bones perform five functions in the body: support, protection, movement, mineral storage, and hematopoiesis. In the discussion of body mechanics, which are the most important? (Select all that apply.) a. Support b. Protection c. Movement d. Mineral storage e. Hematopoiesis

A, C (Bones perform five functions in the body: support, protection, movement, mineral storage, and hematopoiesis. In the discussion of body mechanics, two of these functions—support and movement—are most important. In support, bones serve as the framework and contribute to the shape, alignment, and positioning of body parts. In movement, bones together with their joints constitute levers for muscle attachment. As muscles contract and shorten, they pull on bones, producing joint movement. Protection involves encasing the soft tissue organs in a protective cage. Mineral storage helps to strengthen bones but also helps regulate blood levels of certain nutrients. Hematopoiesis is the formation of blood cells.)

The nurse is administering ibuprofen (Advil) to an older patient. Which of the following assessment data causes the nurse to hold the medication? (Select all that apply.) a. Past medical history of gastric ulcer b. Patient states last bowel movement was 4 days ago c. Stated allergy to aspirin d. Patient states has 2/10 intermittent joint pain e. Patient experienced respiratory depression after administration of an opioid medication

A, C (NSAIDs can cause bleeding, especially in the gastrointestinal (GI) tract; therefore, NSAIDs are most likely contraindicated in this patient. Patients with an allergy to aspirin are sometimes also allergic to other NSAIDs. The nurse needs to verify that the health care provider is aware of the history of GI bleeding and of allergy to aspirin before administering ibuprofen. NSAIDs do not interfere with bowel function and are used for the treatment of mild to moderate acute intermittent pain. NSAIDs also do not suppress the central nervous system.)

A nurse is making a home visit to a client who has AD. The client's partner states that the client is often disoriented to time and place, is unsteady on his feet, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? Select all that apply. a. Remove floor rugs b. Have door locks that can be opened easily c. Provide increased lighting in stairwells d. Install handrails in the bathroom e. Place mattress on the floor

A, C, D, E

A nurse if providing dietary teaching about calcium rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions? a. White bread b. White beans c. White meat of chicken d. White rice

B

A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? Select all that apply a. Clean the incision daily with soap and water b. Turn the toes inward when sitting or lying c. Sit in a straight-backed armchair d. Bend at waist when putting on socks e. Use a raised toilet seat

A, C, E

A nurse is caring for a client who has AD. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurse's response? Select all that apply. a. Exposure to metal waste products b. Long-term estrogen therapy c. Sustained use of vitamin E d. Previous head injury e. History of herpes infection

A, D, E

A nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? Select all that apply a. Encourage complete autologous blood donation b. Sit in a low reclining chair c. Instruct the client to roll onto the operative hip d. Use an abductor pillow when turning the client e. Perform isometric exercises

A, D, E

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? a. Teach the client to scan to the right to see objects on the right side of her body b. Place the bedside table on the right side of the bed c. Orient the client to the food on her plate using the clock method d. Place the wheelchair on the client's left side

B

A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following is an appropriate action by the nurse? a. Apply heat to the puncture site b. Place the client in a supine position c. Turn the client every 1 hour d. Ambulate the client within the first hour postprocedure

B

A nurse is providing information about capsaicin cream to a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse include in the discussion? a. Continuous pain relief is provided b. Inspect for skin irritation and cuts prior to application c. Cover the area with tight bandages after application d. Apply the medication every 2 hr during the day

B

11. A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior and response to surgery? a. The surgery successfully cured the patient's pain. b. The patient's culture is possibly influencing the patient's experience of pain. c. The patient is experiencing urinary retention because of manipulation of the spine during surgery; this is preventing the patient from experiencing pain. d. The nurse is allowing personal beliefs about pain to influence pain management at this time.

B (A patient's culture often influences the patient's expression of pain. In this case, the patient has just had surgery, and the nurse knows that this surgical procedure usually causes patients to experience pain. It is important at this time for the nurse to examine cultural and ethnic factors that are possibly affecting the patient's lack of expression of pain at this time. Even if surgery corrects neurological factors that create chronic pain, surgery causes pain in the acute period. Urinary retention usually creates pain and does not mask surgical pain. The nurse is not allowing personal beliefs to influence pain management because the nurse is attempting to determine the reason why the patient is not verbalizing the experience of pain.)

4. A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student's knowledge? a. "Older patients often have difficulty determining what is causing their pain." b. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." c. "As adults age, their ability to perceive pain decreases." d. "Patients who have dementia probably experience pain, and their pain is not always well controlled."

B (Aging does not affect the ability to perceive pain. Sometimes older adults have difficulty interpreting their pain and determining its cause because multiple diseases and vague symptoms affect similar parts of the body. Opioids are safe to use in older adults as long as they are slowly titrated and the nurse frequently monitors the patient. Current evidence shows that patients with dementia most likely experience unrelieved pain because their pain is difficult to assess.)

44. The patient is admitted to a skilled care unit for rehabilitation 10 days after the surgical procedure of fixation of a fractured left hip and has a nursing diagnosis of Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which of the following nursing interventions is most appropriate for this patient? a. Obtain assistance and physically transfer the patient to the chair. b. Assist the patient with ambulation and measure how far she walks. c. Withhold pain medication so that she can ambulate with a clear mind. d. Bring the patient to the cafeteria for group instruction on ambulation.

B (Assess the patient as she walks and measure how far she walks to quantify progress. The nurse should allow the patient to do as much for herself as possible. Therefore, she should observe the patient transferring from the bed to the chair using her walker, and should provide assistance as needed. The patient should be encouraged to use adequate pain medication to decrease the effects of pain and to increase mobility. The patient should be instructed on safe transfer and ambulation techniques in an environment with few distractions.)

22. The nurse knows that which technique is best for assessing pain in a child who is 4 years of age? a. Ask the parents if they think their child is in pain. b. Use the FACES scale. c. Ask the child to rate the level of pain on a 0 to 10 pain scale. d. Check to see what previous nurses have charted.

B (Assessing pain intensity in children requires special techniques. Young children often have difficulty expressing their pain. The FACES scale assesses pain in children who are verbal. Because a 4-year-old is verbal, this is an appropriate scale to use with this child. Parents' statement of pain is not an effective way to assess pain in children because children's statements are the most important. The 0 to 10 pain scale is too difficult for a 4-year-old child to understand. Previous documentation by nurses will tell you what the child's pain has been but will not tell you the child's current pain intensity.)

17. The patient is brought to the emergency department with possible injury to his shoulder. To help determine the degree of injury, the nurse should evaluate a. The patient's gait. b. The patient's range of motion. c. Fine motor coordination. d. Activity tolerance.

B (Assessing range of motion is one assessment technique used to determine the degree of damage or injury to a joint. Gait is the manner or style of walking. It may have little bearing on the shoulder damage. Assessing fine motor coordination would be beneficial in helping to assess the patient's ability to perform tasks but would not help in evaluating the shoulder. Activity tolerance refers to the type and amount of exercise or activity a person is able to perform. Damage to the shoulder would affect this, but this would not have a direct bearing on the amount of damage done to the shoulder.)

25. The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? a. "Have you considered working with a physical therapist?" b. "What activities, if any, has your pain prevented you from doing?" c. "Would you please rate your pain on a scale from 1 to 10 for me?" d. "What effect does your pain medication typically have on your pain?"

B (Because the nurse is interested in knowing whether the patient's pain is affecting mobility, the priority assessment question is to ask the patient how the pain affects his or her ability to participate in normal activities of daily living. Although a physical therapist is a good resource to have, especially if pain is severely affecting mobility, considering working with a physical therapist does not describe the effect of pain on the patient's mobility. Assessing quality of pain and effectiveness of pain medication does not help the nurse to understand how it is affecting the patient's mobility.)

15. The nurse is evaluating the body alignment of a patient in the sitting position. In this position a. The body weight is directly on the buttocks only. b. Both feet are supported on the floor with ankles flexed. c. The edge of the seat is in contact with the popliteal space. d. The arms hang comfortably at the sides.

