Potter and Perry Ch 39 & 46 Urinary Elimination; Immobility

Match the urinary pattern alteration to its corresponding cue. 1-Urine output <50 to 100 mL/24 hrs 2-Urine output <400 mL/24 hrs 3-Urine output >2500 mL/24 hrs 4-Excessive urination at night A-Polyuria B-Anuria C-Oliguria D-Nocturia

1-B 2-C 3-A 4-D

Match the type of urinary catheter to its description. 1-Single-lumen, single-use 2-Double-lumen indwelling with anchoring balloon 3-Bent at the tip and slightly stiff; used with urethral constriction 4-Indwelling with anchoring balloon, irrigation and drainage lumens A-Foley B-Coudé C-Triple-lumen D-Straight

1-D 2-A 3-B 4-C

Match the health care team member with the patient cue indicating a need for consult with that individual. 1-Chokes during meals 2-Needs strengthening exercises 3-Experiencing social isolation 4-Needs help on how to bathe at home A-Physical therapist B-Occupational therapist C-Spiritual advisor D-Speech therapist

1-D 2-A 3-C 4-B

Match the urinary function diagnostic test with its description. 1-High-frequency sound waves used to visualize anatomic structures 2-Invasive internal exam of the urethra and bladder with lighted device 3-Detailed x-ray cross-sectional images of the urinary system 4-X-ray using contrast medium to visualize kidneys, ureters, and bladder A-Intravenous pyelogram B-Cystoscopy C-Computed tomography (CT) D-Ultrasound

1-D 2-B 3-C 4-A

Which area is impaired if a tendon is damaged? A-Bone to muscle attachment B-Bone to cartilage attachment C-Joint cushion D-Joint fluid

A A-Bone to muscle attachment is damaged if a tendon is damaged. B-Bone to cartilage attachment is affected if a ligament is damaged, not a tendon. C-Cartilage, not a tendon, forms a joint cushion. D-Joint fluid helps lubricate a joint; it is not affected by tendon damage.

Which finding is unexpected when assessing effects of immobility? A-Skin nonblanches B-Braden Scale score of 21 C-2500 mL intake and 2450 mL output D-Fecal impaction not present

A A-Skin nonblanching is unexpected because it indicates ischemia. B-A Braden Scale score of 21 is normal; any score of 19 or above is expected, not unexpected. C-This is an expected finding (intake is close to output), not unexpected. D-The absence of a fecal impaction is an expected finding; it is not an unexpected finding.

Which cues would likely occur with atelectasis? Select all that apply. A-Cyanosis B-Dyspnea C-Chills D-Graphic record indicates a fever E-Diminished breath sounds noted in nurse's notes

A, B, E A-Cyanosis occurs with atelectasis. B-Dyspnea occurs with atelectasis. C-Chills occur with pneumonia, not atelectasis. D-Fever occurs with pneumonia, not atelectasis. E-Diminished breath sounds occur with atelectasis.

Which conditions would likely cause paralysis on one side of the body? Select all that apply. A-Right-sided stroke B-Paresis C-Cervical spinal cord injury D-Traumatic brain injury E-Left-sided cerebrovascular accident

A, D, E A-A right-sided stroke would likely cause paralysis on one side of the body (the left side). B-Paresis is weakness, not paralysis on one side of the body. C-A cervical spinal cord injury would likely cause paralysis on the upper and lower extremities but not on one side of the body. D-A traumatic brain injury would likely cause paralysis on one side of the body, either the right or the left depending on the location of the injury. E-A left-sided cerebrovascular accident would likely cause paralysis on one side of the body (the right side).

Which patient is prone to paralysis? A-A patient on bed rest B-A patient with prolonged brain ischemia C-A patient with a fracture D-A patient on a low-calcium diet

B A-A patient on bed rest is not prone to paralysis but is prone to other complications. B-Prolonged ischemia in the brain can lead to paralysis. C-A fracture does not lead to paralysis but does cause pain and bruising. D-A low-calcium diet does not lead to paralysis but can lead to osteoporosis.

Which person is most prone to osteoporosis? A-Adult large-frame male B-Older Asian female C-Middle-age Caucasian female D-Adult black female

B A-Adult males are not at high risk for osteoporosis. Small-frame females are more prone to osteoporosis. B-Osteoporosis is more prevalent in the older population and in Asian women. C-Although Caucasian females are prone to osteoporosis, they are usually older, not middle-age. D-Black adult females are not prone to osteoporosis when compared with Caucasian and Asian females.

Which graphic record cue indicates the patient has anorexia? A-Passage of hard, small stools B-Eats less than 50% of meals C-Weight gain D-Presence of a fever

B A-Passage of hard, small stools is a cue for constipation, not anorexia. B-Anorexia is a lack of appetite; thus a graphic record indicating the patient eats less than 50% of meals is a cue for anorexia. C-A graphic record cue for anorexia would indicate weight loss, not gain. D-Fever is a graphic record cue for an infection, not for anorexia.

Which mineral is stored in bones? A-Sodium B-Calcium C-Chloride D-Potassium

B A-Sodium is not stored in bones. Sodium is in body fluids. B-Calcium is stored in bone and assists with maintenance of phosphorus. C-Chloride is not stored in bone. Chloride is in body fluids. D-Potassium is not stored in bone. It is mainly located inside cells.

Which hypothesis would the nurse select for a patient who experiences increased heart rate and increased oxygen requirements when eating? A-Fall B-Activity Intolerance C-Risk for Deep Vein Thrombosis D-Risk for Impaired Skin Integrity

B A-There are no cues to suggest that the patient has fallen. B-The patient is experiencing Activity Intolerance because heart rate and oxygen requirements increase when eating. C-An increased heart rate and increased oxygen requirements do not support a hypothesis of Risk for Deep Vein Thrombosis. Risk for Deep Vein Thrombosis is potential development of a clot. D-There are no cues to support a hypothesis of Risk for Impaired Skin Integrity. A cue for Risk for Impaired Skin Integrity would be inability to move or turn.

The nurse is caring for a patient who has developed urinary retention. While reviewing the patient's medications, the nurse recognizes which medication type as known to contribute to the risk of developing urinary retention? A-Drugs that act on kidneys to increase urine formation and excretion B-Drugs that act on the autonomic nervous system C-Drugs that act on the heart to strengthen muscle contraction D-Supplements with diuretic effects

B A-These drugs result in increased urine volume and frequency rather than urinary retention. B-Drugs that act on the autonomic nervous system may cause urinary retention because they interfere with neurologic signaling such as sphincter and detrusor muscle function. These types of drugs are sometimes prescribed to treat urinary incontinence. C-These drugs usually do not have a side effect of urinary retention but may affect electrolyte reabsorption in the kidneys and alter urine concentration. D-Supplements with diuretic effects typically result in increased urine volume and frequency rather than urinary retention.

Which action by the nurse may prevent a patient from urinating while using a bedpan? A-Placing a cover sheet over the patient and bedpan B-Permitting a family member to stay at the bedside C-Pulling bedside curtains around the patient and bed D-Standing outside the patient's pulled bedside curtain

B A-This action provides privacy and facilitates urination. B-Patients should be provided adequate privacy to urinate. Visitors at the bedside may interfere with the patients' feelings of privacy and prevent them from being able to relax enough to urinate. C-This action provides privacy and facilitates urination. D-This action provides privacy and safety and facilitates urination.

Which parameters would the nurse consider to analyze medical record cues for a patient who is immobile? Select all that apply. A-Physical assessment findings B-Graphic chart information C-X-ray results D-Patient interview E-Diagnostic tests

B, C, E A-The nurse would analyze physical assessment findings for patient observation cues, not medical record cues for mobility needs. B-The nurse would analyze graphic chart information for medical record cues for mobility needs. C-The nurse would analyze x-ray results because these are medical record cues for mobility issues. D-An interview is a patient observation cue, not a medical record cue for mobility. E-Diagnostic tests are medical record cues for mobility issues.

Which action would the nurse take to improve an immobile patient's nutritional intake? A-Monitor the patient's serum albumin. B-Assess the patient's nutritional intake. C-Allow the patient to make food choices. D-Weigh the patient at routine intervals.

C A-Monitoring the serum albumin level will provide information about the patient's nutritional status but will not improve the patient's nutritional intake. B-Assessing the patient's nutritional intake will provide information about the patient's nutritional status but will not improve intake. C-Allowing the patient to make food choices will enable the patient to select foods that are likely to be consumed, improving nutritional intake. D-Weighing the patient at routine intervals will provide information about the patient's nutritional status, but it will not improve intake.

Tissue ischemia related to immobility can directly lead to the development of which complication? A-Atelectasis B-Contractures C-Pulmonary embolus D-Pressure injuries

D A-Atelectasis is the result of decreased lung expansion, not tissue ischemia. B-Contractures are tightening of tissues that used to be elastic and easy to move; they are not the result of tissue ischemia. C-Pulmonary embolus is a result of a clot traveling to the lung, not tissue ischemia. D-Tissue ischemia related to immobility can directly lead to the development of pressure injuries.

Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills? A-Place the patient flat in bed. B-Encourage the patient to take deep breaths. C-Assess the patient for signs of deep vein thrombosis. D-Notify the health care provider that the patient may have pneumonia.

D A-The patient would not be placed flat because the lungs have more room to expand in an upright position. B-Encouraging the patient to take deep breaths is not enough, as the patient may already have developed pneumonia as evidenced by the thick secretions and chills. C-Coughing up thick secretions is a sign of pneumonia, not a deep vein thrombosis. D-The nurse would notify the health care provider that the patient may have pneumonia as a consequence of prolonged immobility, decreased lung expansion, and pooling of secretions in the lungs.

Which action would the nurse take when using a mechanical lift for a patient who is experiencing limited mobility? A-Ensures that no more than 35 lb (15.9 kg) is placed in the lift B-Has the patient grab the bars for stability C-Transfers the patient toward the weaker side D-Obtains two unlicensed assistive personnel to help

D A-This is the amount a nurse lifts independently; it is not the weight limit for a mechanical lift. Mechanical lifts can lift much more than 35 lb (15.9 kg). B-Patients keep their arms inside and crossed over the chest; it is unsafe to have the patient grab the bars. C-The nurse transfers toward the stronger side, not the weaker side. D-The total personnel are three: the nurse and two other personnel (in this case, two unlicensed assistive personnel). To use a mechanical lift, two personnel are needed but three are better.

Which fall risk score would the nurse anticipate in a patient who is weak? A-Hendrich II Fall Risk Model score of 8 B-Morse Fall Scale score of 10 C-Braden Scale score of 22 D-Johns Hopkins Fall Risk Assessment Tool score of 5

A A-A patient with weakness is at risk for falls. A score of 8, which is in the 5 or above range, indicates the patient is at high risk for falls. B-A score of 10 on the Morse Fall Scale indicates a normal finding. A patient with weakness is prone to falls and would have a higher score. C-The Braden Scale assesses pressure injury risk, not fall risk. D-Johns Hopkins Fall Assessment Tool score of 5 (below 6) is normal. A patient with weakness is prone to falls and would have a higher score.

Which cue is relevant to alterations in the musculoskeletal system? A-Has a shoulder joint that is edematous B-Has a low sodium level C-Has a history of hemorrhoids D-Has five grandchildren

A A-A shoulder joint that is edematous is relevant to the musculoskeletal system because it is a component of the system. B-A low sodium level is an irrelevant cue for the musculoskeletal system. A low sodium level is relevant for fluid issues, not for musculoskeletal issues. C-A history of hemorrhoids is an irrelevant cue for the musculoskeletal system. Hemorrhoids are relevant for bowel elimination. D-Having five grandchildren is an irrelevant cue for the musculoskeletal system. Having grandchildren does not affect the musculoskeletal system.

Which solution would the nurse select for a patient who has a hypothesis of Risk for Deep Vein Thrombosis? A-TED hose B-Texting C-Dietitian consult D-Fall risk protocol

A A-A solution for Risk for Deep Vein Thrombosis is TED hose. B-Texting is a solution for Social Isolation, not for Risk for Deep Vein Thrombosis. C-A dietitian consult is for anorexia, not for Risk for Deep Vein Thrombosis. D-A fall risk protocol is for Fall, not for Risk for Deep Vein Thrombosis.

Which patient finding would alert the nurse to stop passive range-of-motion exercises? A-Resistance to movement is felt. B-The patient is unable to participate. C-The patient's joints move freely. D-Atrophy occurs.

A A-Range-of-motion exercises are stopped when resistance to movement is experienced. B-Passive range-of-motion exercises do not require active patient participation; thus the exercises can continue without patient participation. C-Range-of-motion exercises are continued as long as the joints move freely. D-Range-of-motion exercises are initiated to prevent and help alleviate atrophy.

Which interpretation would the nurse make when observing a darkened or reddened area of skin in an immobile patient? A-Tissue ischemia has occurred. B-Blanching has developed. C-Cyanosis has occurred. D-Deep vein thrombosis has developed.

A A-Skin that appears darkened or reddened is indicative of tissue ischemia. B-Blanching occurs when pressure produces a white area but returns to its normal color promptly, indicating adequate perfusion; it does not cause a darkened or reddened area of skin. C-Cyanosis is a bluing of the skin, not a darkened or reddened area of skin. D-Deep vein thrombosis presents as an area of warmth, redness, swelling, or pain in a lower extremity, not a darkened or reddened area of skin.

