CoursePoint Ch. 9-10

A patient undergoing rehabilitation reports problems with constipation. Which suggestion would be least appropriate? "Keep your fluid intake to fewer than 2 liters per day." "Do not delay the urge to move your bowels when it occurs." "Eat plenty of fruits and vegetables throughout the day." "Try to increase your activity level a bit more."

"Keep your fluid intake to fewer than 2 liters per day."

A nurse is caring for a client who requires a wheelchair. Which piece of equipment impedes circulation to the area it's meant to protect? Specialty mattress Ring or donut Gel flotation pad Water bed

Ring or donut

In which stage is a pressure ulcer considered a partial-thickness wound? Stage I Stage II Stage III Stage IV

Stage II

A type of therapeutic exercise, performed by a client, in which the muscle alternately contracts and relaxes is isometric. resistive. passive. active-assistive.

isometric.

A client with spinal cord injury has no awareness of the need to void. This type of incontinence is termed reflex (neurogenic) incontinence. stress incontinence. toilet incontinence. functional incontinence.

reflex (neurogenic) incontinence.

The nurse is caring for a client with muscular dystrophy who is confined to bed. The client develops a pressure ulcer on the sacrum. The nurse documents the pressure ulcer as a(n) self-limiting condition. impairment disease. secondary condition. primary disease.

secondary condition.

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called: functional incontinence. reflex incontinence. stress incontinence. total incontinence.

stress incontinence.

The nurse is caring for an adult paraplegic with an ostomy. Which is an appropriate statement for the nurse to make? "What type of pouching system do you use, honey?" "I insist that I empty your ostomy pouch now." "Who changes your pouching system at home?" "Do you need assistance managing your ostomy?"

"Do you need assistance managing your ostomy?"

A nurse is describing the concept of habilitation to a group of families who have members in need of these services. Which of the following statements would the nurse include in this description? "Habilitation begins once the patient is ready for discharge." "Habilitation focuses on the person's abilities." "Habilitation is primarily geared to those who can achieve independence." "Habilitation negates the need for assistive devices."

"Habilitation focuses on the person's abilities."

A nurse is caring for a client with multiple chronic conditions and some physical disabilities. The nurse is using "people-first" language with the following statement during end-of-shift report: "Last evening, Mr. Rudd, a 44-year-old patient with diabetes was admitted to the unit." "I admitted another diabetic patient last evening; his name is Mr. Rudd." "A new diabetic admit came to the floor last night during my shift. He is 44 and his name is Mr. Rudd." "Mr. Rudd is a 44-year-old diabetic patient who was admitted last evening."

"Last evening, Mr. Rudd, a 44-year-old patient with diabetes was admitted to the unit."

A family will be providing care at home to an immobilized patient at risk for impaired skin integrity. After teaching the family about reducing the patient's risk for skin breakdown, the nurse determines that the teaching was successful when the family states which of the following? "We need to make sure that the patient drinks enough fluids." "We need to use an antibacterial soap on the skin when bathing." "We need to remove any tape or bandages from the skin quickly" "We need to massage any reddened areas that may appear."

"We need to make sure that the patient drinks enough fluids."

The nurse assessing a client on a rehabilitation units notices that the patient experiences pain when his right arm is moved away from the midline of his body. The nurse documents pain upon which type of movement? Adduction Abduction Flexion Extension

Abduction

A client is diagnosed with type 2 diabetes mellitus. The client takes metformin (Glucophage) and exenatide (Byetta) and reports adhering to her diet. The glycohemoglobin is 5.9%. In the stable phase of the Trajectory Model of Chronic Illness, the nurse States, "The glycohemoglobin is too high" Advises the client that changes must be made to her diet Responds, "There are some adjustments to your medications that need to be made" Acknowledges to the client she is performing satisfactorily

Acknowledges to the client she is performing satisfactorily

A patient has had a traumatic amputation of the left leg above the knee following an industrial accident. What type of disability does this patient have? Developmental disability Acquired disability Chronic disability Impaired disability

Acquired disability

A nurse is working with a patient to establish a bowel training program. Based on the nurse's understanding of bowel function, the nurse would suggest planning for bowel evacuation at which time? Before bed After breakfast Around lunchtime Upon arising

After breakfast

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? Putting slippers on the client's feet Crossing the client's ankles every 2 hours Placing hand rolls on the balls of each foot Attaching braces or splints to each foot and leg

Attaching braces or splints to each foot and leg

A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply. Bathing Cleaning Cooking Toileting Eating

Bathing Toileting Eating

The nurse is helping a client who experiences frequent constipation select meal choices for the day. Which food should the nurse encourage the client to order? Bananas Applesauce Bran cereal Pop-Tart

Bran cereal

Which phase of the Trajectory Model does the nurse recognize is present when the patient is in remission, after an exacerbation of illness? Acute Crisis Downward course Comeback

Comeback

A nurse is assessing a client who will be discharged home after rehabilitation for a stroke. The nurse is questioning the client about his instrumental activities of daily living (IADLs). Which of the following would the nurse address? Bathing Grooming Dressing Cooking

Cooking

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan? Turn and reposition the client at least once every 8 hours. Vigorously massage lotion over bony prominences. Develop a written, individual turning schedule. Slide the client, rather than lifting, when turning.