B (Both feet are supported on the floor, and the ankles are comfortably flexed. With patients of short stature, a footstool is used to ensure that the ankles are comfortably flexed. Body weight is evenly distributed on the buttocks and thighs. A 1- to 2-inch space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee to ensure that no pressure is placed on the popliteal artery or nerve. The patient's forearms are supported on the armrest, in the lap, or on a table in front of the chair.)

19. When assessing the skin of an immobilized patient, the nurse should a. Assess the skin at least every 4 hours. b. Use a standardized tool such as the Braden Scale. c. Use nursing instinct instead of a standardized tool. d. Have special times for inspection so as to not interrupt routine care.

B (Consistently use a standardized tool, such as the Braden Scale. This identifies patients with high risk of impaired skin integrity. Nursing instinct in this case is not enough. At a minimum, skin assessment occurs every 2 hours. Continually assess the patient's skin for breakdown and color changes such as pallor or redness. Continual assessment reduces the need for the creation of special times for inspection.)

3. The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patients functional ability. What question would be the most appropriate? a. Are you able to shop for yourself? b. Do you use a cane, walker, or wheelchair to ambulate? c. Do you know what todays date is? d. Were you sad or depressed more than once in the last 3 days?

B (Do you use a cane, walker, or wheelchair to ambulate? will assist the nurse in determining the patients ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening.)

15. The nurse is developing an exercise plan for someone diagnosed with congestive heart failure and exercise intolerance. In doing so, the nurse should a. Plan for 20 minutes of continuous aerobic activity and increase as tolerated. b. Perform 6-minute walks at the patient's pace at least 2 times a day. c. Instruct the patient that he should not take his beta blocker medication on exercise days. d. Encourage a high-calorie diet to plan for extra calorie expenditure.

B (For the diagnosis of exercise intolerance, the patient should begin by performing 6-minute walks at his own pace at least twice a day. The patient would not be able to tolerate 20 minutes of continuous aerobic activity. Patients should be instructed to take medications as ordered. Low-calorie, low-sodium, and high-protein diets are best for this type of patient.)

31. The patient is immobilized after undergoing hip replacement surgery. Which of the following would place the patient at risk for hemorrhage? a. Thick, tenacious pulmonary secretions b. Low-molecular-weight heparin doses to prevent DVT c. SCDs wrapped around the legs to prevent DVT formation d. Elastic stockings (TED hose) to promote venous return

B (Heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of DVT. Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding. Pulmonary secretions that become thick and tenacious are difficult to remove and are a sign of inadequate hydration, but not of bleeding. SCDs consist of sleeves or stockings made of fabric or plastic that are wrapped around the leg and are secured with Velcro. They decrease venous stasis by increasing venous return through the deep veins of the legs. They do not usually cause bleeding. Elastic stockings also aid in maintaining external pressure on the muscles of the lower extremities and in promoting venous return. They do not usually cause bleeding.)

24. The nurse is ambulating a patient in the hall when she notices that he is beginning to fall. The nurse should a. Grab the patient and hold him tight to prevent the fall. b. Gently lower the patient to the floor. c. Jump back and let the patient fall naturally. d. Push the patient against the wall and guide him to the floor.

B (If the patient has a fainting episode or begins to fall, assume a wide base of support with one foot in front of the other, thus supporting the patient's body weight. Then extend one leg and let the patient slide against the leg, and gently lower the patient to the floor, protecting the patient's head. Grabbing the patient will shift the nurse's center of gravity and may lead to a back injury. Allowing the patient to fall could lead to head injury for the patient. Pushing the patient against the wall could also cause the patient to hit his head and cause injury.)

23. Which statement made by a nursing educator best explains why it is important for nurses to determine a patient's medical history and recent drug use? a. "Health care providers have a responsibility to prevent drug seekers from gaining access to drugs." b. "This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief." c. "Some recreational drugs have pharmaceutical counterparts that may be more effective in managing pain." d. "Getting this information gives the nurse an opportunity to provide patient teaching about drug abstinence."

B (In providing effective pain management, it is important to understand the patient's history, what drugs the patient has already tried, and what interventions work best or have negative actions. It is not the nurse's responsibility to judge or question a patient's pain or label her as a drug seeker. Nurses need to avoid labeling patients as drug seekers because this term is poorly defined and creates bias and prejudice among other health care providers. Although certain recreational drugs do have pharmaceutical counterparts, this is not the sole purpose of assessing drug use. The nurse needs more information beyond a patient's medical and medication history to determine whether a patient needs teaching about drug abstinence.)

18. The nurse is examining a patient who is admitted to the emergency department with severe elbow pain. Of the following situations, which would cause the nurse to suspect a ligament tear or joint fracture? a. Range of motion of the elbow is limited. b. Joint motion is greater than normal. c. The patient has arthritis. d. The elbow cannot be moved (frozen).

B (Increased mobility (beyond normal) of a joint may indicate connective tissue disorders, ligament tears, or possible joint fractures. Limited range of motion often indicates inflammation such as arthritis, fluid in the joint, altered nerve supply, or contractures (frozen joints).)

26. The nurse is developing a plan of care for a patient diagnosed with activity intolerance. Of the following strategies, which has the best chance of maintaining patient compliance? a. Performing 20 minutes of aerobic exercise daily with 10 minute warm-up and cool-down periods b. Instructing the patient to use an exercise log to record day, time, duration, and responses to exercise activity c. Instructing the patient on the evils of not exercising, and getting her to take responsibility for her current health status d. Arranging for the patient to join a gym that she will have to pay, for so that she does not need to depend on insurance

B (Keeping a log may increase adherence to an exercise prescription. Cross-training (combination of exercise activities) provides variety to combat boredom and increases the potential for total body conditioning as opposed to daily aerobic exercise. "Blaming" a patient for his or her health status is usually counterproductive. Instead, the nurse should instruct the patient about the physiological benefits of a regular exercise program. Developing a plan of exercise that the patient may perform at home may improve compliance.)

2. Muscles that attach to bones to provide the needed strength to move an object use which of the following to obtain their objective? a. Posture b. Leverage c. Isometric contraction d. Muscle tone

B (Leverage is an inducing or compelling force that occurs when specific bones, such as the humerus, ulna, and radius, and associated joints, such as the elbows, act together as a lever. Posture is the position of the body in relation to the surrounding space. Isometric contraction causes an increase in muscle tension but no active movement. Muscle tone is the normal state of balanced muscle tension.)

18. The nurse is aware that patients who are immobile are at increased risk of developing deep vein thromboses (DVTs). Because of this, the nurse should a. Make sure that elastic stockings are not removed. b. Measure the calf circumference of both legs. c. Dorsiflex the foot while assessing for patient discomfort. d. Measure both ankles to determine size.

B (Measure bilateral calf circumference and record it daily as an assessment for DVT. Homans' sign, or calf pain on dorsiflexion of the foot, is contraindicated in patients when a DVT is suspected. It is no longer a reliable indicator in assessing for DVT, and it is present in other conditions. Remove the patient's elastic stockings and/or sequential compression devices (SCDs) every 8 hours, and observe the calves for redness, warmth, and tenderness. Bilateral calf circumferences (not ankle) should be measured daily to detect unilateral increases that may be an early indication of thrombosis.)

5. Jan is a 70-year-old retired nurse who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should you consider in her plan of care considering her expressed wishes? a. Stationary exercise bicycle, free weights, and spinning class b. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy c. Chamomile tea and IcyHot gel d. Acupuncture and attending church services

B (Mind-body therapies are designed to enhance the minds capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Stationary exercise bicycle, free weights, and spinning are not mind-body therapies. They are classified as exercise therapies. Chamomile tea and IcyHot gel are not mid-body therapies per se. They are classified as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending church services is a religious prayer mind-body therapy capable of enhancing the minds capacity to affect bodily function and symptoms.)

1. Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of a. neuropathic pain. b. nociceptive pain. c. chronic pain. d. mixed pain syndrome.

B (Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.)

41. The nurse is caring for a patient who has had a stroke causing total paralysis of the right side. To help maintain joint function and to prevent contractures, passive ROM will be initiated. When should therapy begin? a. After the acute phase of the disease has passed b. As soon as the ability to move is lost c. Once the patient enters the rehab unit d. No ROM is needed.