A sterile urine sample via catheterization is prescribed for a patient who is temporarily unable to provide a clean catch sample. Which type of urinary catheter will the nurse use to obtain the sample? A-Straight catheter B-Foley catheter C-Triple-lumen Foley catheter D-Condom catheter

A A-Straight catheters are designed for single-use "in-and-out" catheterization and are ideal for sterile sample collection. B-Foley catheters are indwelling catheters that are designed for continuous drainage of urine. A simple straight catheter is the preferred catheter for single-use catheterization like sterile sample collection. C-Triple-lumen Foley catheters are indwelling catheters that are designed for continuous drainage of urine and installation of fluid into the bladder. A simple straight catheter is the preferred catheter for single-use catheterization like sterile sample collection. D-Condom catheters are noninvasive catheters that are secured over the penis. A condom catheter exposes the skin of the penis to the interior of the condom catheter collection bag and is therefore not sterile. A simple straight catheter is the preferred catheter for single-use catheterization like sterile sample collection.

Which cues are relevant for activity intolerance? Select all that apply. A-Struggles to complete activities of daily living B-Exhibits dyspnea on exertion C-Has to sit down while doing the dishes D-Has an inability to move E-Has no feeling in the lower extremities

A, B,C A-Struggling to complete activities of daily living is a relevant cue for activity intolerance. B-Dyspnea on exertion is a relevant cue for activity intolerance. C-Having to sit down while doing the dishes is a relevant cue for activity intolerance. D-The inability to move is paralysis, not activity intolerance. E-Having no feeling in the lower extremities is paralysis, not activity intolerance.

Which cues alert the nurse that the patient with Paralysis is declining? Select all that apply. A-Develops disuse osteoporosis B-Has not lost muscle mass C-Does not participate in physical therapy D-Controls wheelchair according to capabilities E-Avoids muscle atrophy

A, C A-Disuse osteoporosis indicates the patient is declining from loss of bone. B-Not losing muscle mass indicates the patient is improving, not deteriorating. C-Not participating in physical therapy indicates the patient is declining and withdrawing from measures that would increase independence and functioning to the best of the patient's abilities. D-Controlling the wheelchair according to capabilities indicates the patient is improving by taking control and caring for self. E-Avoiding muscle atrophy indicates the patient is improving, not declining.

A patient has a standard creatinine clearance test ordered. Which information would the nurse include when teaching a patient about the test? Select all that apply. A-It is a 24-hour urine collection. B-A high urine creatinine clearance result suggests kidney damage. C-All urine must be collected during the designated time period once the test starts. D-The test measures how well the kidneys enable creatinine retention in the blood. E-High creatinine levels in the blood indicate healthy kidney function.

A, C A-The creatinine clearance test is timed. It should last for exactly the required period (standard is 24 hours) to ensure an accurate representation of the patient's kidney function. B-A low, not high, creatinine clearance rate suggests kidney damage. Healthy kidneys remove creatinine from the blood and excrete it in the urine. A high result may reflect a large muscle mass or a high protein diet, not kidney damage. C-Once the collection starts, no urine should be discarded. It is crucial that all urine is collected, or the collection must begin again for another 24-hour period. D-Kidneys do not enable creatinine retention in the blood but instead clear creatinine from the blood. The creatinine clearance test measures the rate at which the kidneys perform creatinine clearance. E-High creatinine levels in the blood (serum creatinine) generally indicate kidney damage. Healthy kidneys remove creatinine from the blood and excrete it in the urine.

Which cues are relevant for weakness? Select all that apply. A-Flaccidity B-Hypertonicity C-Shuffling gait D-Feeble handgrip E-Score of 5 on Johns Hopkins Fall Risk Assessment Tool

A, C, D A-Flaccidity is a relevant cue for weakness. B-Hypotonicity, not hypertonicity, is a relevant cue for weakness. C-Shuffling gait is a relevant cue for weakness. D-Feeble handgrip is a relevant cue for weakness. E-A score below 6 is an expected finding and indicates the patient is not weak; a score of 6 or above indicates the patient may be weak. A score between 6 and 13 indicates a moderate fall risk, and a score of 13 or above indicates a high fall risk.

Which solutions would the nurse generate for a hypothesis of Impaired Kidney Function? Select all that apply. A-Monitor serum creatinine and blood urea nitrogen (BUN) level. B-Teach pelvic floor strengthening exercises. C-Assess for swelling in extremities. D-Provide education about urinary incontinence self-management. E-Monitor for cardiac arrhythmia.

A, C, E A-Serum creatinine and BUN monitoring is a solution the nurse would generate for a hypothesis of Impaired Kidney Function. Increasing serum BUN and creatinine levels are indicators of worsening kidney function. B-Pelvic floor strengthening exercises are an appropriate solution for a patient with pelvic floor weakness, not kidney disease. Kidney disease is not associated with pelvic floor weakness. C-The nurse would generate the solution of assessing for swelling in the extremities. Kidney impairment can cause fluid buildup in the blood if kidneys are not filtering and regulating fluid, electrolytes, and protein correctly. Swelling in extremities can lead to circulatory problems such as blood clots. D-Education about urinary incontinence self-management is a solution the nurse would generate for a patient with incontinence, not Impaired Kidney Function. Impaired Kidney Function does not cause incontinence. E-Monitoring for arrhythmias is a solution the nurse would generate. Impaired Kidney Function results in serum electrolyte imbalances including alterations in potassium, which may cause dangerous cardiac arrhythmias.

Which urine tests require the collection of the specimen by the clean catch or urinary catheterization technique? Select all that apply. A-Urine culture B-Urine glucose screen C-Urine ketone screen D-Urinalysis E-Urine drug screen

A, D A-A urine culture test cultures and identifies the specific microorganisms present in a urine sample. Contamination with bacteria from the environment will yield false-positive results, so the specimen must be collected using "very clean" or sterile techniques, such as those used with clean catch or catheterization. B-A glucose screen of the urine does not require a specimen collection technique such as clean catch ("very clean") or catheterization (sterile) because it tests only for glucose (sugar), not microorganisms. A nonsterile urine sample can be collected to test for glucose in urine. C-A ketone screen of the urine does not require a specimen collection technique such as clean catch ("very clean") or catheterization (sterile) because it tests only for ketones, not microorganisms. A nonsterile urine sample can be collected to test for ketones in urine. D-Because urinalysis includes analysis for the presence of bacteria, it requires a sterile technique such as that used with clean catch or catheterization. E-A urine drug screen does not require sterile collection because it tests only for the presence of certain illicit drugs, not microorganisms. A nonsterile urine sample can be collected to screen for drugs in urine.

Which disorders decrease the body's ability to deliver oxygen and nutrients to the muscles and bones? Select all that apply. A-Heart failure B-Renal failure C-Spina bifida D-Peripheral vascular disease E-Chronic obstructive pulmonary disease

A, D, E A-Heart failure decreases the body's ability to deliver oxygen and nutrients to the muscles and bones because of impaired pumping action of the heart. B-Renal failure is the partial or complete impairment of kidney function; it does not decrease the body's ability to deliver oxygen and nutrients to the muscles and bones. C-Spina bifida is a genetic disorder that affects mobility due to abnormal formation of the spinal cord, not due to the decreased ability of the body to deliver oxygen and nutrients to the muscles and bones. D-Peripheral vascular disease decreases the body's ability to deliver oxygen and nutrients to the muscles and bones because of decreased tissue perfusion. E-Chronic obstructive pulmonary disease decreases the body's ability to deliver oxygen and nutrients to the muscles and bones because of diminished respiratory capacity.

Which question would the nurse ask a patient to determine symptom-related issues with the musculoskeletal system? A-"Do any of your family members have osteoporosis?" B-"Have you noticed any differences in your gait?" C-"Do you have an active lifestyle or sedentary lifestyle?" D-"Have you ever found yourself on the floor and don't know how you got there?"

B A-Asking about family members' issues with the musculoskeletal system is a health history question, not a symptom-related question. B-Asking about any difference in gait is a symptom-related question. C-Asking if the patient has an active or sedentary lifestyle is an activity-related question, not a symptom-related question. D-Asking patients if they have ever found themselves on the floor without knowing how they got there is a question for older adult patients; it is not a symptom-related question.

The nurse is evaluating the effectiveness of teaching a patient to independently collect a clean catch midstream urine sample for a suspected urinary tract infection (UTI). Which action by the patient indicates that further teaching is needed? A-Cleanses the perineum and urinary meatus with multiple antiseptic wipes from front to back B-Grasps the rim of the specimen cup with the forefinger inside the cup and the thumb outside the cup C-Passes a small amount of urine into the toilet without collecting it, then passes the cup into the urine stream D-Tightly caps the specimen cup and places it on a paper towel on the countertop

B A-Cleansing the perineum and urinary meatus with multiple antiseptic wipes from front to back is a correct action that indicates that teaching has been effective. B-By touching the inside of the cup, the patient has contaminated the specimen through the introduction of external microorganisms. The nurse recognizes that further teaching is needed. C-Passing a small amount of urine into the toilet without collecting it, then passing the cup into the urine stream, are correct actions that indicate that teaching has been effective. D-Tightly capping the specimen cup and placing it on a paper towel on the countertop are correct actions that indicate that teaching has been effective.

Which action would the nurse take for a newly admitted patient who is unsteady when transferring from the wheelchair to the bed? A-Place the patient on complete bed rest. B-Initiate a fall prevention plan for the patient. C-Start passive range-of-motion exercises twice a day. D-Make sure the patient only ambulates with a walker.

B A-Placing the patient on bed rest will only exacerbate the problem and does not address the safety issue of unsteadiness when transferring. B-An unsteady gait places the patient at risk for falling, and the nurse would initiate fall prevention measures to ensure the patient's safety. C-Passive range-of-motions exercises do not address the unsteadiness or the safety risk. D-While this action may help, the issue at the present time is transferring, not ambulating, and the safety risk for falling is not addressed. Additionally, the patient may be able to ambulate with other ambulation aids rather than only with a walker.

A patient with redness, warmth, and swelling in the right lower leg is at risk for which complication? A-Joint damage B-Pulmonary embolism C-Orthostatic hypotension D-Pathologic bone fractures

B A-Redness, warmth, and swelling in the leg is indicative of deep vein thrombosis. This is not a risk factor for joint damage, which occurs when the joints are hyperextended or flexed beyond their limits. B-Redness, warmth, and swelling in an extremity is indicative of a deep vein thrombosis, which places the patient at risk for developing a pulmonary embolism. C-Redness, warmth, and swelling in the leg is indicative of deep vein thrombosis. This is not a risk factor for orthostatic hypotension, which is a change in vital signs upon standing, and is associated with immobility. D-Redness, warmth, and swelling in an extremity is indicative of deep vein thrombosis. This is not a risk factor for pathologic bone fractures, which occur secondary to disuse osteoporosis.

Which evaluation outcome indicates that a male patient with urinary incontinence using a condom catheter is improving? A-No signs of urinary tract infection are present. B-Previously macerated perineal skin shows signs of healing. C-Patient reports discomfort using the condom catheter. D-Skin breakdown is evident on the head of the penis.

B A-The absence of infection indicates an unchanged status, not an improvement in the patient's condition. B-Healing is an indication of improvement. C-Discomfort using the condom catheter indicates a worsening of the patient's situation, not an improvement. D-Skin breakdown on the head of the penis is a complication of using the condom catheter, which indicates a worsening of the patient's condition, not an improvement.

Which actions by the nurse caring for patients with mobility problems would require correction by the charge nurse? Select all that apply. A-Refuses to massage a patient's leg with deep vein thrombosis B-Places a gait belt on a patient with osteoporosis to assist with ambulation C-Allows the patient's elbows to be bent at a 45-degree angle when using a cane D-Tells the patient with a four-point crutch gait to move one crutch forward simultaneously with the opposite leg E-Has the patient cough two times after using an incentive spirometer

B, C, D A-This action would not require correction because it is appropriate; the nurse would not massage the patient's leg with deep vein thrombosis because it could dislodge the clot. B-This action would cause the charge nurse to correct the nurse. The nurse does not use a gait belt on a patient with osteoporosis because it can cause vertebral compression fractures. C-This action would cause the charge nurse to correct the nurse. The angle is 30 degrees, not 45 degrees. D-A four-point walking gait moves one crutch forward, followed by opposite leg, and then repeats with the opposite crutch and leg. The two-point walking gait moves one crutch forward simultaneously with the opposite leg. E-This action would not require correction; the nurse would have the patient cough two times after using an incentive spirometer.

Which cues are relevant for a deep vein thrombosis (DVT)? Select all that apply. A-Tunneling B-Redness C-Edema D-Cramping E-Chest pain

B, C, D A-Tunneling occurs with a pressure injury, not a DVT. B-Redness occurs with a DVT. C-Edema occurs with a DVT. D-Cramping occurs with a DVT. E-Chest pain occurs with a pulmonary embolus, not a DVT.

Which changes in vital signs are indicative of postural hypotension when a patient stands up? Select all that apply. A-Heart rate increases from 60 to 70 beats/min B-Systolic blood pressure drops from 120 to 100 mm Hg C-Heart rate increases from 65 to 85 beats/min D-Systolic blood pressure drops from 110 to 100 mm Hg E-Diastolic blood pressure drops from 70 to 60 mm Hg

B, C, E A-An increase in heart rate of 10 beats/min is not significant enough to be classified as postural hypotension. B-A drop in systolic blood pressure of 20 mm Hg when a patient stands is classified as postural hypotension. C-An increase in heart rate of 20 beats/min when a patient stands is classified as postural hypotension. D-A drop in systolic blood pressure of 10 mm Hg is not significant enough to be classified as postural hypotension. E-A drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as postural hypotension.