Develop a written, individual turning schedule.

A graduate nurse is assigned to care for a client with an acute exacerbation of chronic obstructive pulmonary disease. The client also has Down syndrome. During the shift, the nurse discovers that the client lives alone and holds a full-time job. Which type of disability would the nurse state the client has? Acute nontraumatic Developmental Age-related Acquired

Developmental

A rehabilitation nurse is assisting a patient to cope with a disability. Which of the following would the nurse suggest? Stop any activity once fatigue occurs. Group any heavy work to be done at the same time. Emphasize areas of strengths. Avoid seeking help from others.

Emphasize areas of strengths.

The nurse practitioner has four patients with chronic illness that require consistent medical and nursing management. Select the condition that is the best example of a "chronically critical and progressively ill" condition. Type 2 diabetes mellitus End-stage renal disease Coronary artery disease Carcinoma-in-situ

End-stage renal disease

A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use? Functional Independence Measure PULSES profile Barthel Index Patient Evaluation Conference System

Functional Independence Measure

A nurse is assessing a client for potential problems related to function and mobility. Which of the following would alert the nurse to identify a potential problem related to function or movement? Uses the handrail on one side to go down the stairs Lifts one leg by raising it off the ground Holds onto the furniture when walking in the house Keeps the head erect while combing the hair

Holds onto the furniture when walking in the house

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area? Greater trochanter Lateral malleous Scapula Ischial tuberosity

Ischial tuberosity

Which intervention has the highest priority when providing skin care to a bedridden client? Changing the client's position frequently Keeping the skin clean and dry without using harsh soaps Gently massaging the skin around the pressure areas Rubbing moisturizing lotion over the pressure areas

Keeping the skin clean and dry without using harsh soaps

Which is a true statement regarding characteristics of chronic conditions? Few ethical issues arise in the care of people with chronic conditions. Living with chronic illness means living with certainty. Managing chronic conditions must be a collaborative process. Managing chronic conditions is becoming less costly.

Managing chronic conditions must be a collaborative process.

Which disciplines should be consulted when caring for a client with a stage III heel ulcer? Nutrition support and orthotics Physical therapy and respiratory therapy Occupational therapy and infectious disease Plastic surgery and cardiology

Nutrition support and orthotics

A nurse prepares a diabetes prevention health seminar for community residents. Her teaching points should emphasize the most important factor influencing metabolic syndrome (pre-diabetes). What is that factor? Obesity Smoking Sedentary lifestyle Stress

Obesity

A client who is blind is hospitalized for hip surgery. The nurse notices that the containers on the client's lunch tray are unopened, the client is fumbling with items, and food is on the front of the client's gown. The nurse assists the client by Obtaining help from a nursing assistant to feed the client Contacting a family member to assist with feeding the client at meal times Sitting down in a chair and feeding the client Opening containers and orienting the client to placement of items on the tray

Opening containers and orienting the client to placement of items on the tray

A nurse is performing passive range of motion to a client's upper extremeities. The nurse touches the client's thumb to each fingertip on the same hand. The nurse is performing which of the following? Adduction Pronation Opposition Dorsiflexion

Opposition

When describing the role of the various members of the rehabilitation team, which member would the nurse identify as the one who determines the final outcome of the process? Nurse Physician Physical therapist Patient

Patient

A nurse is talking on the phone with a doctor and states, "I am calling you about Mrs. Nye, my client with cancer in room 213." This is an example of what type of language that is important to all people? Medical jargon First nation People-first Nursing speak

People-first

A rehabilitation nurse is preparing a presentation for clients and caregivers about issues that clients with disabilities may face. Which of the following would be most appropriate for the nurse to include in the presentation? A loss of sexual functioning correlates with a loss of sexual feeling. Fatigue primarily results from physical demands. Most care tasks required after discharge focus on the physical care. Priority setting is helpful in dealing with the impact of the disability.

Priority setting is helpful in dealing with the impact of the disability.

A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair? Water Vitamin C Protein Zinc sulfate

Protein

The client had a cerebrovascular accident with drooping of the face. Speech is slurred. The nurse is obtaining the admission assessment data. It would be best for the nurse to Chart that the nurse is unable to obtain information. Wait until past medical records can be obtained. Repeat back what the client states. Ask a family member the questions.

Repeat back what the client states.