B (Passive ROM exercises should begin as soon as the patient's ability to move the extremity or joint is lost. The nurse should not wait for the acute phase to end. It may be some time before the patient enters the rehab unit, and contractures could form by then. ROM is certainly needed in this patient.)

8. Immobilized patients frequently have hypercalcemia, placing them at risk for a. Osteoporosis. b. Renal calculi. c. Pressure ulcers. d. Thrombus formation.

B (Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi because they frequently have hypercalcemia. Osteoporosis is caused by accelerated bone loss. A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) within tissues. A thrombus is an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel.)

33. A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. What does type of pain does the nurse document that the patient has? a. Visceral pain b. Somatic pain c. Peripherally generated pain d. Centrally generated pain

B (Somatic pain comes from bone, joint, or muscle. Visceral pain arises from the visceral organs such as the GI tract and pancreas. Peripherally generated pain can be caused by polyneuropathies or mononeuropathies. Centrally generated pain results from injury to the central or peripheral nervous system.)

7. An 80-year-old male patient is in the ICU status fractured femur and MVA. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioids doses q 4 hours. The best immediate course of nursing action is to a. call a Code Blue. b. stop opioid; consider administering naloxone, call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status. c. call the primary hospitalist in charge of patient. d. call the anesthesia provider on call.

B (Stop opioid; consider administering naloxone; call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status; notify primary or anesthesia provider; and monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory. Calling a Code Blue solely for a somnolent patient is not indicated as a solitary response. Calling the hospitalist assigned to the patient is an option only after the immediate treatment plan is enacted to reverse the opioid. Calling anesthesia is appropriate after stopping the opioid first.)

9. In planning a physical activity program for a patient, the nurse must understand that a. Isotonic exercises cause contraction without changing muscle length. b. The best program includes a combination of exercises. c. Isometric contraction involves the movement of body parts. d. Resistive isometric exercises can lead to bone wasting.

B (The best program of physical activity includes a combination of exercises that produce different physiological and psychological benefits. Isotonic exercises cause muscle contractions and changes in muscle length. Isometric exercises involve tightening or tensing of muscles without moving body parts. Resistive isometric exercises help promote muscle strength and provide sufficient stress against bone to promote osteoblastic activity.)

16. A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA? a. The patient is sleeping and is difficult to arouse. b. The patient rates pain at an acceptable level of 3 on a 0 to 10 scale. c. Sufficient medication is left in the PCA syringe. d. The patient presses the control button to deliver pain medication.

B (The effectiveness of pain relief measures is determined by the patient. If the patient is satisfied with the amount of pain relief, then pain measures are effective. A patient who is sleeping and is difficult to arouse is possibly oversedated; the nurse needs to assess this patient further. The amount of medication left in the PCA syringe does not indicate whether pain management is effective. Pressing the button shows that the patient knows how to use the PCA but does not evaluate pain management.)

A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's best next action? a. Give the Vicodin ES to the patient immediately because the patient is experiencing severe pain. b. Ask the health care provider to verify the dosage and frequency of the medication. c. Ask the health care provider for an order for a nonsteroidal antiinflammatory drug (NSAID). d. Ask the health care provider for an order to play music for the patient, in addition to providing the pain medication.

B (The maximum 24-hour dosage for acetaminophen is 4 grams. If the patient took 2 tablets of Vicodin ES every 6 hours, the patient would take in 6 grams of acetaminophen in 24 hours. This exceeds the safe dosage of acetaminophen, so the best action is to question this order. Giving the medication as ordered would possibly result in the patient taking more acetaminophen than what is considered a safe dose. Acetaminophen overdose can result in liver failure. NSAIDs are used to treat mild to moderate pain. At this moment, the patient is experiencing severe pain. Implementing music therapy is a nursing intervention and is an independent nursing action. Thus, an order to start music therapy is not needed.)

17. The nurse recognizes that which of the following is a modifiable contributor to a patient's perception of pain? a. Age and gender b. Anxiety and fear c. Culture d. Previous pain experience

B (The nurse can take measures to ease the patient's anxiety and fear related to pain. Age, gender, culture, and previous pain experience are all nonmodifiable factors that the nurse can help the patient to understand, but the nurse cannot alter them.)

30. The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? a. Call the rapid response team. b. Ask the patient to rate and describe the pain. c. Raise the head of the bed. d. Administer pain relief medications.

B (The nurse's ability to establish a nursing diagnosis, plan and implement care, and evaluate the effectiveness of care depends on an accurate and timely assessment. The other responses are all interventions; the nurse cannot know which intervention is appropriate until the nurse completes the assessment, makes a nursing diagnosis, and plans care.)

6. The term body alignment refers to positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. A term that is similar to body alignment is a. Weight. b. Posture. c. Friction. d. Body mechanics.

B (The terms body alignment and posture are similar and refer to positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Weight is the force exerted on a body by gravity. Friction is a force that occurs in a direction to oppose movement. Body mechanics is a term used to describe the coordinated efforts of the musculoskeletal and nervous systems.)

13. The patient is eager to begin his exercise program with a 2-mile jog. The nurse instructs the patient to warm up with stretching exercises. The patient states that he is ready and does not want to waste time with a "warm-up." The nurse explains that the warm-up a. Allows the body to readjust gradually to baseline functioning. b. Prepares the body and decreases the potential for injury. c. Should not involve stretching exercises because they can lead to injury. d. Should be performed with high intensity to prepare for the coming challenge.

B (The warm-up activity prepares the body for activity and decreases the potential for injury. It usually lasts about 5 to 10 minutes and may include stretching, calisthenics, and/or aerobic activity performed at a lower intensity. The cool-down period allows the body to readjust gradually to baseline functioning and provides an opportunity to combine movement such as stretching with relaxation-enhancing mind-body awareness.)

1. A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. The nurses best response is You are weak because a. your iron level is low. This is known as anemia. b. of your immobility in the hospital. This is known as deconditioning. c. of your poor appetite. This is known as malnutrition. d. of your medications. This is known as drug induced weakness.

B (When a person is ill and immobile the body becomes weak. This is known as deconditioning. Anemia, malnutrition, and medications may have an adverse effect on the body, but this is not known as deconditioning.)

22. The patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move his right arm and leg. The nurse understands that a. Active range of motion is the only thing that will prevent contractures from forming. b. Passive range of motion must be instituted to help prevent contracture formation. c. Range-of-motion exercises should be started 2 days after the patient is stable. d. Range-of-motion exercises should be done on major joints only.

B (When patients cannot participate in active range of motion, the nurse must institute passive range of motion to maintain joint mobility and prevent contractures. Passive range of motion can be substituted for active when needed. For the patient who does not have voluntary motor control, passive range-of-motion exercises are the exercises of choice. Unless contraindicated, the nursing care plan includes exercising each joint (not just major joints) through as nearly a full range of motion as possible. Initiate passive range-of-motion exercises as soon as the patient loses the ability to move the extremity or joint.)

14. When assessing the body alignment of a patient while he or she is standing, the nurse is aware that a. When observed posteriorly, the hips and shoulders form an "S" pattern. b. When observed laterally, the spinal curves align in a reversed "S" pattern. c. The arms should be crossed over the chest or in the lap. d. The feet should be close together with toes pointed out.

B (When the patient is observed laterally, the head is erect and the spinal curves are aligned in a reversed "S" pattern. When observed posteriorly, the shoulders and hips are straight and parallel. The arms hang comfortably at the sides. The feet are slightly apart to achieve a base of support, and the toes are pointed forward.)

1. Correct body alignment reduces strain on musculoskeletal structures and contributes to balance. Balance control is attained by (Select all that apply.) a. Keeping the body's center of gravity high. b. Maintaining a wide base of support. c. Keeping the body's center of gravity low. d. Maintaining correct body posture. e. Maintaining immobility to prevent falls.

B, C, D (Without balance control, the center of gravity is displaced, thus creating risk for falls and injuries. Balance is enhanced by keeping the body's center of gravity low (not high) with a wide base of support and by maintaining correct body posture. Prolonged immobility leads to impaired balance.)