An infection of which structure would likely be the source for balance problems? A-Eye B-Cornea C-Inner ear D-Tonsils

C A-An eye infection would likely cause vision problems, not balance problems. B-The cornea is located in the eye, so an infection would likely cause vision problems, not balance problems. C-An inner ear infection would likely cause balance problems because the inner ear, along with the cerebellum, helps maintain balance. D-Tonsils are located in the throat, so an infection would likely cause difficulty swallowing, not balance problems.

Which finding is a psychological consequence of bed rest and manifests in the patient becoming lonely or depressed? A-Faulty equilibrium B-Sensory deprivation C-Feelings of isolation D-Alteration in self-concept

C A-Equilibrium is a physical, not psychological, consequence of bed rest. B-Although sensory deprivation is a psychological consequence of bed rest, it does not manifest in the patient becoming lonely or depressed. C-Feelings of isolation are a consequence of bed rest and can manifest in the patient becoming lonely or depressed. D-Alteration in self-concept results in irregular patterns of behavior, not by becoming lonely or depressed, which are emotions.

Which cue would the nurse rank as priority for a patient who suffered multiple fractures after a motor vehicle accident? A-Pain B-Elevated heart rate C-Respiratory distress D-Decreased mobility

C A-Pain would occur with multiple fractures, but it is not the priority cue because it is not life-threatening. B-Elevated heart rate may occur as a response to increased pain or the accident, but it is not the priority cue because it is not life-threatening. C-Respiratory distress following multiple fractures would be the priority cue because it is life-threatening and follows the ABCs (airway, breathing, circulation). D-Decreased mobility would occur as a result of fractures, but it is not the priority cue because it is not life-threatening.

Which health care team member would the nurse likely collaborate with to assist a paraplegic patient with how to perform tasks at home? A-Primary health care provider B-Physical therapist C-Occupational therapist D-Social worker

C A-The primary health care provider assists with medical prescriptions, not with helping patients perform tasks at home. B-A physical therapist works on ambulation, transfer, range of motion, and dexterity issues, not on helping patients perform tasks at home. C-Because an occupational therapist assists patients with activities of daily living/tasks, this health care team member is an appropriate choice to help the patient perform tasks at home. D-The social worker would help find resources for the patient going home but would not help with how to perform tasks at home.

Which structure is located at the junction of the neck of the urinary bladder and the urethra? A-External urethral sphincter B-Urinary meatus C-Ureter D-Internal urethral sphincter

D A-External urethral sphincter IS located distal to the internal urethral sphincter, which is found at the neck of the bladder. B-The urinary meatus is the opening to the exterior of the body at the distal end of the urethra. C-The ureters are paired structures that connect the kidneys to the urinary bladder. The ureters are not connected to the urethra. D-The internal urethral sphincter is located at the neck of the bladder, separating the bladder from the urethra.

Which graphic record cue is associated with constipation? A-Fever B-Soft stools C-90% of meals eaten D-Infrequent stools

D A-Fever is a graphic record cue for pneumonia, not constipation. B-Hard, not soft, stools are a graphic record cue for constipation. C-Ninety percent of meals eaten is a normal finding; it is not a cue for constipation. D-Infrequent stools is a graphic record cue for constipation.

Which patient would likely be prone to reduced bone density? A-One with muscular dystrophy B-One with burns C-One who has been physically abused D-One who cannot perform weight-bearing exercises

D A-Muscular dystrophy affects muscles, not bones. B-Burns can lead to contractures, not reduced bone density. C-Physical abuse can lead to fractures, not reduced bone density. D-The patient who cannot perform weight-bearing exercises is prone to reduced bone density by allowing calcium to leak out of the bones.

Which solution would the nurse select for an immobile patient who appears withdrawn and reports not having any visitors in the past week? A-Removal of cell phone B-Laxative administration C-Rest periods D-Spiritual consult

D A-The patient is experiencing social isolation; thus, removing the cell phone would make the situation worse. B-A laxative is administered for constipation, not for a patient experiencing social isolation. C-Rest periods are for a patient experiencing weakness or activity intolerance, not for a patient displaying cues for social isolation. D-One solution for social isolation is a spiritual consult because the patient is displaying signs and symptoms of social isolation.

Which hypothesis would the nurse select for a patient who refuses to turn on their side and lies supine most of the time? A-Impaired Mobility B-Weakness C-Risk for Fall D-Risk for Impaired Skin Integrity

D A-The primary issue is the patient refusing to change positions, which is not Impaired Mobility. Impaired Mobility is a result of a physical problem. B-The patient is not weak; the patient is refusing to turn or change positions. C-Because the patient is refusing to change position, the hypothesis is not Risk for Fall. There are no cues to indicate weakness or orthostatic hypotension, which would increase the risk for falls. D-This patient is at Risk for Impaired Skin Integrity because lying primarily in one position and refusing to change positions places pressure on bony prominences.

Place the assessment techniques of the abdominal physical examination in the correct order. A-Auscultation B-Palpation C-Percussion D-Inspection

D, A, C, B During any assessment of the abdominal area, whether urinary, bowel, or other, best practice is to examine in this order: inspection, auscultation, percussion, and palpation. This differs from the physical examination order used for other body systems (inspection, palpation, percussion, and auscultation). The reason for postponing palpation until after auscultation is because the pressure from palpation of the abdomen can alter peristaltic activity of the bowels and cause extraneous sounds to be present, which complicate listening for sounds actually originating from the patient's body.

1-D 2-A 3-B 4-C

Label the anatomic structures of the urinary system. (From top to bottom) 1- 2- 3- 4- A-Ureter B-Bladder C-Urethra D-Kidney

A patient involved in a motor vehicle accident is transferred to your facility. Multiple patient problem hypotheses are generated. Which hypothesis is the highest priority? A-Impaired Airway Clearance B-Urinary Incontinence due to spinal injury C-Impaired Cognition D-Risk for Fall-Related Injury

A A-Hypotheses about life-threatening issues such as alterations in airway, breathing, and/or circulation always have top priority. Impaired Airway Clearance is a life-threatening alteration in breathing. B-Hypotheses about life-threatening issues such as alterations in airway, breathing, and/or circulation always have top priority. Urinary Incontinence is not life threatening. C-Hypotheses about life-threatening issues such as alterations in airway, breathing, and/or circulation always have top priority. Impaired Cognition may be very dangerous for the patient, but Impaired Airway Clearance is more urgent. D-Hypotheses about life-threatening issues such as alterations in airway, breathing, and/or circulation always have top priority. Falls may be very dangerous for the patient, but Impaired Airway Clearance is more urgent.

Which musculoskeletal alterations does immobility predispose a patient to developing? Select all that apply. A-Weakness B-Decreased muscle tone C-Decreased muscle mass D-Increased bone mass E-Reduced bone density

A, B, C, E A-Immobility predisposes a patient to weakness due to inactivity. B-Immobility predisposes a patient to decreased muscle tone due to inactivity. C-Immobility predisposes a patient to decreased muscle mass due to inactivity. D-Immobility predisposes a patient to decreased, not increased, bone mass due to disuse osteoporosis. E-Immobility predisposes a patient to reduced bone density due to lack of weight-bearing on bones.

In which areas would the patient experience pain if a urinary tract infection is present? Select all that apply. A-Calf B-Back C-Bladder D-Upper chest E-Lower abdomen

B, C, E A-Calf pain may occur with a thrombus but not with a urinary tract infection. B-The patient may experience pain in the back because of the location of the kidneys. C-The patient may experience pain in the bladder with a urinary tract infection. D-Chest pain may occur with pneumonia, pulmonary embolus, or atelectasis but not with a urinary tract infection. E-The patient may experience pain in the lower abdomen because of the location of the bladder.

Urinary continence depends on adequate muscle tone of which structures? Select all that apply. A-Abdominal wall B-Bladder C-Vaginal wall D-Urethral sphincters E-Pelvic floor

B, D, E A-Urinary continence does not depend on the muscle tone of the abdominal wall. B-Urinary continence depends on the muscle tone of the urinary bladder, both urethral sphincters, and the pelvic floor. C-Urinary continence does not depend on the muscle tone of the vaginal wall. D-Urinary continence depends on the muscle tone of the urinary bladder, both urethral sphincters, and the pelvic floor. E-Urinary continence depends on the muscle tone of the urinary bladder, both urethral sphincters, and the pelvic floor.

Which term is used to describe a slightly movable joint? A-Patellar B-Fibrous C-Cartilaginous D-Synovial

C A-Patellar relates to the knee bone, not a joint. B-A fibrous joint is immobile, not slightly movable. C-A cartilaginous joint is slightly movable. D-A synovial joint is freely movable, not slightly movable.

Which effects are typical of decreased physical activity? Select all that apply. A-Spasticity B-Hypertonicity C-Deterioration D-Bone fragility E-Loss of strength

C, D, E A-Spasticity is related to cerebral palsy, not decreased physical activity. B-Hypotonicity, not hypertonicity, may result from lack of physical activity. C-Decreased physical activity contributes to deterioration of the body and muscles. D-Decreased physical activity contributes to bone fragility by allowing calcium to leak out of bone. E-Decreased physical activity leads to loss of strength by decreased stimulation to the muscles.

Which evaluative findings will alert the nurse an immobile patient with a left hip stage 1 pressure injury is declining? Select all that apply. A-Has a reddened area on hip that will not blanch B-Has dry, warm, intact skin C-Has a Braden Scale score that indicates a high risk for skin breakdown D-Develops a Stage 1 pressure injury on the buttocks E-Develops a Stage 2 pressure injury on the left hip

C, D, E A-This finding indicates the patient is unchanged, not declining. A stage 1 pressure injury is redness on a bony prominence that will not blanch. B-This finding indicates the patient is improving, not declining because the skin is intact, not broken down. C-This indicates the patient is declining because the score indicates a high risk for skin breakdown. D-This indicates the patient is declining because another pressure injury has developed. E-This indicates the patient is declining because the pressure injury is worsening (from Stage 1 to Stage 2).

Which characteristic is typical of lower extremity flaccidity? A-Bone fragility B-Muscle spasms C-Joint inflammation D-Lack of muscle tone

D A-Bone fragility is typical of osteoporosis, not lower extremity flaccidity. B-Muscle spasms are characteristic of spasticity, not lower extremity flaccidity. C-Joint inflammation is typical of rheumatoid arthritis and osteoarthritis, not lower extremity flaccidity. D-Lack of muscle tone is typical of lower extremity flaccidity.

Which complication from immobility causes the alveoli to collapse? A-Pressure injury B-Deep vein thrombosis C-Anorexia D-Atelectasis

D A-Pressure injury does not cause the alveoli to collapse. Alveoli are in the lungs, not the skin. B-Deep vein thrombosis does not cause the alveoli to collapse. Alveoli are in the lungs, not the blood vessels. C-Anorexia causes a loss of appetite; it does not cause the alveoli to collapse. D-Atelectasis causes the alveoli in the lungs to collapse.

Which action would the nurse take when caring for a patient with sequential compression devices (SCDs)? A-Ensure the fit of the sleeves is tight. B-Roll the sleeves inside out to apply them. C-Activate the heating feature once a shift. D-Monitor the patient's toes for impaired circulation.

D A-SCDs should fit snugly, not tightly, and allow two fingers between the leg and the sleeve when not inflated. B-Antiembolism stocking are rolled inside out to apply them; SCDs are wrapped around the patient's leg and secured with Velcro. C-SCDs have a cooling feature but not a heating feature. D-Because SCDs can impair circulation if too tight, it is important for the nurse to check the patient's circulation to the toes.

Place the steps of clean catch midstream urine specimen collection in order. 1-Open the specimen cup without touching the inside. 2-Pass the specimen cup into the stream of urine and collect the specimen. 3-Cleanse the perineum and urinary meatus with antiseptic wipes from front to back. 4-Tightly cap the specimen cup. 5-Remove the cup from the urine stream and finish urinating. 6-Urinate a small amount of urine into the toilet without collecting it.

1, 3, 6, 2, 5, 4 Clean catch midstream urine specimen collection requires careful specimen handling to avoid contamination. Proper technique involves opening the cup, cleansing the urinary meatus, voiding a small amount into the toilet, collecting a urine sample from midstream, finishing urinating, and promptly capping the specimen container.

Place the patients in the order in which the nurse would prioritize their care. 1-Patient with a cervical fracture and altered respirations 2-Patient from a car accident with impaired mobility from a fractured leg 3-Patient with osteoporosis

1-1 2-2 3-3 The priority is the patient with a cervical fracture and altered respirations because the fracture is affecting airway and breathing (two of the ABCs). The next patient to be prioritized is the one with the fractured leg because this condition is more acute than osteoporosis. The patient with osteoporosis is the last to be seen, as osteoporosis is a chronic condition.

Place the steps in the order the nurse would follow to teach a patient how to use a cane. 1-Move the stronger leg. 2-Place cane on the patient's stronger side. 3-Move the cane. 4-Move the weaker leg.