A nurse is developing a plan of care for an 85-year-old woman who is bedridden following a stroke. Which of the following would the nurse be least likely to include in the plan of care for this patient to reduce her risk for pressure ulcers? Repositioning the patient about once a shift Lubricating the skin with a non-irritating lotion Using a static support device on the patient's bed Lifting rather than sliding the patient when repositioning her

Repositioning the patient about once a shift

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk? Serum albumin Serum glucose Prothrombin time Sedimentation rate

Serum albumin

The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? (Select all that apply.) Set a daily defecation time that is within 15 minutes of the same time every day. Have an adequate intake of fiber containing foods. Have a fluid intake between 2 and 4 L/day. Take a retention enema daily. Take a laxative daily.

Set a daily defecation time that is within 15 minutes of the same time every day. Have an adequate intake of fiber containing foods. Have a fluid intake between 2 and 4 L/day.

A community nurse is working to decrease the incidence of cardiac disease in Nicaragua. The nurse should plan educational health promotion activities around which element? Vaccinations Birth control Breastfeeding Smoking cessation

Smoking cessation

During which phase of the Trajectory Model of chronic illness is the focus of nursing care on reinforcing positive behaviors and offering ongoing monitoring? Unstable Pretrajectory Stable Trajectory onset

Stable

The nurse is with a client who has a chronic illness and is reinforcing positive behaviors and teaching about health promotion. For which phase of the trajectory model of chronic illness are these nursing actions appropriate? Acute Downward Stable Comeback

Stable

The nurse is reading the previous shift's documentation of an open area on the client's sacrum. The wound is documented as a partial-thickness wound whose etiology is pressure. The nurse anticipates the assessment of the client's sacrum will reveal a pressure ulcer in which stage? Stage I Stage II Stage III Stage IV

Stage II

Students are reviewing information about the stages of pressure ulcer development. They demonstrate understanding when they identify which stage as characterized by a full-thickness wound? Select all that apply. Deep tissue injury Stage I Stage II Stage III Stage IV

Stage III Stage IV

During assessment, a patient reports that she sometimes "wets herself" when sneezing. The nurse documents this as which of the following? Urge incontinence Functional incontinence Stress incontinence Reflex incontinence

Stress incontinence

Which of the following describes the crisis phase of the trajectory model of chronic illness? The client is in the final days or weeks before death characterized by gradual or rapid shutting down of body processes. The client may require more diagnostic tests. The client is experiencing a critical or life-threatening situation requiring emergency treatment. The course of the illness and symptoms are under control.

The client is experiencing a critical or life-threatening situation requiring emergency treatment.

Clients must contend with chronic illness daily. Nurses relate more effectively to clients when they understand the following as characteristics of chronic illness. Choose all that apply. Chronic conditions only involve one phase of a person's life. Chronic illness affects the entire family. Chronic illness involves treating only the medical problems. The management of chronic conditions is a process of discovery. Managing chronic conditions must be a collaborative process.

The management of chronic conditions is a process of discovery. Managing chronic conditions must be a collaborative process. Chronic illness affects the entire family.

The number of people with disabilities is expected to increase over time. What is a major contributor to this prediction? The survival of people with severe trauma, chronic disorders, and early-onset disabilites The decrease in the number of people with early-onset disabilities The decrease in risk factors for early-onset disabilities that are genetic in cause The ability to cure chronic disorders that are acquired

The survival of people with severe trauma, chronic disorders, and early-onset disabilites

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip? Trochanter roll Range-of-motion exercises Protective boots Pillow between the legs

Trochanter roll

A client is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility? Decreasing fluid intake to ease dependent edema Turning the client every 2 hours and providing a low-air-loss mattress Raising the head of the bed to maximize the client's lung inflation Bathing and feeding the client to decrease energy expenditure

Turning the client every 2 hours and providing a low-air-loss mattress

A client is hospitalized with a traumatic brain injury following an automobile accident. The client has difficulty processing information and needs information to be repeated. A consulting physician enters the room. The nurse Turns off the television Removes unnecessary items from the beside table while the physican meets with the client Leaves the room Communicates with the daughter while the physician talks with the client

Turns off the television

The nurse is fitting a patient for crutches that are required for an ankle injury. What quick method can the nurse use to measure so that the crutches will be of appropriate height? Use the patient's height and add 6 inches. Use the patient's height and add 12 inches. Use the patient's height and subtract 8 inches. Use the patient's height and subtract 16 inches.

Use the patient's height and subtract 16 inches.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then: advance both legs. advance the unaffected leg. advance the affected leg. advance both crutches.

advance both crutches.

To prevent footdrop, the client is positioned in a semi-sitting position in bed. in a sitting position with legs hanging off the side of the bed. in a side-lying position. to keep the feet at right angles to the leg.

to keep the feet at right angles to the leg.