A nurse is admitting an older adult client who has suspected osteoporosis. Which of the following is an expected finding? Select all that apply a. History of consuming one glass of wine daily b. Loss in height of 2 in c. BMI of 21 d. Kyphotic curve at upper thoracic spine e. History of lactose intolerance

B, C, D, E

A nurse is assessing a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings? Select all that apply a. Skin reddened over the joint b. Pain when bearing weight c. Joint crepitus d. Swelling of the affected joint e. Limited joint motion

B, C, D, E

A nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? (Select all that apply) a. Decreased vision b. Pill-rolling tremor of the fingers c. Shuffling gait d. Drooling e. Bilateral ankle edema f. Lack of facial expression

B, C, D, F

3. In developing a nursing care plan for increasing activity tolerance in a patient, the nurse should (Select all that apply.) a. Use generalized therapies because they work for everyone. b. Consult with members of the health care team. c. Avoid goals published by the American College of Sports Medicine. d. Involve the patient and the patient's family in designing an exercise plan. e. Consider the patient's ability to increase activity level.

B, D, E (When planning care, the nurse should consult/collaborate with members of the health care team to increase activity, involve the patient and family in designing an activity and exercise plan (especially if family members are also providers of care), and consider the patient's ability to increase activity level. Therapies should be individualized to the patient's activity tolerance. Information from the American College of Sports Medicine serves as a standard that the nurse should use when

1. A 65-year-old female patient has been admitted to the medical-surgical unit. The nurse is assessing the patients risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patients history and physical. (Select all that apply.) a. Being a woman b. Taking more than six medications c. Having hypertension d. Having cataracts e. Muscle strength 3-5 bilaterally f. Incontinence

B, D, E, F (Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Dizziness does contribute to falls.)

A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which action should the nurse include in the plan of Care? (Select all that apply.) a. Prove three large balanced meals daily b. Record diet and fluid intake daily c. Document weight every other week d. Place the client in Fowler's position to eat e. Offer nutritional supplements between meals

B, E (The nurse should record the client's diet and fluid intake daily to assess for dietary needs and maintain adequate nutrition and hydration. Nutritional supplements should be offered between meals to maintain the clients weight)

A nurse is reviewing the health record of a client who is to undergo a total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure? a. Age 78 years b. History of cancer c. Previous joint replacement d. Bronchitis 2 weeks ago

C

A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? a. Impulse control difficulty b. Poor judgement c. Inability to recognize familiar objects d. Loss of depth perception

C

A nurse is providing teaching to the partner of an older adult client who has Alzheimer's disease and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective? a. This medication should increase my husband's appetite. b. This medication should help my husband sleep better. c. This medication should help my husband's daily function. d. This medication should increase my husband's energy level

C

9. Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective? a. "This is the only pain medication I will need to be on." b. "I can administer the pain medication as frequently as I need to" c. "I feel less anxiety about the possibility of overdosing." d. "I will need the nurse to notify me when it is time for another dose."

C (A PCA is a device that allows the patient to determine the level of pain relief delivered, reducing the risk of oversedation. Its use often eases anxiety because the patient is not reliant on the nurse for pain relief. Other medications, such as oral analgesics, can be given in addition to the PCA machine. The PCA does have a time limit to prevent overdose, but the patient can lengthen the amount of time between doses. One benefit of PCA is that the patient does not need to rely on the nurse to administer pain medication; the patient determines when to take the medication.)

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide? a. "Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer." b. "Narcotics can be addictive, so do not take them unless you are in severe pain." c. "You need to drink plenty of fluids and eat a diet high in fiber." d. "As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections."

C (A common side effect of opioid analgesics is constipation. Therefore, the nurse encourages the patient to drink fluids and eat fiber to prevent constipation. Although medications can be irritating to the stomach, eating a diet high in fat does not prevent gastric ulcers. To best manage pain, the patient needs to take pain medication before painful procedures or activities or before pain becomes severe. As the patient's pain gets better, the strength of the medications will decrease. IM, IV, and topical analgesics are used for more severe and chronic pain.)

6. The nurse anticipates administering an opioid fentanyl patch to which patient? a. A 15-year-old adolescent with a broken femur b. A 30-year-old adult with cellulitis c. A 50-year-old patient with prostate cancer d. An 80-year-old patient with a broken hip

C (A fentanyl patch is an extended-relief opioid that provides pain relief for 24 hours a day. This is ideal for patients who have chronic severe pain, such as those who have cancer. The other patients are expected to experience acute pain. Therefore, they will most likely benefit from oral or IV opioids for short-term pain relief.)

6. What percentage of hip fractures are the result of falls? a. 50% b. 80% c. 90% d. 100%

C (About 90% of falls end with a hip fracture.)

40. The nurse needs to reposition a 300-lb patient. Which of the following strategies is most likely to prevent back injury? a. Turn the patient alone using the lift pad and applying pillows. b. Put the bed in Trendelenburg and pull from the head of the bed. c. Assess and obtain the number of people needed to help. d. Bend at the waist and pull the lift pad using the arms.

C (Assess and determine the number of people needed; to prevent injury, do not start until the task can be completed safely. Assess the situation and do not turn the patient alone if this cannot be done safely. The trunk should be erect and the knees bent, so that multiple muscle groups (not just the arms) work together in a coordinated manner. This is not a one-person task: DO NOT PULL FROM THE HEAD OF THE BED.)

17. The nurse must assess the patient for hazards of immobility by performing a head-to-toe physical assessment. When assessing the respiratory system, the nurse should a. Assess the patient at least every 4 hours. b. Inspect chest wall movements during the expiratory cycle only. c. Auscultate the entire lung region to assess lung sounds. d. Focus auscultation on the upper lung fields.

C (Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes. Perform a respiratory assessment at least every 2 hours for patients with restricted activity. Inspect chest wall movements during the full inspiratory-expiratory cycle. Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions.)

11. Immobility is a major risk factor for pressure ulcers. In caring for the patient who is immobilized, the nurse needs to be aware that a. Breaks in skin integrity are easy to heal. b. Preventing a pressure ulcer is more expensive than treating one. c. Immobilized patients can develop skin breakdown within 3 hours. d. Pressure ulcers are caused by a sudden influx of oxygen to the tissue.

C (Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore, preventive nursing interventions are imperative. An older adult who is immobilized can develop skin breakdown within 3 hours. Tissue metabolism depends on the supply of oxygen and nutrients to and the elimination of metabolic wastes from the blood. Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation.)

24. A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management? a. "This patient says her pain is a 5, but she is not acting like it. I am not going to give her any pain medication." b. "The patient is sleeping, so I pushed her PCA button for her." c. "I need to reassess the patient's pain 1 hour after administering oral pain medication." d. "It wasn't time for the patient's medication, so when she requested it, I gave her a placebo."

C (Because oral medications usually peak in about an hour, you need to reassess the patient's pain within an hour of administration. Nurses must believe any patient report of pain, even if nonverbal communication is not consistent with pain ratings. The patient is the only person who should push the PCA button. Pushing the PCA when a patient is sleeping is dangerous and may lead to narcotic overdose or respiratory depression. Giving the patient a placebo and telling her it is her medication is unethical.)

1. The coordinated efforts of the musculoskeletal and nervous system maintain balance, posture, and body alignment. Body alignment refers to a. A low center of gravity balanced over a wide base of support. b. The result of weight, center of gravity, and balance. c. The relationship of one body part to another. d. The force that occurs in a direction to oppose movement.

C (Body alignment refers to the relationship of one body part to another body part along a horizontal or vertical line. Body balance occurs when a relatively low center of gravity is balanced over a wide, stable base of support. Coordinated body movement is a result of weight, center of gravity, and balance. Friction is a force that occurs in a direction to oppose movement.)

2. A patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. The nurses best response is which of the following? a. Walk at least 5 miles every day for exercise. b. Wear proper fitting shoes to prevent tripping. c. Talk with your physician about a calcium supplement. d. Stand up slowly so you dont feel faint.

C (Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones but a calcium supplement is a good addition. Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures.)

32. The nurse needs to transfer the patient from the bed to the chair. The nurse should a. Avoid using a transfer or gait belt around the patient's waist prior to transfer. b. Not allow the patient to help in any way because resistance can lead to injury. c. Assess for the need of a mechanical lift and help. d. Ensure that the patient has stockings on his feet for transfer.