1-4 2-1 3-2 4-3

Match the solution to the expected patient outcome. 1-Fewer urine leakage episodes within 48 hours 2-Decreased residual urine volume after void within one day 3-No urinary tract infections (UTIs) one month from hospital discharge 4-No perineal redness two weeks from hospital discharge A-Incontinence trigger education B-Bladder emptying technique education C-Education about UTI prevention D-Skin care barrier cream use training

1-A 2-B 3-C 4-D

Match the activity-related condition to the correct patient. 1-Older adult who has an intact inner ear with fluid and hairlike sensors 2-Young adult who injured the structure connecting bone to cartilage 3-Adult with decreased oxygen to muscles/bones from reduced cardiac pumping 4-Adult with impaired gas exchange due to reduced lung capacity A-Steady equilibrium B-Heart failure C-Torn ligament D-Chronic obstructive pulmonary disease

1-A 2-C 3-B 4-D

Match the multidisciplinary care team member with an example of urinary care they commonly provide. 1-Documenting urine volume output under supervision of a nurse 2-Supervising bladder training regimen and pelvic floor muscle training plan 3-Teaching the patient how to manage toileting using assistive equipment 4-Placing indwelling urinary catheters A-Unlicensed assistive personnel (UAP) B-Occupational therapist C-Registered nurse D-Nurse continence specialist

1-A 2-D 3-B 4-C

Match the pressure injury stage to its cues. 1-Blistering of epidermis or dermis 2-Intact skin with reddened area 3-Exposure of muscle and bone 4-Subcutaneous injury with possible tunneling A-Stage 4 B-Stage 2 C-Stage 1 D-Stage 3

1-B 2-C 3-A 4-D

Match the pathophysiology (cause) to its activity/movement hypothesis. 1-Risk for Deep Vein Thrombosis 2-Deficient Food Intake 3-Impaired Skin Integrity 4-Weakness A-Lack of strength from musculoskeletal disuse B-Venous stasis C-Reduced basal metabolic rate D-Prolonged pressure and friction

1-B 2-C 3-D 4-A

Match the function to its nervous system component of mobility. 1-Regulated by the cerebral cortex 2-Dependent on proprioception 3-Dependent on the cerebellum and inner ear 4-Regulated by the cerebellum A-Coordination B-Voluntary movement C-Balance D-Posture and gait

1-B 2-D 3-C 4-A

Match the musculoskeletal system alteration to its cause. 1-Porous, brittle bones 2-Deterioration of the muscle itself 3-Tissue that is usually easy to move tightens and pulls inward A-Muscle atrophy B-Contracture C-Pathologic fracture

1-C 2-A 3-B

Match the solution the nurse would select based on the patient's pathophysiology. 1-Venous stasis 2-Friction and prolonged pressure 3-Loss of sensation 4-Reduced basal metabolic rate A-Turning B-Dietitian/nutritionist consult C-Sequential compression devices D-Rehabilitation therapy

1-C 2-A 3-D 4-B

Match the mobility hypothesis with the patient's cue. 1-Altered mobility secondary to stroke 2-Hemiplegia 3-Oxygen saturation reading is 88% when brushing teeth A-Activity Intolerance B-Paralysis C-Risk for Fall

1-C 2-B 3-A

Match the nursing diagnoses with their relevant urinary cues. 1-Inability to completely empty bladder and difficulty starting void 2-Dysuria, urgency, frequency, and cloudy urine 3-Decreased urine output, abnormal blood results, and swelling in feet 4-Urinary urgency and inability to reach toilet in time A-Impaired Kidney Function B-Urinary Tract Infection C-Urinary Retention D-Urinary Incontinence

1-C 2-B 3-A 4-D

Match each type of exercise to its example. 1-Ambulating 2-Kegel exercises 3-Heavy weight-lifting 4-Repeated stair-climbing A-Aerobic B-Anaerobic C-Isotonic D-Isometric

1-C 2-D 3-B 4-A

Match the musculoskeletal condition to its associated description or causative factor. 1-Bone deterioration 2-Autoimmune disease 3-Genetic disorder 4-Decreased activity level A-Hypotonicity B-Muscular dystrophy C-Osteoporosis D-Rheumatoid arthritis

1-C 2-D 3-B 4-A

Match the type of urinary incontinence to its description. 1-Loss of bladder control with an increase in intraabdominal pressure 2-Sudden need to urinate, followed by bladder contraction and urination 3-Physical limitation (e.g., immobility) preventing controlled elimination 4-Dribbling and urinary frequency related to an inability to fully empty the bladder A-Overflow incontinence B-Functional incontinence C-Stress incontinence D-Urge incontinence

1-C 2-D 3-B 4-A

Match each altered urinary elimination pattern with its description. 1-Need to urinate more often than usual 2-Difficulty initiating urine stream 3-Inability to fully empty bladder 4-Painful urination A-Dysuria B-Retention C-Hesitancy D-Frequency

1-D 2-C 3-B 4-A

The nurse would inform unlicensed assistive personnel to turn the patient how often (in hours) to maintain skin integrity?

2

Place the hypotheses in order from highest to lowest priority. 1-Lack of knowledge of incontinence support groups 2-Painful and debilitating urethral trauma with pain rating of 7/10 3-Skin breakdown related to urinary incontinence 4-Systemic urinary tract infection with shock and multiple organ failure

4, 2, 3, 1 Addressing airway, breathing, and circulation (ABCs) is always the highest priority, so systemic urinary tract infection with shock and multiple organ failure is the highest priority hypothesis. The next highest priority is the most urgent or serious problem after ABCs, which is urethral trauma with a high pain level of 7/10. The next highest priority again is the next most urgent or serious problem, which is skin breakdown related to urinary incontinence. The lowest priority hypothesis is the least urgent, which is educating the patient about incontinence support groups.

Place the spread of a urinary tract infection in ascending anatomical order. 1-Spread to the ureters, causing ureteritis (rare) 2-Spread to the urethra, causing urethritis 3-Spread to the urinary bladder, causing cystitis 4-Spread to the kidneys, causing pyelonephritis 5-Contamination of the urinary meatus by a pathogen

5, 2, 3, 1, 4

Place the anatomic structures in the order through which urine passes as it moves from the kidneys to the exterior of the body. 1-Urinary meatus 2-Ureter 3-External urethral sphincter 4-Bladder 5-Internal urethral sphincter 6-Renal pelvis

6, 2, 4, 5, 3, 1 As urine flows from the kidney to the exterior of the body, it passes through the renal pelvis of the kidney and down the ureter to be stored in the bladder. It exits the bladder by way of the internal urethral sphincter at the neck of the bladder, travels through the urethra (which passes through the prostate [in males] and pelvic floor muscles [in males and females]), goes through the external urethral sphincter, and exits the body from the urinary meatus at the distal end of the ureter.

Which patient finding is expected in a musculoskeletal assessment? A-Morse Fall Scale score of 20 B-Asymmetry of joints C-Slumped posture D-Hendrich II Fall Risk Model score of 7

A A-A Morse Fall Scale score of 20 is within the normal and expected range of 0 to 24, indicating the patient is not a fall risk. B-Asymmetry of joints, or joints that are not similar, is an unexpected finding; it is not an expected finding. C-Slumped posture is an unexpected finding, not an expected finding. Straight, erect posture is expected. D-A Hendrich II Fall Risk Model score of 7 indicates a high risk for falls; a normal, expected score is 0 to 4.

Which device would be most appropriate for a patient who has had surgery on a fractured femur and needs help repositioning in bed? A-Trapeze bar B-Mechanical lift C-Transfer board D-Friction-reducing sheet

A A-A trapeze bar would allow the patient to assist with repositioning, as the patient can grasp the bar to pull his or her own weight when repositioning. B-A mechanical lift allows nurses to transfer patients but would not be of any assistance to the patient when repositioning. C-A transfer board allows nurses to slide patients but would not be of any assistance for repositioning. D-A friction-reducing sheet allows nurses to reposition patients but would not be of any assistance to the patient when repositioning.

In which way do changes in fluid intake affect urinary elimination? A-Increased fluid intake results in increased urine output. B-Decreased fluid intake results in less concentrated urine. C-Increased fluid intake results in more concentrated urine. D-Increased fluid intake results in decreased urine output.

A A-Assuming normal heart and kidney function, increased fluid intake results in increased urine output. B-Decreased fluid intake results in more concentrated urine because there is a similar amount of solute in less water. C-Increased fluid intake results in less concentrated urine because there is a similar amount of solute in more water. D-Increased fluid intake results in increased, not decreased, urine output.

Which solution would the nurse select for a patient who is experiencing anorexia? A-Dietary measures for favorite foods B-Fall risk protocol C-Occupational therapist consult D-Mobility aids for ambulation

A A-Dietary measures for favorite foods are solutions used for anorexia. B-Fall risk protocol is a solution for Falls or Risk for Falls, not anorexia. C-A dietitian/nutritionist consult, not an occupational therapist consult, is a solution for anorexia. D-Mobility aids for ambulation are solutions for Impaired Mobility, not anorexia.

Which finding would be unexpected when the nurse is assessing for mobility issues? A-Joint crepitus B-Morse Fall Scale score of 18 C-Braden Scale score of 22 D-Straight posture

A A-Joint crepitus (air trapped under the skin that makes a crackling sound when palpated) is an unexpected finding. B-A Morse Fall Scale score of 18 is an expected finding; a normal score is 0 to 24. C-A Braden Scale score of 22 is an expected finding; a normal score is 19 or above. D-Straight posture is an expected finding, not an unexpected finding.

Which process is directly affected by nephron damage? A-Regulation of blood components B-Voluntary control of bladder emptying C-Internal urethral sphincter relaxation D-Neurologic awareness of bladder fullness

A A-Nephrons filter and regulate circulating blood, flushing undesirable components out of the body in urine. Nephron damage will affect the regulation of blood components. B-Nephrons filter and regulate components of the blood. Bladder control would not be directly affected by damage to the nephrons. However, indirectly, bladder control could potentially be compromised in a person with nephron damage if blood components such as electrolytes become so altered that the nervous system is also affected. C-Nephrons filter and regulate components of the blood. Internal urethral sphincter relaxation would not be directly affected by damage to the nephrons. However, indirectly, sphincter control could potentially be compromised in a person with nephron damage if blood components such as electrolytes become so altered that the nervous system is also affected. D-Nephrons filter and regulate components of the blood. Neurologic awareness of bladder fullness would not be directly affected by damage to the nephrons. However, indirectly, neurologic sensations could potentially be compromised in a person with nephron damage if blood components such as electrolytes become so altered that the nervous system is also affected.

The nurse recognizes which physiologic connection between Kegel exercises and improved urinary continence? A-Urethral sphincter tone increases. B-Intraabdominal pressure is reduced. C-Urine volume decreases. D-Ureter tone increases.

A A-Pelvic floor muscle exercises like Kegels tone the urinary and anal sphincters and support musculature, which improves voluntary control of urine flow. B-Kegel exercises may slightly increase, rather than decrease, intraabdominal pressure by creating a stronger pelvic floor to support the abdominal cavity. The stronger pelvic floor muscles developed through Kegels significantly support and enhance the function of the urethral sphincters, making the slight increase in intraabdominal pressure negligible in the overall benefit of Kegels to urinary continence. C-The amount of urine created by the kidneys is unaffected by pelvic floor muscle exercises such as Kegels. D-Kegel exercises target pelvic floor muscles located immediately below the bladder. The ureters, located above the bladder, are not directly affected by pelvic floor muscle training.

A urinalysis is performed for a patient with suspected dehydration. The nurse recognizes that which urinalysis result correlates with fluid volume deficit? A-Elevated specific gravity B-Positive urine proteins C-Positive urine glucose D-Positive red blood cells

A A-Specific gravity measures urine concentration, which reflects hydration status. A high specific gravity occurs with dehydration. B-Protein in urine is not a cue specifically related to dehydration. Protein levels increase with nephron injury but may also increase with vigorous exercise and pregnancy. C-Glucose in urine is not a cue specifically related to hydration level. Urine glucose levels may increase with poorly controlled diabetes and kidney injury. D-The presence of red blood cells in the urine is not an expected finding at any hydration level. Red blood cells indicate damage or trauma somewhere in the urinary system.

Which action would the nurse take first when assisting a patient who has been in bed for several days after surgery to transfer from the bed to the chair? A-Allow the patient to dangle. B-Stand the patient up with assistance. C-Transfer the patient with a slide board. D-Place the transfer belt after the patient stands.

A A-The first action the nurse would take to assist the patient to transfer is to allow the patient to dangle. B-Although this is an appropriate action to take, it is not the first step. Another step is required before standing with assistance. C-Transfer with a slide board would only be necessary if it is determined that the patient is unable to stand. D-The transfer belt would be placed before, not after, the patient stands.

Which overall mobility goal would the nurse select for a patient on bed rest? A-Prevent complications of immobility B-Maintain activity levels C-Promote oxygen content level D-Relieve constipation

A A-The overall goal for a patient on bed rest is to prevent complications of immobility. B-Because the patient is on bed rest, the goal to maintain activity levels is not beneficial; the goal would be to return to previous level of functioning. C-Although promoting oxygen content level is important, it is not the overall mobility goal for a patient on bed rest. D-Although relieving constipation is appropriate for a patient with constipation, the patient has no cues to suggest constipation.

Which action would the nurse take for a patient on bed rest who is concerned about developing constipation? A-Increase the patient's dietary fiber and fluid intake. B-Complete the Braden Scale assessment tool. C-Increase the frequency of passive range-of-motion exercises. D-Administer enoxaparin prophylactically.

A A-The patient's dietary fiber and fluid intake would be increased to prevent constipation in the immobile patient. B-Completing the Braden Scale assessment would identify if the patient is prone to pressure injuries but does not prevent constipation. C-Increasing the frequency of passive range-of-motion exercises would not be enough to prevent constipation due to immobility. Passive range-of-motion exercises maintain the joints. D-Enoxaparin is administered prophylactically to prevent deep vein thrombosis, not constipation. Laxatives, stool softeners, and enemas are given for constipation.

The nurse recognizes the following cues during assessment of a patient: urinary frequency, urgency, cloudy urine, and dysuria. Which urinary problem typically includes all of these cues? A-Urinary tract infection (UTI) B-Urinary incontinence C-Polyuria D-Kidney failure

A A-UTI is associated with all of the four cues recognized: urinary frequency, urgency, cloudy urine, and dysuria. B-Urinary incontinence is loss of bladder control. Urinary incontinence may include frequency and urgency but does not include cloudy urine and dysuria. C-Polyuria is excessive urine output. Polyuria may include frequency and possibly urgency because of large volumes of urine being excreted but does not include cloudy urine and dysuria. D-Kidney failure is recognized by fluid, electrolyte, acid-base, and waste imbalances, and decreased urine output. Cues such as urinary frequency, urgency, and dysuria are uncommon in kidney failure. Cloudy urine is possible with kidney failure because the kidneys fail to filter molecules effectively.

Which cues would alert the nurse to develop a hypothesis of Risk for Impaired Skin Integrity for a patient? Select all that apply. A-Braden Scale score of 16 B-Inability to move or turn C-Braden Scale score of 20 D-Pulse oximetry of 95% E-Dyspnea on exertion

A, B A-A Braden Scale score below 19 is a cue for the hypothesis Risk for Impaired Skin Integrity. B-Inability to move or turn is a cue for the hypothesis Risk for Impaired Skin Integrity. C-A Braden Scale score above 19 is high and indicates the patient is not at risk for impaired skin integrity. D-A pulse oximetry reading of 95% is normal and is not a cue for the hypothesis Risk for Impaired Skin Integrity. E-Dyspnea on exertion is a cue for Activity Intolerance, not Risk for Impaired Skin Integrity.

Which musculoskeletal diseases are more prevalent in the older adult population? Select all that apply. A-Osteoporosis B-Osteoarthritis C-Cerebral palsy D-Spina bifida E-Muscular dystrophy

A, B A-Osteoporosis is a disease in which bones deteriorate and is prevalent in the older adult population. B-Osteoarthritis causes cartilage breakdown and is prevalent in the older adult population. C-Cerebral palsy is a developmental muscle disorder in children, not older adults. D-Spina bifida is a genetic bone disorder that occurs in infants, not older adults. E-Muscular dystrophy is a genetic disorder that occurs in very young children, not older adults.

Which evaluative cues indicate the patient with a Risk for Deep Vein Thrombosis is deteriorating? Select all that apply. A-Experiences a pulmonary embolus B-Has dusky toes C-Has coagulation laboratory results that indicate the patient is clotting too fast D-States the sequential compression device pressure is maintained at 40 mm Hg E-Experiences intact skin with no abnormalities in the lower leg

A, B, C A-A pulmonary embolus indicates the patient is declining/deteriorating because the clot developed, broke free, and traveled to the lung. B-Dusky toes indicate the patient is deteriorating/declining because this cue indicates circulation is impaired. C-A patient who is clotting too fast is deteriorating/declining because the patient with Risk for Deep Vein Thrombosis should have laboratory results that indicate the patient takes longer to clot. D-The pressure is maintained between 35 to 55 mm Hg to be effective. E-Experiencing intact skin with no abnormalities in the lower leg indicates the patient's status has remained unchanged.

In which ways does pregnancy alter urinary elimination? Select all that apply. A-Bladder compression B-Increased urine output C-Increased urinary frequency D-Constriction of ureteral sphincters E-Decreased urinary frequency

A, B, C A-Bladder compression during pregnancy results from increased abdominal tone and pressure from the fetus. B-Pregnancy causes increased renal workload and urine output because of a significant increase in circulating blood volume. C-Increased urinary frequency during pregnancy occurs from compression of the bladder and increased urine output related to increased circulatory volume. D-The urethral sphincters relax rather than constrict during pregnancy because of the release of the hormone relaxin. E-Increased, not decreased, urinary frequency occurs during pregnancy as a result of compression of the bladder and increased urine output related to increased circulatory volume.

When providing care to patients, which safety and body mechanic aspects would the nurse consider to prevent injury to him- or herself and the patient? Select all that apply. A-Leave top side rails up. B-Bend at the knees. C-Carry weight close to the body. D-Use mechanical lift equipment. E-Relax pelvic muscles.

A, B, C, D A-Leaving the top side rails up allows patients to self-position and is a safety action the nurse would implement. B-Bending at the knees maintains the center of gravity and lets leg muscles do the lifting; it is a body mechanics action the nurse would implement. C-Carrying weight close to the body places the weight in the same plane as the lifter and near the center of gravity for balance; it is a body mechanics action the nurse would implement. D-Using mechanical lifts is a safe action to implement when moving patients. E-The nurse would tighten pelvic muscles, not relax them, to engage the core.

Cloudy urine is noted by the nurse during inspection of a urine sample. The nurse knows that this unexpected finding may occur with the presence of which substances in the urine? Select all that apply. A-Bacteria B-Mucus C-White blood cells D-Sperm E-Urobilin

A, B, C, D, A-When cloudy urine is noted, the nurse considers the presence of bacteria, especially if the patient has other symptoms of a urinary tract infection (UTI). B-Mucus is an unexpected finding that may cause cloudy urine. Mucus may be present in the urine when urinary tract tissue is inflamed. C-The presence of white blood cells in the urine may cause the urine to appear cloudy. White blood cells may be present in the urine if there is a UTI. D-Sperm in the urine may cause the urine to appear cloudy. Sperm are an unexpected finding in a correctly collected urine sample. E-Urobilin is a yellow pigment molecule found in the urine that gives it the distinctive yellow color. Urobilin affects urine color, not clarity.

Which instructions about respiratory and range-of-motion measures would the nurse share with a patient who has limited mobility? Select all that apply. A-Use the incentive spirometer 5 to 12 times every 1 to 2 hours. B-Deep breathe 10 times every hour. C-Cough two to three times every 2 hours. D-Perform range-of-motion exercises at least five to six times each day. E-Move each joint three to five times during range-of-motion exercises.

A, B, C, E A-The incentive spirometer is used 5 to 12 times every 1 to 2 hours to promote deep breathing and expansion of the lungs. B-Deep breathing is performed 10 times every hour to prevent pneumonia and atelectasis. C-Coughing is performed two to three times every 2 hours to promote pulmonary health. D-Range-of-motion exercises are performed at least two to four times each day, not five to six times each day. E-Each joint is moved three to five times during range-of-motion exercises to prevent complications from being stationary for a long period of time.

Which actions would the nurse take if the patient falls while ambulating in the hall? Select all that apply. A-Call for help. B-Assess the patient's physical and neurologic status. C-Notify charge nurse and primary health care provider. D-Leave the patient to go get help. E-Complete occurrence report.

A, B, C, E A-The nurse calls for help so he or she can stay with the patient. B-The nurse assesses the patient's physical and neurologic state to determine the extent of injuries. C-The charge nurse and primary health care provider are notified to determine the next course of action. D-The nurse does not leave the patient unattended; this is unsafe. E-Anytime an unusual event happens, an occurrence report is completed.

For which reasons is urinary specimen collection prescribed? Select all that apply. A-Establishing a diagnosis of urinary tract infection (UTI) B-Testing the urine for illicit drugs C-Culturing specific bacteria infecting the urinary tract D-Determining the location of pain in the urinary system E-Monitoring a condition such as impaired kidney function

A, B, C, E A-Urinalysis results indicate the presence of cues like bacteria, white blood cells, mucus, and blood in the urine, which enable the diagnosis of UTI. B-Certain urine analysis tests specifically test for illicit drugs, glucose, protein, pregnancy hormones, and other substances. C-A urine culture test identifies the specific bacteria infecting the urinary tract. D-Urine specimen analysis cannot determine the exact location of pain in the urinary system but can provide important information about the urinary system problem causing the pain. E-Urinalysis results indicate the absence or presence of protein in the urine, which can help monitor a condition such as impaired kidney function.

Patients on bed rest are likely at risk for which physiologic effects and conditions? Select all that apply. A-Increased venous return B-Decreased lung expansion C-Decreased cardiac workload D-Atelectasis E-Pneumonia

A, B, D, E A-Patients on bed rest are at risk for increased venous return due to supine positioning. B-Patients on bed rest are at risk for decreased lung expansion due to pressure on the rib cage. C-Patients on bed rest are at risk for increased, not decreased, cardiac workload as a result of increased blood flow to the heart. D-Patients on bed rest are at risk for atelectasis due to dependent positioning and limited lung expansion. E-Patients on bed rest are at risk for pneumonia due to pooling of secretions in the lungs.

The nurse recognizes which findings as normal in a urine specimen from a healthy adult? Select all that apply. A-Creatinine B-Electrolytes C-Bacteria D-Ammonia E-Parasites F-Urea

A, B, D, F A-Some creatinine is expected in normal urine from a healthy adult. Creatinine is a nitrogenous waste filtered and excreted by the kidneys. B-Some electrolytes are expected in normal urine. Kidneys regulate and excrete electrolytes such as sodium and potassium to maintain homeostasis in the body. C-Normal urine is free of microorganisms, including bacteria. The presence of bacteria in the urine indicates infection. D-Some ammonia is expected in normal urine from a healthy adult. Ammonia is a nitrogenous waste filtered and excreted by the kidneys. E-Normal urine is free of microorganisms, including parasites. The presence of parasites in the urine is rare but indicates urethral contamination or urinary tract infection such as schistosomiasis. F-Some urea is expected in normal urine from a healthy adult. Urea is a nitrogenous waste filtered and excreted by the kidneys.

Which interventions would the nurse select for a patient who is on bed rest? Select all that apply. A-Have the patient shift weight every 15 minutes while awake. B-Have the unlicensed assistive personnel teach about the importance of mobility. C-Reduce hallway light at night. Apply a pressure-relief ankle-foot orthotic (PRAFO) boot. D-Turn patient every 4 hours.

A, C, D A-Teaching patients with some mobility to shift their position every 15 minutes while awake is recommended. B-Nurses cannot delegate patient teaching about mobility to unlicensed assistive personnel. Teaching is the responsibility of the registered nurse. C-The hallway light should be reduced at night for patients on bed rest to assist with restful sleep and maintain a normal sleep-wake cycle. D-A PRAFO boot keeps heels protected by relieving pressure off heels. E-The nurse turns the patient every 2 hours, not every 4 hours.

Which outcomes and solutions would the nurse choose for a patient with a hypothesis of Constipation? Select all that apply. A-Patient will have a soft stool daily. B-Patient will state three favorite foods within 6 hours. C-Ambulation, if possible D-Dietary measures E-Mobility aids

A, C, D A-The nurse would choose having a soft stool daily as an outcome for a patient with Constipation. B-Having the patient state three favorite foods within 6 hours is an outcome for anorexia, not for Constipation. C-The nurse would choose ambulation, if possible, for a patient with Constipation to stimulate peristalsis. D-The nurse would choose dietary measures for a patient with Constipation. E-The nurse would choose mobility aids as a solution for Impaired Mobility, not for Constipation.

Which hypotheses would the nurse develop for a patient post surgery for hip replacement who is receiving opioid pain medication while the patient's spouse is in the room? Select all that apply. A-Impaired Mobility B-Social Isolation C-Risk for Deep Vein Thrombosis D-Risk for Constipation E-Activity Intolerance

A, C, D A-The patient is post surgery for hip replacement, making Impaired Mobility a hypothesis for this patient. B-Social Isolation is not a hypothesis for this patient because a spouse is in the room. C-The patient had hip surgery, making Risk for Deep Vein Thrombosis a hypothesis for this patient. D-The patient is taking opioid pain medication, making Risk for Constipation a hypothesis for this patient. E-Activity Intolerance is not a hypothesis for this patient at this time because there are no cues for this hypothesis, such as increased heart rate and oxygen requirements when performing tasks.

A patient newly diagnosed with kidney disease is learning about basic kidney functions during a patient education session. Which statements would the nurse include? Select all that apply. A-The kidneys regulate electrolytes and fluid in the blood. B-Kidney function does not affect blood pressure. C-The kidneys help maintain the body's red blood cell count. D-The kidneys help regulate blood pH. E-The kidneys synthesize the active form of vitamin K.

A, C, D A-Electrolyte and fluid regulation are primary functions of the kidneys. This happens through filtration, reabsorption, and secretion. B-The kidneys help regulate blood pressure through fluid and electrolyte balancing, as well as secretion of hormones related to blood pressure regulation. C-Erythropoietin is a hormone produced by the kidneys that is necessary for formation of red blood cells. D-The kidneys regulate acid-base balance of the body (pH balance) by reabsorption of bicarbonate (buffer) and excretion of hydrogen ions (acid). E-The kidneys synthesize the biologically active form of vitamin D, which is a hormone for regulation of calcium and phosphorus. Vitamin K is obtained through the diet; good sources include kale and other green leafy vegetables.