C (Careful assessment of your patient's ability to assist in the positioning technique to be used is extremely important. Consider the use of a mechanical lift. Your role in assisting your patient to a sitting position is to guide and instruct. If the patient can bear weight and move to a sitting position independently, allow him or her to do so and offer assistance. A transfer belt maintains stability of the patient during transfer and reduces risk for falls. Ensure that the patient has stable nonskid shoes on his feet.)

A nurse is caring for a client who displays signs of stage III Parkinson's disease. Which of the following actions should the nurse include in the plan of care? a. Recommend a community support group b. Integrate a daily exercise routine c. Provide a walker for ambulation d. Perform ADLs for the client

C (Client should use a walker for ambulation in stage III because movement slows down significantly and gait disturbances occur)

14. Many patients find it difficult to incorporate an exercise program into their daily lives because of time constraints. For these patients, it is beneficial to reinforce that many ADLs are used to accumulate the recommended 30 minutes or more per day of moderate-intensity physical activity. When instructing these patients, the nurse explains that a. Housework is not considered an aerobic exercise. b. To strengthen back muscles, the patient should bend using back muscles. c. Daily chores should begin with gentle stretches. d. The patient should stick to one chore until it is done before beginning a new one.

C (Daily chores should begin with gentle stretches. Housework is considered aerobic exercise. To make it more aerobic, work faster and scrub harder. Bend your legs rather than your back to prevent back injury. Alternate cleaning activities to prevent overworking the same muscle groups.)

30. To prevent injury, the nurse should not begin a task (e.g., moving a bed from one room to another, lifting heavy objects) until the task can be completed safely. To prevent injury a. Keep the weight as far from the body as possible. b. Keep the knees still to prevent loss of balance. c. Tighten abdominal muscles and tuck the pelvis. d. Bend at the waist to move weight forward.

C (Follow these steps to prevent injury: (1) tighten abdominal muscles and tuck the pelvis to provide balance and help protect the back; (2) keep the weight to be lifted as close to the body as possible; (3) bend at the knees to maintain the center of gravity, and use the stronger leg muscles; and (4) maintain the trunk erect and the knees bent so that multiple muscle groups work together in a coordinated manner.)

42. The nurse is admitting a patient who has been diagnosed as having had a stroke. The physician writes orders for "ROM as needed." The nurse understands that a. The nurse will have to move all the patient's extremities. b. The patient is unable to move his extremities. c. Further assessment of the patient is needed. d. The patient needs to restrict his mobility as much as possible.

C (Further assessment of the patient is needed. Some patients are able to move some joints actively, whereas the nurse passively moves others. With a weak patient, the nurse may have to support an extremity while the patient performs the movement. In general, exercises need to be as active as health and mobility allow.)

5. Approximately what percentage of all back pain is associated with manual lifting tasks? a. 10% b. 25% c. 50% d. 75%

C (Half of all back pain is associated with manual lifting tasks.)

9. Patients on bed rest or otherwise immobile are at risk for a. Increased metabolic rate. b. Increased diarrhea (peristalsis). c. Altered metabolic function. d. Increased appetite.

C (Immobility disrupts normal metabolic functioning: decreasing the metabolic rate, altering the metabolism of carbohydrates, fats, and proteins (nutritional function); causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.)

3. Unlike arthritis, joint degeneration a. Occurs only from noninflammatory disease. b. Occurs only from inflammatory disease. c. Involves overgrowth of bone at the articular ends. d. Affects mostly non-weight-bearing joints

C (Joint degeneration, which can occur with inflammatory and noninflammatory disease, is marked by changes in articular cartilage combined with overgrowth of bone at the articular ends. Degenerative changes commonly affect weight-bearing joints.)

19. A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal antiinflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works? a. "Ibuprofen helps to remove factors that cause or stimulate pain." b. "Ibuprofen reduces anxiety, which will help you better cope with your pain." c. "Ibuprofen helps to decrease the production of prostaglandins." d. "Ibuprofen binds with opiate receptors to reduce your pain."

C (NSAIDs like ibuprofen most likely work by decreasing the synthesis of prostaglandins to inhibit cellular responses to inflammation. Ibuprofen does not remove factors that cause pain, nor does it enhance coping with pain. Opioids bind with opiate receptors to modify perceptions of pain.)

37. In applying for a job on a nursing unit that requires frequent patient positioning, the nurse should be aware that nurses a. Are at low risk for back injury. b. Are especially at risk for high back injuries. c. Should be aware of agency policies. d. Should not need to use assistive devices.

C (Nurses and other health care staff are especially at risk for injury to lumbar muscles when lifting, transferring, or positioning immobilized patients. Therefore, the nurse should be aware of agency policies and protocols that protect staff and patients from injury. Current evidence supports that using mechanical or other ergonomic assistive devices is the safest way to reposition and lift patients who are unable to do these activities themselves.)

1. What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? a. Assess the patient's body language. b. Observe cardiac monitor for increased heart rate. c. Ask the patient to rate the level of pain. d. Ask the patient to describe the effect of pain on the ability to cope.

C (Pain is a subjective measure. Therefore, the best way to assess a patient's pain is to ask the patient to rate the pain. Nonverbal communication, such as body language, is not as effective in assessing pain, especially when the patient is oriented. Heart rate sometimes increases when a patient is in pain, but this is not a symptom that is specific to pain. Pain sometimes affects a patient's ability to cope, but assessing the effect of pain on coping assesses the patient's ability to cope; it does not assess the patient's pain.)

39. The director of a nursing home has decided to institute ergonomic programs in the facility because these programs increase employee satisfaction and have been shown to a. Be ineffective in reducing injury. b. Be cost neutral in budgeting. c. Enhance recruitment. d. Decrease retention rates.

C (Research has demonstrated that ergonomic programs in health care facilities reduce costs, injuries to employees, and missed workdays. These programs also enhance recruitment, retention, and satisfaction of employees.)

20. A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic? a. "This medication will still be providing you relief at the time of your dressing change." b. "OK, swallow this pain pill, and I will return in a minute to fill your wound." c. "Would you like medication to be given for dressing changes on top of your regularly scheduled medication?" d. "Your medication is scheduled for this time, and I can't adjust the time for you. I'm sorry, but you must take your pill right now."

C (STAT doses of medication can be given to patients in certain circumstances, as with an extensive dressing change. By asking to hold off on the dose, the patient is indicating that the dressing changes are extremely painful. The regularly scheduled dose might not be as effective for the patient. Oral medications take 30 to 60 minutes to take effect. If the nurse began the dressing change right then, the medication would not have been absorbed yet. The patient has the right to refuse to take a medication. It is the nurse's responsibility to communicate with the provider and with the patient about a pain control plan that works for both.)

5. The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care service status after left knee replacement. Which tool(s) will assist with this determination? a. Minimum Data Set (MDS) b. Functional Status Scale (FSS) c. 24-Hour Functional Ability Questionnaire (24hFAQ) d. The Edmonton Functional Assessment Tool

C (The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursing home patients. The FSS is for children. The Edmonton is for cancer patients.)

13. A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider? a. Frequently reassesses the patient's pain scores b. Reassures the patient that the provider will come to the emergency department soon c. Softly plays music that the patient finds relaxing d. Teaches the patient how to do yoga

C (The appropriate nonpharmacological pain management intervention is to quietly play music that the patient finds relaxing. Music diverts a person's attention away from pain and creates relaxation. Reassessing the patient's pain scores is done during evaluation. Building the patient's expectation of the provider's arrival does not address the patient's pain. Although yoga promotes relaxation, nurses teach relaxation techniques only when a patient is not experiencing acute pain. Because the patient is having acute pain, this is not an appropriate time to provide patient teaching.)

10. A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management? a. "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." b. "You should take your medication after you walk to make sure you do not fall while you are walking." c. "We should work together to create a regular schedule of medications that does not allow for breakthrough pain." d. "You need to take oral pain medications when you experience severe pain."