Which cues support the hypothesis of Risk for Urinary Infection? Select all that apply. A-Impaired perineal hygiene practices related to immobility B-Urinalysis positive for bacteria in urine C-History of urinary tract infections (UTIs) D-Urinary retention E-Lack of knowledge of UTI prevention practices

A, C, D, E A-Impaired perineal hygiene practices place a patient at risk for a UTI because of increased risk of bacteria entering the urinary meatus. B-Urinalysis positive for bacteria in the urine indicates a current UTI rather than the risk for a UTI. C-History of UTI is a risk factor for development of a future UTI, so this supports the hypothesis. D-Urinary retention causes stagnation of the urine in the bladder, which increases risk of bacteria colonizing the urinary tract. Urinary retention supports the hypothesis. E-Lack of knowledge of UTI prevention practices is a risk factor for UTI development.

Which alterations in urinary function are typical with certain surgical and diagnostic procedures? Select all that apply. A-Temporary urine retention with anesthesia B-Temporary urine incontinence with anesthesia C-Changes in urine color with procedures causing bleeding D-Increased urine concentration and decreased volume after procedures that include intravenous fluids E-Urinary retention with procedures causing urethral swelling

A, C, E A-Anesthesia effects can dull awareness of the need to urinate, causing urinary retention. B-Anesthesia more typically causes temporary urine retention rather than incontinence. C-If the procedure involving the urinary tract causes bleeding, it is often noticed as pink or red urine. D-Administration of intravenous fluids during a procedure would likely decrease, not increase, urine concentration, and increase, not decrease, volume. E-Tissue damage of or near a ureter during a procedure can cause swelling, which may obstruct the ureter, causing urine retention.

Which safety measures would the nurse implement for a patient who is a fall risk? Select all that apply. A-Use a low bed. B-Place in a room away from the nurses' station for quietness. C-Raise all four side rails. D-Frequently orient the patient. E-Place floor mats beside the bed.

A, D, E A-The nurse would use a low bed to decrease the distance if a patient falls. B-The nurse would place the patient in a room near the nurses' station, not far away from it. The patient needs to be close for safety reasons. C-Raising all four side rails is considered a restraint and is to be avoided. D-The nurse would frequently orient the patient who is at risk for falls to promote safety by familiarizing the patient to the environment, date, and time. E-The nurse would place floor mats beside the bed to cushion a possible fall.

Which effects can occur with cerebellar damage related to traumatic brain injury? Select all that apply. A-Poor balance B-Abnormal formation of the spinal cord C-Ability to move joints D-Lack of sensors in the inner ear E-Uncoordinated movement

A, E A-The cerebellum is responsible for equilibrium and, if damaged, would likely cause poor balance. B-Spina bifida would cause abnormal formation of the spinal cord, not cerebellar damage. C-Impairment or injury of any component of the musculoskeletal system affects the body's ability to move joints, not damage to the cerebellum. D-Sensors in the inner ear are affected by cerebral damage, not by cerebellar damage. E-Coordination is controlled by the cerebellum, and cerebellar damage would likely cause uncoordinated movement.

Which equipment would the nurse use to collect a nonsterile urine sample from an ambulatory hospitalized female patient with limited manual dexterity? A-Bedside commode B-Urine hat C-Urine collection cup D-Bedpan

B A-A bedside commode is not an ideal equipment choice for specimen collection for an ambulatory patient. Bedside commodes are used for patients with limited ambulatory ability. B-A urine hat is ideal for collecting a nonsterile urine sample from an ambulatory hospitalized patient with limited manual dexterity. A urine hat is placed in the front of the patient's toilet before voiding. C-A urine collection cup is not an ideal equipment choice for collecting a nonsterile urine sample from this patient with limited manual dexterity. D-The preferred toileting method for ambulatory patients is the use of a regular toilet. Obtaining a sample using a bedpan would be excessively difficult and uncomfortable for the patient.

Which ambulation aid would the nurse suggest for a patient who has a history of falls, is displaying generalized weakness, and requires some assistance with ambulation? A-Cane B-Walker C-Crutches D-Trochanter roll

B A-A cane would not provide enough support for this patient because of the generalized weakness. B-A walker would provide the patient with support to prevent falls and provides a wide base of support. C-Crutches would not be a good choice for this patient because the patient has a history of falls and has generalized weakness. It takes strength to use crutches. D-A trochanter roll is used for hip patients before and after surgery to prevent the hip from externally rotating; it does not help a patient ambulate.

In which area would the nurse place a pillow for a patient in the supine position? A-Between the legs B-Under the calves C-Between the arms D-Under the scapula

B A-A pillow is placed between the legs when the patient is positioned in the side-lying position, not the supine position. B-When a patient is in the supine position a pillow is placed under the calves to alleviate pressure off the heels, preventing pressure injuries. C-A pillow is placed between the arms when the patient is positioned in the side-lying position, not the supine position. D-Proper positioning of patients does not include positioning a pillow under the patient's scapula when in the supine position.

Which patient situation is a medical emergency? A-Deep vein thrombosis B-Pulmonary embolus C-Stage 3 pressure injury D-Urinary tract infection

B A-Although a deep vein thrombosis can lead to a pulmonary embolus, a deep vein thrombosis is not a medical emergency because it is still attached to the vein. B-A patient with a pulmonary embolus is having a medical emergency because the condition is life-threatening. C-Although a patient with a Stage 3 pressure injury has significant tissue damage, it is not a medical emergency. D-Although a patient with a urinary tract infection may have pain, it is not a medical emergency.

The nurse is planning a short presentation for unit nurses that will include cultural aspects of urinary elimination. Which information would the nurse include? A-Urination is generally considered a public matter to people in American culture. Privacy during toileting varies culturally. B-Culture influences the decision to seek help for problems with urinary elimination. C-Most cultures are accepting of nursing care delivered by a nurse of either sex. D-Cultural background generally is not a priority issue in hospitalized patients.

B A-As a culture, Americans view urination as a private, rather than a public, matter. B-Cultural influences may cause a delay in treatment or may prevent a person from seeking help with a problem involving urinary elimination. C-Some cultures view care by a person of the opposite sex as unacceptable, particularly with respect to toileting needs. This must be taken into consideration when planning patient care. D-A person's culture should always be taken into consideration. The plan of care should be adjusted to meet the needs of the patient and family members whenever possible.

Which condition would likely result in right-sided hemiplegia? A-Right-sided brain injury B-Left-sided brain injury C-Lower spinal cord trauma D-Upper spinal cord trauma

B A-Brain injury to the right side results in left-sided hemiplegia, not right-sided hemiplegia. B-Left-sided brain injury results in right-sided hemiparesis or hemiplegia because the motor fibers in the brain affect the opposite side of the body. C-Paraplegia, not right-sided hemiplegia, is commonly associated with lower spinal cord trauma. D-Quadriplegia and breathing difficulties, not right-sided hemiplegia, are associated with upper spinal cord trauma.

The nurse provides education about fluid intake to a patient worried about recurrent urinary tract infections (UTIs). Which statement by the patient indicates that teaching was successful? A-"I plan to drink 1.5 to 2 liters of fluid every day." B-"High fluid intake flushes out my urinary system and reduces my chances of getting a UTI." C-"I drink a lot of coffee, so taking in enough fluids will not be a problem for me." D-"I will equally divide up my fluid intake for morning, afternoon, and night."

B A-In adult patients with a history of UTI, the recommended fluid intake is 2 to 2.5 liters of fluid per day, assuming normal heart and kidney function. B-Increased fluid intake increases volume and frequency of urination, which helps prevent urinary stagnation and bacteria colonization, preventing UTI. Increased fluid intake also helps prevent the formation of renal calculi. C-Caffeine should be limited in patients with a history of UTI because of its diuretic (dehydrating) effect and possible irritation of the bladder. D-To allow for uninterrupted sleep (prevent nocturia), fluid intake should be minimized within 2 hours of bedtime.

During assessment of a pregnant patient, the nurse recognizes the cues of urinary frequency and small volume urine leakage as supportive of the hypothesis of Urinary Incontinence. Knowledge of which physiologic process provides the rationale for this hypothesis? A-The prostate enlarges with age. B-A hormone causes relaxation of urethral sphincters. C-Urine output increases during pregnancy. D-Excess fluid intake results in less concentrated urine.

B A-The knowledge that the male prostate enlarges with age does not relate to Urinary Incontinence in a pregnant patient. B-The nurse knows that the hormone relaxin is released during pregnancy to allow for pelvic joint relaxation, which facilitates the passage of the baby at birth. This same hormone causes the relaxation of the urethral sphincters, contributing to Urinary Incontinence. C-The knowledge that urine output increases during pregnancy supports a hypothesis of altered urinary elimination pattern (more frequent urination) rather than Urinary Incontinence. It does not provide a rationale for why incontinence may occur during pregnancy. D-The knowledge that excess fluid intake results in less concentrated urine does not relate to Urinary Incontinence in a pregnant patient.

In which position would the nurse place the patient to perform coughing and deep breathing? A-Dorsal recumbent B-Fowler's C-Side-lying D-Sim's

B A-The nurse would not use the dorsal recumbent position to cough and deep breathe; dorsal recumbent is lying supine with knees bent. B-The patient must be upright (Fowler's position) to perform coughing and deep breathing to allow full expansion of the lungs. C-The nurse would not use the side-lying position to cough and deep breathe; side-lying would allow only limited chest expansion. D-The nurse would not use Sim's position to cough and deep breathe; Sim's position is lying on the left side with the right knee pulled slighter higher than in the side-lying position.

Which instruction would the nurse share with the patient about coughing techniques? A-Fully inhale between coughs. B-Take two deep breaths in and out to start. C-Inhale through the nose as deeply as possible. D-Exhale slowly through the spirometer's mouthpiece.

B A-The patient is instructed not to fully inhale between coughs. B-Taking two deep breaths in and out is part of the instructions for teaching coughing techniques. C-Inhaling through the nose as deeply as possible is part of the instruction for teaching deep-breathing exercises, not coughing techniques. D-Exhaling slowly through the spirometer's mouthpiece is not part of the instructions for teaching coughing techniques, nor is it for teaching incentive spirometer. The patient exhales by removing the mouthpiece.

The nurse caring for a patient with a major urethral obstruction and urinary retention anticipates a prescription for which type of catheter? A-Condom B-Suprapubic C-Foley D-Triple-lumen Foley with bladder irrigation

B A-The use of a condom catheter would not be expected in this situation because the urinary obstruction would prevent urine outflow through the urethra. With a condom catheter, urine exits the body through the urethra and collects in the condom drainage bag. B-Suprapubic catheters pass through the abdomen, not the urethra, into the bladder. This is a useful approach for patients with major urethral problems such as a urethral obstruction, benign prostatic hyperplasia, or prostate cancer. C-The use of a regular Foley catheter would not be expected in this situation because the major urethral obstruction would prevent the insertion of the catheter through the urethra. D-The use of a triple-lumen Foley catheter with bladder irrigation would not be expected in this situation because the major urethral obstruction would prevent the insertion of the catheter through the urethra, and there is no indication of the need for bladder irrigation. Bladder irrigation is used to instill sterile fluids into the bladder, rinse the bladder of clots after surgical procedures, or keep the catheter free of clots, none of which are needed in this case.

Which interview question about the urinary system focuses on the patient's symptoms? A-Has anyone in your family ever had kidney problems? B-Do you have difficulty starting your flow of urine? C-Have you ever had a urinary tract infection? D-How much coffee do you drink per day?

B A-This question focuses on the patient's health history rather than recent or current urinary symptoms. Family health history can include relevant cues, but it is not a symptom. B-This question focuses on the patient's current symptoms by investigating current urinary elimination patterns and problems. C-This question focuses on the patient's health history rather than recent or current urinary symptoms. Historical patterns can be relevant cues but are not symptoms. D-This question focuses on the patient's current diet. While coffee intake may be related to a current urinary problem, it is not a symptom.

Which rationale would the nurse recognize for placing a patient in the high-Fowler position to facilitate urination in a bedpan? A-Produces contraction of perineal muscles B-Increases intraabdominal pressure C-Maintains medical asepsis D-Stimulates urge to urinate

B A-This type of positioning does not cause contraction of perineal muscles. A cold bedpan can cause contraction of perineal muscles. B-The high-Fowler position increases intraabdominal pressure and helps voiding. C-Cleaning the bedpan, not positioning the patient, maintains medical asepsis. D-Positioning of the bedpan does not stimulate the urge to void. Strategies such as turning on running water may stimulate the urge to urinate.

Which actions would the nurse take for a patient who is immobile? Select all that apply. A-Encourage at least 1500 mL of fluid daily. B-Suggest drinking at least 2000 mL during a 24-hour period. C-Encourage passive range-of-motion exercises. D-Place high-top tennis shoes on feet. E-Reposition at least once every 8 hours.

B, C, D A-The nurse would encourage 2000 mL, not 1500 mL, of fluid daily. B-The nurse would encourage the patient to drink at least 2000 mL in a 24-hour period. C-Range-of-motion exercises must be done to prevent complications from being stationary for a long period of time. D-High-top tennis shoes can be used to prevent foot drop. E-Repositioning is performed at least every 2 hours, not every 8 hours.

Which conditions are general risk factors for developing urinary incontinence? Select all that apply. A-Urinary tract obstruction B-Older age C-Immobility D-Pregnancy E-Kidney disease

B, C, D A-Urinary tract obstruction is a more common risk factor for urinary retention than urinary incontinence. B-The muscle tone of the bladder, urethra, and pelvic floor decreases with age, increasing the risk of urinary incontinence. C-Immobility is a significant risk factor for developing incontinence. Functional incontinence refers to a lack of urine control related to a physical limitation rather than any abnormality of the urinary tract. The physical limitation delays the person's ability to use the toilet and incontinence occurs. D-Pregnancy is a risk factor for urinary incontinence because of increased abdominal pressure and relaxation of the urethral sphincters secondary to the pregnancy hormone relaxin. E-Kidney disease may contribute to anuria or oliguria but not typically incontinence.

For which reasons is urinary catheterization prescribed? Select all that apply. A-Visualizing the interior of the bladder B-Collecting a urine sample C-Measuring residual urine D-Intermittently emptying the bladder E-Continuously emptying the bladder

B, C, D, E A-Cystoscopy, not catheterization, is the insertion of a lighted device into the bladder through the urethra to visualize the interior of the bladder. B-Catheterization is performed to obtain urine samples. C-Catheterization is performed to determine the amount of urine remaining in the bladder after the patient urinates, which is known as residual urine. D-Catheterization is sometimes performed on an intermittent schedule to empty the patient's bladder when a patient cannot urinate or in the case of paralysis. E-Catheterization is performed to continuously empty the patient's bladder when a patient cannot urinate, such as after a surgery or during complete bedrest.

The nurse caring for an adult patient with a urine output of 350 mL in the past 24 hours is evaluating the previously selected hypothesis of Impaired Kidney Function. Which new cues in the patient chart indicate a need to begin the clinical judgment process again and create a new hypothesis? Select all that apply. A-Urinalysis negative for bacteria B-Serum creatinine level within expected range C-Specific gravity of urine above the expected range D-Urinalysis negative for protein E-Serum blood urea nitrogen (BUN)/creatinine ratio within expected range

B, C, D, E A-Urinalysis negative for bacteria neither supports nor contradicts a hypothesis of Impaired Kidney Function. It is a normal finding that does not suggest a different hypothesis. B-Serum creatinine within the expected range does not support a hypothesis of Impaired Kidney Function and suggests the need to create a new hypothesis. Serum creatinine levels are typically elevated with impaired kidney function. C-Higher-than-expected specific gravity of urine neither specifically supports nor contradicts a hypothesis of Impaired Kidney Function, although typically specific gravity of urine is decreased in kidney function. Elevated specific gravity indicates concentrated urine, which is common with dehydration. A better hypothesis for this cue in combination with other cues presented (low urine output) would be Dehydration or fluid volume deficit rather than Impaired Kidney Function. D-Urinalysis negative for protein does not support a hypothesis of Impaired Kidney Function and suggests the need to create a new hypothesis. The presence of protein in urine suggests impaired kidney function. E-Serum BUN/creatinine ratio within the expected range does not support a hypothesis of Impaired Kidney Function and suggests the need to create a new hypothesis. High BUN/creatinine ratios occur suddenly in acute kidney failure.

Which solutions would the nurse generate for a hypothesis of Disturbed Body Image due to urine leakage and odor management? Select all that apply. A-Allowing adequate time for voiding B-Assistance with leakage management products C-Patient education about personal hygiene practices to minimize odor D-Patient education about urinary tract infection (UTI) prevention E-Individual and small group emotional support

B, C, E A-Allowing adequate time for voiding is a solution the nurse would generate for a patient with Urinary Retention or hesitancy, not Disturbed Body Image. B-Assistance with leakage management products is a solution the nurse would generate for a patient with Disturbed Body Image related to odor management. This solution could help prevent visible signs of incontinence and reduce odors that might be embarrassing for the patient. C-Patient education about personal hygiene practices to minimize odor is a solution the nurse would generate for a patient with Disturbed Body Image. Reducing odors may help the patient minimize embarrassment and gain self-confidence. D-Patient education about UTI prevention is a solution the nurse would generate for a patient at risk for UTI, not Disturbed Body Image. E-Support is a solution the nurse would generate for a patient with Disturbed Body Image. Individual support can help patients cope with the emotional burden of their physical condition. Small support group participation can help provide insight and support from individuals with similar problems.

Which interventions would the nurse implement for a patient with lower extremity Paralysis? Select all that apply. A-Apply oxygen. B-Turn every 2 hours. C-Arrange for a special bed. D-Use a gait belt for transfers and ambulation. E-Perform range-of-motion (ROM) exercises at least two times per day.

B, C, E A-Applying oxygen is an intervention for a patient with Activity Intolerance, not Paralysis. B-The patient with lower extremity Paralysis is turned every 2 hours to prevent skin breakdown. C-Patients with Paralysis need a special bed to prevent pressure injuries and to make turning easier. D-The patient is paralyzed and will not be able to transfer or ambulate. E-ROM exercises are needed to maintain joint and muscle movements.

Which parameters would the nurse assess to determine if a urinary tract infection (UTI) has developed? Select all that apply. A-Peripheral pulses B-Chills C-Urinary frequency D-Serum albumin levels E-Presence of dysuria

B, C, E A-Assessment of urinary elimination does not include assessment of peripheral pulses, because this information would not contribute to the identification of a urinary tract infection. B-Chills are a cue for a urinary tract infection. C-Assessment of urinary elimination would include the frequency of urination to determine a UTI. D-Serum albumin levels relate to anorexia and nutritional issues, not a UTI. E-Pain upon urination (dysuria) is a cue for a UTI.

Which cues support the hypothesis of Urinary Retention? Select all that apply. A-Hematuria B-Bladder palpable after voiding C-Urinary frequency D-Unexpected urinalysis result: positive for bacteria E-Diagnosis of prostate enlargement

B, C, E A-Hematuria (presence of blood in the urine) does not specifically support the hypothesis of Urinary Retention, as retention is unlikely to cause bleeding. Hematuria is more commonly associated with urinary tract trauma or infection. B-A palpable bladder after voiding suggests inadequate emptying of the bladder and supports the hypothesis of Urinary Retention. C-Urinary frequency supports the hypothesis of Urinary Retention because a continually near-full bladder frequently stimulates the urge to void. D-Urinalysis positive for bacteria is a cue that supports a hypothesis of urinary infection, not Urinary Retention. Urinary retention is a risk factor for urinary infection. E-Prostate enlargement may cause urinary retention because of the obstruction of the ureter by the enlarged prostate. This cue supports the hypothesis of Urinary Retention.

Which functions are the primary responsibilities of the cardiopulmonary system in relation to movement? Select all that apply. A-Control posture and gait B-Circulate blood throughout the body C-Provide framework for movement D-Supply tissues with oxygen and nutrients E-Provide essential fluids for the body

B, D, E A-The nervous system, not the cardiopulmonary system, controls posture and gait. B-The cardiopulmonary system circulates blood throughout the body. C-The musculoskeletal system, not the cardiopulmonary system, provides the framework for movement. D-The cardiopulmonary system supplies tissues with oxygen and nutrients. E-The cardiopulmonary system supplies fluids that are essential for the body.

Which types of impairments are expected with a cerebrovascular accident that occurred on the right side of the brain? Select all that apply. A-Right-sided paralysis B-Left-sided hemiparesis C-Lower body paralysis D-Inability to move all four extremities E-Left-sided hemiplegia

B, E A-Left-sided brain cerebrovascular accident, not right side of the brain, could cause right-sided paralysis. B-Right-sided brain cerebrovascular accident would likely cause left-sided hemiparesis (weakness). C-Lower body paralysis is related to lower spinal cord trauma, not a cerebrovascular accident that occurred on the right side of the brain. D-Inability to move all four extremities is quadriplegia and occurs from an upper spinal cord trauma, not from a cerebrovascular accident that occurred on the right side of the brain. E-A cerebrovascular accident that occurred on the right side of the brain would likely cause left-sided hemiplegia (paralysis).

Which cues prompt the nurse to determine the patient with impaired mobility who needs a one-person assist is improving? Select all that apply. A-Needs a one-person assist to ambulate B-Needs no assistance to transfer C-Ambulates unassisted down the corridor and back D-Needs a two-person assist to walk to the bathroom E-Ambulates with no slips on the floor

B,C, E A-This cue indicates the person is unchanged; the patient needs a one-person assist, and the patient used a one-person assist to ambulate. B-Needing no assistance indicates the patient improved. The patient went from one-person assist to no-person assist. C-Ambulating without assistance indicates the patient is improving because he or she used to need a one-person assist. D-This cue indicates the patient is deteriorating. The patient went from a one-person assist to a two-person assist. E-Ambulating with no slips on the floor indicates the patient is improving. The patient did not need a one-person assist and did not slip.

Which action would the nurse take for an immobile patient who needs help maintaining a normal sleep-wake cycle? A-Encourage contact with family and friends. B-Provide a clock in the patient's room. C-Open the window blinds during the day. D-Allow access to the radio.

C A-Encouraging contact with family and friends assists with keeping the patient emotionally healthy and prevents social isolation, but it does not help maintain a normal sleep-wake cycle. B-Providing a clock in the patient's room helps with keeping the patient oriented to time, but it does not help maintain a normal sleep-wake cycle. C-Opening the window blinds during the day can assist the patient with maintaining a normal sleep-wake cycle. D-Allowing access to the radio helps prevent patient boredom and sensory deprivation, but it does not help maintain a normal sleep-wake cycle.

Which exercise benefit would the nurse likely emphasize to a patient who has limited mobility to help facilitate normal movement? A-Improves mood B-Minimizes joint flexibility C-Promotes muscle strength D-Stimulates bone reabsorption

C A-Exercise does improve mood, but this is not the primary aspect to emphasize to facilitate normal movement for a patient with impaired mobility. B-Exercise maintains, not minimizes, joint flexibility. C-Exercise promotes muscle strength and helps prevent the negative impacts of immobility. This is the most important aspect to emphasize in the discussion. D-Exercise decreases, not stimulates, bone reabsorption.

The UAP is assisting the nurse in the care of a patient with an indwelling urinary catheter. Which instruction would the nurse provide to the UAP to prevent urine from flowing back into the sterile bladder? A-Hang the urine collection bag on the patient's intravenous (IV) pole at waist height. B-Place the urine collection bag on the patient's mattress near his or her abdomen. C-Hang the patient's urine collection bag below the patient's mattress on a nonmovable part of the bed frame. D-Ask the patient to hold the urine collection bag at waist height while ambulating.

C A-Hanging the urine collection bag on the IV pole is incorrect as it would place the urine collection bag at or above the height of the patient's bladder, potentially allowing contaminated urine in the bag to flow back into the sterile bladder. B-Placing the urine collection bag on the patient's mattress is incorrect as it would place the urine collection bag at or above the height of the patient's bladder, potentially allowing contaminated urine in the bag to flow back into the sterile bladder. C-This action would keep the urine collection bag below the level of the bladder and prevent urine from flowing back into the bladder. D-Asking the patient to hold the urine collection bag at waist height while ambulating is incorrect as it would place the urine collection bag at or above the height of the patient's bladder, potentially allowing contaminated urine in the bag to flow back into the sterile bladder.

Which nutritional alteration is associated with immobility? A-Enhanced appetite B-Positive nitrogen balance C-Decreased basal metabolic rate D-Increased serum albumin levels

C A-Immobility is associated with a lack of appetite (anorexia), not enhanced appetite. B-Immobility is associated with a negative, not positive, nitrogen balance due to a breakdown of muscle protein. C-Immobility is associated with a decreased metabolic rate due to a diminished activity level. D-Immobility is associated with decreased, not increased, serum albumin levels due to catabolism and lack of protein intake.

Which action by the nurse initiates the physical assessment of a patient's mobility? A-Inquiring about the patient's health history B-Asking the patient questions C-Observing the patient D-Palpating the patient's joints

C A-Inquiring about the patient's health history does not initiate the physical assessment; this occurs before the physical assessment. B-Asking the patient questions is a part of assessment, but this does not initiate the physical assessment. C-Observing the patient initiates the physical assessment of the patient's mobility; inspection is the first step in a physical assessment. D-Palpating the patient's joints occurs after, not before, inspection/observation of the patient.

Patient reports of shortness of breath and fatigue while performing activities of daily living are indicative of which alteration? A-Orthostatic hypotension B-Deep vein thrombosis C-Activity intolerance D-Cerebellar problems

C A-Orthostatic hypotension is associated with changes in vital signs. It is a sudden drop of blood pressure when the patient moves from a lying to sitting to standing position; it does not cause shortness of breath and fatigue. B-Cues for deep vein thrombosis include an area of warmth, redness, swelling, or pain in an extremity, not shortness of breath and fatigue. C-Patient reports of shortness of breath and fatigue while performing activities of daily living are cues for activity intolerance. D-Cerebellar problems are associated with gait, posture, and balance disturbances, not shortness of breath and fatigue.

Which characteristic is typical of paresis? A-Lower body paralysis B-Complete loss of movement C-Impaired mobility and movement D-Weakness on one side of the body

C A-Paraplegia, not paresis, is lower body paralysis. B-Paralysis, not paresis, is complete loss of movement. C-Paresis is impaired mobility and movement. D-Weakness on one side of the body is characteristic of hemiparesis, not paresis.