C (The best way to manage pain is to develop a schedule of medications that are given around the clock to prevent breakthrough pain. The nurse should not wait until pain is experienced because it takes medications 10-30 minutes to begin to relieve pain. The nurse administers pain medications before painful activities, such as walking, and administers intravenous medications when a patient is having severe pain.)

24. In developing an individualized plan of care for a patient, it is important for the nurse to a. Set goals that are a little beyond the capabilities of the patient. b. Use his or her judgment and not be swayed by family desires. c. Establish goals that are measurable and realistic. d. Explain that without taking alignment risks, there can be no progress.

C (The nurse must develop an individualized plan of care for each nursing diagnosis and must set goals that are individualized, realistic, and measurable. The nurse should set realistic expectations for care and should include the patient and family when possible. The goals focus on preventing problems or risks to body alignment and mobility.)

33. The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair. The nurse opts to use a mechanical lift (Hoyer lift). The nurse understands that when this lift is used, the a. Straps need to be removed before lowering the patient to the chair. b. Horseshoe-shaped base should be on the opposite side from the chair. c. Longer straps hook to the bottom of the sling. d. Short straps are hooked to the bottom of the sling.

C (The nurse should attach the hooks on the strap to the holes in the sling. Short straps hook to top holes of the sling; longer straps hook to the bottom of the sling. This prevents the sling from flipping upside down. The horseshoe-shaped base goes under the side of the bed on the side with the chair. Position the patient and lower slowly into the chair in accordance with manufacturer guidelines to safely guide the patient into the back of the chair as the seat descends; then remove the straps and the mechanical/hydraulic lift.)

25. When creating a plan of care for a patient who is experiencing alterations in mobility, the nurse a. Cannot delegate interventions to nursing assistive personnel. b. Is solely responsible for modifying ADLs. c. Consults other health care team members to help plan therapy. d. Consults wound care specialists only when wounds are apparent.

C (The nurse should collaborate with other health care team members such as physical or occupational therapists when considering mobility needs. Nurses often delegate some interventions to nursing assistive personnel. Nursing assistive personnel may turn and position patients, apply elastic stockings, help patient use the incentive spirometer, etc. Occupational therapists are a resource for planning ADLs that patients need to modify or relearn. It is especially important in priority setting to make sure not to overlook potential complications. Many times, actual problems such as pressure ulcers are addressed only after they develop. They should be addressed before they develop.)

5. The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? a. Neurological factors b. Competency of the surgeon c. Meaning of pain d. Postoperative support personnel

C (The patient's perception of pain is influenced by psychological factors, such as anxiety and coping, which in turn influence the patient's experience of pain. Each patient's experience is different. The degree and quality of pain perceived by a patient are related to the meaning of the pain. Neurological factors can interrupt or influence pain perception, but neither of these patients is experiencing alterations in neurological function. The knowledge, attitudes, and beliefs of nurses, physicians, and other health care personnel about pain affect pain management but do not necessarily influence a patient's pain perceptions.)

28. The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. The nurse is aware that the rate of occupational injury and illness in the hospital setting a. Is the same as in the private industry sector. b. Is higher than in the nursing home setting. c. Is about 4.4%. d. Has decreased in recent years.

C (The rate of work-related injury in health care settings has increased in recent years. In 2006, 4.4 cases per 100 full-time workers who experienced occupational injury and illness were reported compared with 5 cases per 100 for private industry overall. The rate for nursing homes was 10.1 per 100 workers.)

3. During voluntary movement, impulses descend from the motor strip to the spinal cord. Impulses stimulate muscles by way of a. Ligaments. b. Tendons. c. Neurotransmitters. d. Cartilage.

C (Through a complex process, neurotransmitters, or chemicals such as acetylcholine transfer electrical impulses from the nerve across the neuromuscular junction to the muscle. The neurotransmitter reaches a muscle and stimulates it. Ligaments are white, shiny, flexible bands of fibrous tissue that bind joints together and connect bones and cartilages. Tendons connect muscle to bone. Cartilage is nonvascular, supporting connective tissue located chiefly in the joints and in the thorax, trachea, larynx, nose, and ear.)

26. The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding? a. "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." b. "When patients say they don't need pain medication, they aren't in pain." c. "Pain assessment scales determine the quality of a patient's pain." d. "A patient's behavior is more reliable than the patient's report of pain."

C (To gain a better understanding of a patient's current pain status and to determine what interventions are needed, the nurse should assess both current and previous pain scores. A patient who rates pain at 4 might find the pain manageable if over the previous 24 hours, he had rated his pain at 10. Some patients do not express their pain or do not wish to take medications to relieve the pain. This does not mean they aren't in pain; the nurse can try nonpharmacological therapies for this patient.)

7. What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia? a. Keeping the reversal agent in a syringe in the patient's bedside table b. Applying a gauze dressing to the epidural catheter insertion site c. Labeling the tubing that leads to the epidural catheter d. Asking the nursing assistive personnel to check on the patient at least once every 2 hours

C (To reduce the accidental administration of IV medications into the epidural catheter, the tubing that leads to the epidural catheter needs to be labeled clearly. Medications used to reverse the action of the anesthetic medication need to be kept in a secured location, not in the patient's room in an unsecured location. The epidural insertion site needs to be covered by a clear occlusive dressing to prevent infection and allow the nurse to assess the site. Patients receiving epidural anesthesia need to be monitored every 15 minutes until stabilized and then at least hourly.)

32. Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis? a. Administer pain medication before any activity. b. Provide intravascular bolus as needed for breakthrough pain. c. Give medications around-the-clock. d. Administer pain medication only when nonpharmacological measures have failed.

C (When a patient with arthritis has chronic pain, the best way to manage pain is to take medication regularly throughout the day to maintain constant pain relief. "Before activity" is nonspecific, and the medication may not have time to work before activity. If the patient waits until having pain to take the medication, pain relief takes longer. Nonpharmacological measures are used in conjunction with medications unless requested otherwise by the patient.)

4. An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis pain (OA). You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include a. Pilates, breathing exercises, and aloe vera. b. guided imagery, relaxation breathing, and meditation. c. herbs, vitamins, and tai chi. d. alternating ice and heat to relieve pain and inflammation.

C Nonpharmacologic strategies encompass a wide variety of nondrug treatments that may contribute to comfort and pain relief. These include the body-based (physical) modalities, such as massage, acupuncture, and application of heat and cold, and the mind-body methods, such as guided imagery, relaxation breathing, and meditation. There are also biologically based therapies which involve the use of herbs and vitamins, and energy therapies such as reiki and tai chi. Pilates, breathing exercises, aloe vera, guided imagery, relaxation breathing, meditation, and alternating ice and heat are multimodal therapies for pain management. They are not exclusively biologically based, which involves the use of herbs and vitamins.)

10. In caring for a patient who is immobile, it is important for the nurse to understand that a. The effects of immobility are the same for everyone. b. Immobility helps maintain sleep-wake patterns. c. Changes in role and self-concept may lead to depression. d. Immobile patients are often eager to help in their own care.

C The immobilized patient often becomes depressed because of changes in role and self-concept. Every patient responds to immobility differently. Immobility or bed rest frequently affects coping and creates sleep-wake alterations because of changes in routine or in the environment. Because immobilization removes the patient from a daily routine, he or she has more time to worry about disability. Worrying quickly increases the patient's depression, causing withdrawal. Withdrawn patients often do not want to participate in their own care.)

A nurse is teaching a client who has MS and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? a. This medication will help you with your tremors b. This medication will help you with your bladder function c. This medication may cause your skin to bruise easily d. This medication may cause you to experience weakness

D

A nurse working in a LTC facility is planning care for a client in stage V of Alzheimer's disease. Which of the following interventions should be included in the plan of care? a. Use a gait belt for ambulation b. Thicken all liquids c. Provide protective undergarments d. Assist with ADLs

D

4. Although isometric contractions do not result in muscle shortening, the nurse understands that isometric contractions a. Result in decreased energy expenditure. b. Are always desirable regardless of patient condition. c. Are necessary for the active movement of muscles. d. Result in increased energy expenditure.

D (Although isometric contractions do not result in muscle shortening, energy expenditure increases. It is important to understand the energy expenditure associated with isometric exercises because they are sometimes contraindicated in certain illnesses. Isometric contractions increase muscle tension but not active movement of the muscle.)