Which response would the nurse make to an immobile patient who says, "I am just not hungry. I don't understand it. I am always hungry"? A-"Don't worry about it, every patient gets that way in the hospital." B-"Your loss of appetite is unusual; I will let your health care provider know." C-"You have been immobile for several days, which can decrease your metabolism and appetite." D-"Your lack of appetite is your body's way of telling you that bed rest interferes with your body's ability to digest food and not to eat too much."

C A-Telling a patient not to worry is nontherapeutic and belittles the patient's feelings; not every patient loses appetite while in the hospital. B-In this situation, the patient's loss of appetite is not that unusual, and the health care provider would not need to know unless the patient stops eating. C-Decreased activity decreases the body's basal metabolic rate and appetite. D-Immobility does not interfere with the ability to digest food; the patient needs to eat to prevent negative nitrogen balance.

The nurse provides education about urinary tract infection prevention self-care to a female patient. Which statement by the patient indicates further teaching is needed? A-"I should report any burning or pain when I urinate." B-"I need to make sure that I wipe myself from front to back after urinating." C-"I plan to take a warm bubble bath every evening to relax." D-"I will be sure to urinate and clean my urethral area after sex."

C A-The patient is correct in stating this. Burning or pain with urination suggests a urinary tract infection. B-The patient is correct in stating this. It is essential that females wipe from front to back to prevent cross- contamination of bacteria among the anus, the vagina, and the urethra. C-This statement indicates that further teaching is needed. Bubble baths and other potentially irritating chemicals should be avoided near the urethral meatus to reduce risk of irritation and infection. D-The patient is correct in stating this. Urinating and cleaning the urethral area immediately after sex help prevent urinary tract infections.

Enlargement of the prostate may directly affect which structure in the male urinary system? A-Kidney B-Ureter C-Urethra D-Urinary meatus

C A-The prostate is located in the lower part of the urinary system, not in the upper part; therefore enlargement of the prostate does not directly affect the kidney(s). B-The prostate is located in the lower part of the urinary system below the bladder, not in the upper part; therefore enlargement of the prostate does not directly affect the ureter(s). C-The male urethra passes through the central part of the male prostate. Enlargement of the prostate can directly cause obstruction of the urethra and disruption of urine flow. D-The urinary meatus in a male is located at the distal end of the urethra (at the end of the penis). The prostate surrounds the central part of the male urethra, which is located internally. Enlargement of the prostate does not directly affect the urinary meatus.

A nurse is caring for a patient with continuous urinary bladder irrigation. Which cue indicates a complication of urinary bladder irrigation and warrants further investigation and action by the nurse? A-Pale yellow, dilute catheter output B-Catheter output greater than bladder irrigation input C-Decrease in hourly catheter output D-Mild smell to urine

C A-This is an expected finding. Urine mixes with bladder irrigation fluid, causing the catheter output fluid to appear pale yellow and diluted. B-This is an expected finding. During continuous bladder irrigation, the catheter output equals the amount of bladder irrigation fluid input plus the patient's urine output. C-A decrease in hourly catheter output indicates a complication and warrants immediate further investigation by the nurse. Possible causes include an obstruction such as a blood or mucus clot in the drainage tubing, a decrease in patient urine output, or an obstruction of the bladder irrigation input system. D-Urine has a mild smell influenced by diet and medications. A mild smell is an expected finding.

List steps of normal micturition in the correct order. A-The brain registers a message of urgency. B-The bladder muscle contracts and the urethral sphincters relax. C-Nerve endings in the bladder are stimulated by distention. D-Urine flows out of the body through the urinary meatus.

C, A, B, D

Which outcomes would the nurse develop for a patient experiencing weakness, cerebellum injury, and orthostatic hypotension? Select all that apply. A-Patient will not lose muscle mass during hospital stay. B-Patient will ambulate with no assistance. C-Patient will not fall during hospitalization. D-Patient will not injure self during hospital stay. E-Patient will not experience a pulmonary embolus during hospitalization.

C, D A-Not losing muscle mass is an outcome for paralysis; this patient is at risk for falls. B-This patient is at risk for falls, so ambulating with no assistance is unsafe. C-The nurse would develop this outcome for the patient. The patient is experiencing cues that indicate a risk for falls. D-The nurse would develop this outcome for the patient. The patient is experiencing cues that indicate a risk for falls. E-This outcome is for a patient at risk for deep vein thrombosis; this patient is at risk for falls.

Which solutions would the nurse choose for a patient experiencing dyspnea on exertion, oxygen saturation level of 86%, and pulse of 112 beats/min when grooming? Select all that apply. A-Sequential compression devices B-Turning C-Physical therapist consult D-Special equipment for hygiene needs E-Exercises for strengthening

C, D, E A-Sequential compression devices are solutions for deep vein thrombosis, not for dyspnea on exertion, low oxygen saturation levels, and increased pulse rate, which are cues for Activity Intolerance. B-Turning is indicated for Impaired Skin Integrity, not for dyspnea on exertion, low oxygen saturation levels, and increased pulse rate, which are cues for Activity Intolerance. C-This patient is displaying cues for Activity Intolerance, and physical therapy is needed. D-This patient is displaying cues for Activity Intolerance and requires special equipment for hygiene (grooming) needs. E-This patient is displaying cues for Activity Intolerance and needs exercises for strengthening.

Which cues gathered during the nursing assessment are directly relevant to the hypothesis of Urinary Retention? Select all that apply. A-History of hypertension B-Patient report of one mile of walking daily C-Patient report of feeling unable to fully empty his bladder D-Bladder distention with palpation E-Patient report of discomfort during bladder palpation F-Temperature of 37.1°C (98.9°F)

C, D, E A-The patient's history of hypertension is not directly relevant to the hypothesis of Urinary Retention as hypertension does not directly affect urinary retention. B-The patient's report of walking one mile daily is not directly relevant to the hypothesis of Urinary Retention as physical activity does not directly affect urinary retention. C-The patient's report of feeling unable to fully empty his bladder is directly relevant to the hypothesis as urinary retention is the impaired ability to fully empty the bladder. D-Bladder distention is directly relevant to the hypothesis as urinary retention causes bladder fullness and distention. E-The patient's report of discomfort during bladder palpation is directly relevant to the hypothesis as urinary retention causes bladder fullness and a full bladder can be tender when palpated. F-The patient's normal temperature suggests the absence of a related hypothesis of systemic urinary infection, but it is not directly relevant to the hypothesis of Urinary Retention.

To which other member of a multidisciplinary team would the nurse delegate the task of moving an immobile patient to maintain skin integrity? A-Dietitian B-Primary health care provider C-Occupational therapist D-Unlicensed assistive personnel

D A-A dietitian manages a patient's nutritional concerns related to mobility issues, not moving an immobile patient. B-The primary health care provider is charged with the patient's medical care and does not usually assist with direct bedside care. C-An occupational therapist assists the patient with activities of daily living but does not turn an immobile patient. D-Unlicensed assistive personnel provide hands-on care for patients as directed by the nurse. Nurses delegate turning to unlicensed assistive personnel.

For which hypothesis would the nurse develop an outcome that the patient will exercise leg muscles at least once a shift? A-Paralysis B-Social Isolation C-Impaired Skin Integrity D-Weakness

D A-Although a goal for Paralysis would focus on not losing muscle mass, the patient cannot exercise muscles if paralyzed; thus, this goal is not realistic for the paralyzed patient. B-A goal for Social Isolation involves the patient interacting with someone, not exercising muscles at least once a shift. C-A goal for Impaired Skin Integrity involves protecting the patient's skin, not exercising leg muscles. D-The goal of exercising muscles at least once a shift is associated with the hypothesis of Weakness.

A female patient on strict bedrest requires the use of a bedpan. Which position facilitates urination for this patient? A-Knees and hips fully extended B-Head elevated 30 degrees C-Head elevated nearly upright and legs and knees extended straight D-Head elevated nearly upright and hips and knees flexed

D A-In this position the patient is lying completely flat. This does not simulate a natural voiding position. B-This position would make it difficult for a female patient to urinate because she would be close to lying flat, which does not increase intraabdominal pressure and is not a natural voiding position. C-Elevating the head increases intraabdominal pressure, but extending the patient's legs and knees straight does not simulate a relaxed, natural voiding position. D-In women, sitting upright with flexed hips and knees increases the intraabdominal pressure and simulates the normal voiding position, which facilitates urination.

Which anatomic structure serves the purpose of connecting bones to cartilage? A-Muscles B-Tendons C-Joints D-Ligaments

D A-Muscles provide stability and facilitate posture and movement; they do not connect bones to cartilage. B-Tendons connect muscles to bones, not bones to cartilage. C-Joints are the areas that allow movement of the bones; joints do not connect bones to cartilage. D-Ligaments connect bones to cartilage.

Which hypothesis would the nurse select for a patient who develops redness, warmth, and slight swelling in the right lower leg from bed rest? A-Paralysis B-Weakness C-Activity Intolerance D-Risk for Deep Vein Thrombosis

D A-Paralysis is inability to move extremities, not redness, warmth, and slight swelling in the leg. B-Weakness is indicated by a loss of muscle strength, not redness, warmth, and slight swelling in the leg. C-Activity Intolerance is indicated by an inability to carry out tasks with low oxygen saturation, not redness, warmth, and slight swelling in the leg. D-The patient is displaying signs of possible deep vein thrombosis; bed rest places the patient at Risk for Deep Vein Thrombosis, as well as redness, warmth, and slight swelling in the leg.

Which potential cause of kidney failure is prerenal? A-Renal toxicity related to illicit drugs B-Damage to the nephrons C-Urethral stricture D-Low cardiac output

D A-Renal toxicity related to illicit drug use occurs inside the kidney, categorizing it as intrarenal, not prerenal. B-Nephron damage is categorized as an intrarenal, not prerenal, condition because nephrons are located inside the kidneys. C-Obstructions to urine outflow such as urethral stricture are physiologically located after the kidneys in the urinary system, making them postrenal, not prerenal. D-Prerenal problems occur before reaching the kidneys. A good example is low cardiac output, which can damage the kidney by creating insufficient blood flow to the kidney for adequate function.

Which nervous system factor is likely associated with difficulty breathing? A-Right-sided brain injury B-Left-sided brain injury C-Lower spinal cord trauma D-Cervical spinal cord trauma

D A-Right-sided brain injury is not associated with difficulty breathing. Brain injury to the right side results in left-sided hemiparesis or hemiplegia and can be caused by traumatic brain injury or stroke. B-Left-sided brain injury does not cause difficulty breathing. Left-sided brain injury results in right-sided hemiparesis or hemiplegia and can be caused by stroke or traumatic brain injury. C-Paraplegia, not difficulty breathing, is commonly associated with lower spinal cord trauma. D-Breathing difficulties are associated with cervical (neck) spinal cord trauma.

Which evaluative cue alerts the nurse that a patient with Activity Intolerance is improving? A-Ambulates 15 feet with shortness of breath B-Has a heart rate of 110 beats/min when ambulating C-Brushes hair while sitting in chair with assistance D-Has a pulse oximetry reading of 94% when standing to brush teeth

D A-Shortness of breath while ambulating indicates the patient with Activity Intolerance is declining or staying the same depending upon baseline data, but it does not indicate improvement. B-A pulse rate above 100 beats/min when performing an activity (ambulating) indicates the patient with Activity Intolerance is declining, not improving. C-Requiring assistance brushing hair while sitting indicates the patient with Activity Intolerance is either declining or staying unchanged depending on baseline data, but it would not indicate improvement. D-A pulse oximetry reading above 90% when brushing teeth indicates the patient with Activity Intolerance is improving because the patient is performing activities of daily living without adverse effects.

Which SMART (specific, measurable, assignable, relevant, time-based) outcomes would the nurse develop for a patient who is light-headed and fatigued and has feeble handgrip with reduced bone density? Select all that apply. A-Patient's pulse oximetry will be above 90% during an activity. B-Patient will have intact skin throughout hospital stay. C-Patient will exercise arm and leg muscles. D-Patient will brush teeth after breakfast with one person assisting. E-Patient will exercise joints at least twice per shift.

D, E A-Obtaining pulse oximetry above 90% during an activity is an outcome for activity intolerance, not weakness; this patient has weakness. B-Having intact skin throughout hospital stay is an outcome for skin integrity, not weakness; this patient has weakness. C-Although exercising arm and leg muscles is related to weakness, this outcome is not written as a SMART goal; the time frame and how often the patient will exercise muscles are missing. D-The nurse would develop this outcome for the patient. This is an outcome for weakness, which the patient has, and would indicate handgrip is getting stronger. E-The nurse would develop this outcome for the patient. This is an outcome for weakness, which the patient has, and would help the patient with strengthening of joints and muscles.

D A-The image does not depict assessment of rotation. In rotation, the nurse turns the head from side to side. B-The image does not depict assessment of extension. In extension, the nurse moves the head to a neutral position in normal alignment. C-The image does not depict assessment of hyperextension. In hyperextension, the nurse moves the head backward. D-The nurse is assessing lateral flexion, bending the head and neck to each side.

Which movement is the nurse assessing in this image? A-Rotation B-Extension C-Hyperextension D-Lateral flexion