16. The nurse is assessing body alignment for a patient who is immobilized. To do this, the nurse must a. Place the patient in the supine position. b. Remove the pillow from under the patient's head. c. Insert positioning supports to help the patient. d. Place the patient in a lateral position.

D (Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position, not supine. Remove all positioning support from the bed, except for the pillow under the head.)

25. In assisting the patient to exercise, the nurse should a. Expect that pain will occur with exercise of unused muscle groups. b. Set the pace for the exercise class. c. Force muscles or joints to go just beyond resistance. d. Stop the exercise if pain is experienced

D (Assess for pain, shortness of breath, or a change in vital signs. If present, stop exercise. Let each patient exercise at his or her own pace. Assess for joint limitations, and do not force a muscle or a joint during exercise.)

6. The nurse is preparing to position an immobile patient. Before doing so, the nurse must understand that a. Manual lifting is the easier method and should be tried first. b. Following body mechanics principles alone will prevent back injury. c. Body mechanics can be ignored when patient handling equipment is used. d. Body mechanics alone are not sufficient to prevent injuries.

D (Body mechanics alone are not sufficient to prevent musculoskeletal injuries when positioning or transferring patients. The use of patient-handling equipment in combination with proper body mechanics is more effective than either one in isolation. Body mechanics cannot be ignored even when patient handling equipment is being used. Manual lifting is the last resort, and it is only used when it does not involve lifting most or all of the patient's weight.)

A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse? a. Teach the client to walk more quickly when ambulating b. Complete passive ROM exercises daily c. Place the client on a low-protein, low-calorie diet d. Give the client extra time to perform activities

D (Bradykinesia is abnormally slowed movement and is seen in clients with PD. The client should be given extra time to perform activities and should be encouraged to remain active)

11. The nurse is developing an exercise program for elderly patients living in a nursing home. To develop a beneficial health promotion program, the nurse needs to understand that when dealing with the elderly a. Exercise is of very little benefit because the patients are old. b. It is important to disregard their current interests in favor of exercise. c. No physical benefit can be gained without a formal exercise program. d. Adjustments to exercise programs may have to be made to prevent problems.

D (Exercise is extremely beneficial for older adults, but adjustments to an exercise program may have to be made for those of advanced age to prevent problems. When developing an exercise program for any older adult, consider not only the person's current activity level, range of motion, muscle strength and tone, and response to physical activity, but also the person's interests, capacities, and limitations. Older adults who are unable to participate in a formal exercise program are able to achieve the benefits of improved joint mobility and enhanced circulation by simply stretching and exaggerating movements during performance of routine activities of daily living.)

1. The nurse is assessing a patients functional ability. Which activities most closely match the definition of functional ability? a. Healthy individual, works outside the home, uses a cane, well groomed b. Healthy individual, college educated, travels frequently, can balance a checkbook c. Healthy individual, works out, reads well, cooks and cleans house d. Healthy individual, volunteers at church, works part time, takes care of family and house

D (Functional ability refers to the individuals ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option.)

3. Mobility for the patient changes throughout the life span; this is known as the process of a. aging and illness. b. illness and disease. c. health and wellness. d. growth and development.

D (Growth and development happens from infancy to death. Muscular changes are always happening, and these changes affect the individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person, but they dont always affect mobility.)

34. The nurse is caring for an infant in the intensive care unit. Which of the following is the most accurate description of factors that will influence the perception and management of pain for this patient? a. Infants cannot tolerate analgesics owing to an underdeveloped metabolism. b. Infants have an increased sensitivity to pain when compared with older children. c. Pain cannot be accurately assessed in infants. d. Infants respond behaviorally and physiologically to painful stimuli.

D (Infants cannot verbally express their pain, but they do express pain with behavioral cues and physiological indicators. Infants can tolerate analgesics, but proper dosing and close monitoring are essential. Infants and older children have the same sensitivity to pain. Pain can be assessed even though the neonate cannot verbalize; the nurse can observe behavioral clues. Nurses use behavioral cues and physiological responses to assess pain in infants.)

27. The nurse is working with the patient in developing an exercise plan. The patient tells the nurse that she just will not participate in a formal exercise program. The nurse then suggests that exercise activities can be incorporated into activities of daily living. The patient seems to be agreeable to that concept. Of the following activities, which would be considered a moderate-intensity activity? a. Doing laundry b. Making the bed c. Ironing d. Folding clothes

D (Low-intensity ADLs include doing the laundry, making the bed, ironing, and washing dishes. Moderate-intensity ADLs include sweeping the kitchen or sidewalk, washing windows, folding clothes, and vacuuming.)

29. In caring for immobile patients, the nurse understands that back injuries occur a. Only when lifting patients. b. Only when transferring patients. c. Only when providing direct patient care. d. With many clinical activities.

D (Musculoskeletal injuries among health care workers are related not only to lifting and transferring patients. Nurses spend time in many activities involving bending and twisting, which also cause injury. Examples of such activities include lifting objects, pushing beds, and providing direct patient care such as bathing, feeding, dressing, and undressing patients.)

21. In preparing to create a nursing diagnosis for a patient who is immobile, it is important for the nurse to understand that a. Physiological issues should be the major focus. b. Psychosocial issues should be the major focus. c. Developmental issues should be the major focus. d. All dimensions are important to health.

D (Often the physiological dimension is the major focus of nursing care for patients with impaired mobility. Thus the psychosocial and developmental dimensions are neglected. Yet all dimensions are important to health.)

4. The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when he or she states, Patients must a. have a trapeze over the bed to move properly. b. move themselves in bed to prevent immobility. c. always have a two-person assist to move in bed. d. be moved correctly in bed to prevent shearing.

D (Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over the bed is only functional is the patient can assist in the moving process. A two-person assist is good, but the patient still needs to be moved properly. A patient may move himself or herself if he or she is able, but shearing may still occur.)

10. An active lifestyle is important for maintaining and promoting health. In developing an exercise program, the nurse understands that a. Physical exercise is contraindicated for patients with chronic illnesses. b. Regular physical activity is beneficial only for the body part that is exercised. c. Physical exercise has no effect on psychological well-being. d. Physical activity enhances functioning of all body systems.

D (Regular physical activity and exercise enhance the functioning of all body systems, including cardiopulmonary functioning, musculoskeletal fitness, weight control and maintenance, and psychological well-being. It is also essential in treatment for chronic illness.)

7. Without balance control, the center of gravity is displaced, thus creating risk for falls and subsequent injuries. Balance is enhanced by a. Maintaining a narrow base of support. b. Creating a high center of gravity. c. Disregarding body posture. d. Keeping a low center of gravity.

D (Without balance control, the center of gravity is displaced, thus creating risk for falls and subsequent injuries. Balance is enhanced by keeping the center of gravity of the body low with a wide base of support and by maintaining correct body posture.)

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? a. The patient who needs to take a scheduled dose of maintenance pain medication b. The patient who needs to be premedicated before walking c. The patient with a PCA running who needs to have the syringe replaced d. The patient who is experiencing 8/10 pain and has a STAT order for pain medication

D (STAT medications need to be given as soon as possible. In addition, this patient is the priority because of the report of severe pain. The other patients need pain medication, but their situations are not as high a priority as that of the patient with the STAT medication order.)

23. The patient has been in bed for several days and needs to be ambulated. Before ambulation, the nurse a. Removes the gait belt to allow for unrestricted movement. b. Has the patient get up from bed before he has a chance to get dizzy. c. Has the patient look down to watch his feet to prevent tripping. d. Dangles the patient on the side of the bed.

D (Some patients experience orthostatic hypotension—a drop in blood pressure that occurs when the patient changes from a horizontal to a vertical position. Assist the patient to a position of sitting at the side of the bed, and dangle for 1 to 2 minutes before standing. The nurse needs to provide support at the waist so that the patient's center of gravity remains midline. This is achieved with the use of a gait belt. A gait belt encircles the patient's waist and may have handles attached for the nurse to hold while the patient ambulates. The patient should maintain as normal a walking posture as possible with the head erect.)

16. Which of the following exercise activities would most likely provide the opportunity for mind-body awareness? a. Warm-up activity b. Resistance training c. Aerobic exercise d. Cool-down activity

D (The cool-down period allows the body to readjust gradually to baseline functioning and provides an opportunity to combine movement such as stretching with relaxation-enhancing mind-body awareness. The warm-up activity prepares the body and decreases the potential for injury. Aerobic exercise includes running, bicycling, jumping rope, and so forth, and is the main portion of exercise activity; it precedes the cool-down period. Resistance training increases muscle strength and endurance and is associated with improved performance of daily activities but not with enhancing mind-body awareness.)

23. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. This diagnosis means that the nurse should a. Encourage the patient to do self-care. b. Keep the patient as mobile as possible. c. Encourage the patient to perform ROM. d. Assist the patient with comfort measures.

D (The diagnosis related to pain requires the nurse to assist the patient with comfort measures so that the patient is then willing and better able to move. Pain must be controlled before so that the patient will not be reluctant to initiate movement. The diagnosis of Reluctance to initiate movement requires interventions aimed at keeping the patient as mobile as possible and encouraging the patient to do self-care and ROM. This cannot be accomplished until comfort is achieved.)

4. The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient? a. Eating and drinking, personal cleansing and dressing, working and playing b. Toileting, transferring, dressing, and bathing activities c. Sleeping, expressing sexuality, socializing with peers d. Maintaining a safe environment, breathing, maintaining temperature

D (The most critical aspects of care for an unconscious patient are safe environment, breathing, and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting, transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however, these are not the most critical for developing the plan of care in an unconscious patient.)

43. While performing passive ROM exercises, the nurse stands at the side of the bed closest to the joint being exercised and a. Forces the joint just a bit beyond the point of resistance. b. Moves the joint until the patient complains of pain. c. Repeats each movement twice. d. Carries out movements slowly and smoothly.

D (The nurse carries out movements slowly and smoothly, just to the point of resistance. ROM should not cause pain. Never force a joint beyond its capacity. Each movement needs to be repeated five times during the session.)

A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient's blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic? a. "Your vitals do not show that you are having pain; can you describe your pain?" b. "You do not look like you are in pain." c. "OK, I will go get you some narcotic pain relievers immediately." d. "What would you like to try to alleviate your pain?"

D (The nurse must believe that a patient is in pain whenever the patient reports that he or she is in pain, even if the patient does not appear to be in pain. Whenever the patient reports pain, the nurse needs to collaborate with the patient to determine the best method of pain relief, whether it be medication, meditation, or repositioning. The nurse must be careful to not judge the patient based on vital signs or nonverbal communication and must not assume that the patient is seeking narcotics. The patient is a partner in pain management, so going to get narcotics to treat the pain without consulting with the patient first is not appropriate.)

A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? Select all that apply a. Heberden's nodes b. Swelling of all the joints c. Small body frame d. Enlarged joint size e. Limp when walking

D, E

31. The nurse is caring for a patient who recently had surgery to repair a hernia. The patient's pain was 7 out of 10 before receiving pain medication. One hour after receiving an oral opioid, the patient ranks his pain at 3 out of 10. The patient asks the nurse why he isn't receiving more pain medication. Which is the nurse's best response? a. "This medication can be given only every 4 hours. It is not time for you to have any other pain medication right now." b. "I will notify the health care provider to come perform an assessment if your pain doesn't improve in 30 minutes." c. "If the pain becomes severe, we may need to transfer you to an intensive care unit." d. "It can take 2 hours for oral pain medication to work, and your pain is going down. Let's try boosting you up in bed and putting an ice pack on the incision to see if that helps."

D (The patient is responding well to the oral pain medication and it can take up to 2 hours for oral medications to relieve pain. Trying nonpharmacological interventions as an addition to opioid medications is appropriate at this time. If nonpharmacological interventions combined with the oral opioid are ineffective, the nurse needs to notify the health care provider and ask for a change in the medication or for additional pain medication. Saying that the patient has to wait 4 hours for additional pain medication is inaccurate because the nurse needs to provide further nursing interventions if pain is not relieved at an acceptable level for the patient. Admission to an intensive care unit is not typically necessary to manage pain following surgery for a hernia.)

5. Joints are the connections between bones. The joint that is freely movable is known as the _____ joint. a. Synostotic b. Cartilaginous c. Fibrous d. Synovial

D (The synovial joint, or true joint, is a freely movable joint in which contiguous bony surfaces are covered by articular cartilage and are connected by ligaments lined with a synovial membrane. The synostotic joint refers to bones jointed by bones. No movement is associated with this type of joint. In the cartilaginous joint, or synchondrosis joint, cartilage unites bony components. When bone growth is complete, the joints ossify. The fibrous joint, or syndesmosis joint, is a joint in which a ligament or membrane unites two bony surfaces, permitting a limited amount of movement only.)

13. The nurse is assessing the way the patient walks. The manner of walking is known as the patient's a. Activity tolerance. b. Body alignment. c. Range of motion. d. Gait.

D (The term gait describes a particular manner or style of walking. Activity tolerance is the type and amount of exercise or work that a person is able to perform. Body alignment refers to the position of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Range of motion is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, or transverse.)

35. The patient is unable to move himself and needs to be pulled up in bed. For this repositioning to be done safely, the nurse must understand that a. The procedure can be done by one person if the bed is in the flat position. b. Side rails should be in the up position to prevent the patient from falling out. c. The pillow should be placed under the patient's head and shoulders. d. Assistive devices or additional nurses should be used.

D (This is not a one-person task. Helping a patient move up in bed without help from other coworkers or without the aid of an assistive device (e.g., friction-reducing pad) is not recommended and is not considered safe for the patient or the nurse. When pulling a patient up in bed, the bed should be flat or in a Trendelenburg position (when tolerated) to gain gravity assistance, and the side rails should be down. Remove the pillow from under head and shoulders and place it at the head of the bed to prevent striking the patient's head against the head of the bed.)

14. A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction? a. "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet." b. "Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy." c. "Since you cannot feel pain as much in your feet, you need to open your neurological gates to allow pain sensations to come through. Wearing shoes helps to open those gates, which protects your feet." d. "You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."

D (This patient is losing the ability to feel pain owing to peripheral neuropathy. The patient will no longer have protective reflexes to prevent injury to the feet. Wearing shoes prevents the patient from injuring the foot because they protect the feet. Shoes do not block pain perception, nor do they help people adapt to pain. Shoes are not a form of nonpharmacological pain relief. Wearing shoes will not have an effect on opening or closing the pain gates.)

15. A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." What type of pain does the nurse document that the patient is having at this time? a. Superficial pain b. Idiopathic pain c. Chronic pain d. Visceral pain

D (Visceral pain comes from visceral organs, such as those from the gastrointestinal tract. Visceral pain is diffuse and radiates in several directions. Superficial pain has a short duration and is usually a sharp pain. Pain of an unknown cause is called idiopathic pain. Chronic pain lasts longer than 6 months.)

19. The patient has been bedridden for several months owing to severe congestive heart disease. In determining a plan of care for this patient that will address his activity level, the nurse formulates which of the following nursing diagnoses? a. Fatigue related to poor physical condition b. Impaired gas exchange related to decreased cardiac output c. Decreased cardiac output related to decreased myocardial contractility d. Activity intolerance related to physical deconditioning

D (When activity and exercise are problems for a patient, nursing diagnoses often focus on the individual's ability to move. The diagnostic label directs nursing interventions. In this case, physical deconditioning must be addressed relative to activity level, perhaps leading to 6-minute walks twice a day. Physical deconditioning is the cause of fatigue as well, so it would take priority over that diagnosis. Decreased cardiac output and myocardial contractility are serious concerns that must be addressed before activity intolerance to keep the patient safe and to help determine the level of exercise that the patient can tolerate, but reconditioning of the patient's body will help improve contractility and cardiac output.)

1. The lack of weight bearing leads to bone _________ and __________ from the skeletal system.

demineralization, calcium loss (Weight bearing helps to strengthen the bone. Lack of weight bearing means that the bone is losing minerals and calcium that strengthen it.)