Unit 8 - end of chapter Q/A

Five minutes after the client's first postoperative exercise, the client's vital signs have not yet returned to baseline. Which is an appropriate nursing diagnosis? 1.Activity Intolerance. 2.Risk for Activity Intolerance. 3.Impaired Physical Mobility. 4.Risk for Disuse Syndrome.

1.Activity Intolerance. Rationale: Vital signs that do not return to baseline 5 minutes after exercising indicate intolerance of exercise at that time. This is a real problem, not "at risk for," as in option 2. There is no evidence that the client requires assistance (impaired mobility, option 3), or is immobile (disuse syndrome, option 4).

Performance of activities of daily living (ADLs) and active range of motion (ROM) exercises can be accomplished simultaneously as illustrated by which of the following? Select all that apply. 1.Elbow flexion with eating and bathing. 2.Elbow extension with shaving and eating. 3.Wrist hyperextension with writing. 4.Thumb ROM with eating and writing. 5.Hip flexion with walking.

1.Elbow flexion with eating and bathing. 4.Thumb ROM with eating and writing. 5.Hip flexion with walking. Rationale: Eating and bathing will flex the elbow joint, and grasping and manipulating utensils to eat and write will take the thumb through its normal ROM. Walking flexes the hip. Shaving and eating require elbow flexion, not extension (option 2). Writing brings the fingers toward the inner aspect of the forearm, thus flexing the wrist joint (option 3).

Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply. 1.Increase muscle tone and improve circulation. 2.Increase blood pressure. 3.Increase muscle mass and strength. 4.Decrease heart rate and cardiac output. 5.Maintain joint range of motion.

1.Increase muscle tone and improve circulation. 3.Increase muscle mass and strength. 5.Maintain joint range of motion. Rationale: Isotonic exercise increases muscle tone, mass, and strength, maintains joint flexibility, and improves circulation. During isotonic exercise, both heart rate and cardiac output quicken to increase blood flow to all parts of the body (option 4). Little or no change in blood pressure occurs (option 2).

When assessing a client's gait, which does the nurse look for and encourage? 1.The spine rotates, initiating locomotion. 2.Gaze is slightly downward. 3.Toes strike the ground before the heel. 4.Arm on the same side as the swing-through foot moves forward at the same time.

1.The spine rotates, initiating locomotion. Rationale: Normal gait involves a level gaze, an initial rotation beginning in the spine, heel strike with follow-through to the toes, and opposite arm and leg swinging forward.

The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action? 1.Heart rate 86 2.Reddened area on sacrum 3.Nonproductive cough 4.Urine output of 50 mL/hour

2.Reddened area on sacrum Rationale: The reddened area of the skin can lead to skin breakdown. The other options are within normal limits.

To increase stability during client transfer, the nurse increases the base of support by performing which action? 1.Leaning slightly backward. 2.Spacing the feet farther apart. 3.Tensing the abdominal muscles. 4.Bending the knees.

2.Spacing the feet farther apart. Rationale: A key word in the question is base, and the feet provide this foundation. Leaning backward actually decreases balance (option 1), and tensing abdominal muscles alone (option 3) or bending the knees (option 4) does not affect the base of support.

Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching? 1."Going up, the strong leg goes first, then the weaker leg with both crutches." 2."Going down, the weaker leg goes first with both crutches, then the strong leg." 3."The weaker leg always goes first with both crutches." 4."A cane or single crutch may be used instead of both crutches if held on the weaker side."

3."The weaker leg always goes first with both crutches." Rationale: Although the crutches (or cane) are always used along with the weaker leg, the weaker leg should go down the stairs first. The stronger leg can support the body as the weaker leg moves forward. All of the other statements are correct.

A client weighs 250 pounds and needs to be transferred from the bed to a chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate? 1."Using proper body mechanics will prevent you from injuring yourself." 2."You are physically fit and at lesser risk for injury when transferring the client." 3."Use the mechanical lift and another person to transfer the client from the bed to the chair." 4."Use the back belt to avoid hurting your back."

3."Use the mechanical lift and another person to transfer the client from the bed to the chair." Rationale: It is prudent for nurses to understand and use proper body mechanics at all times to decrease risk, while keeping in mind the importance of assistive devices and help from other staff. While it is generally accepted that proper body mechanics alone will not prevent injury, many work settings do not yet have "no manual lift" and "no solo lift" policies and resources in place.

The client is ambulating for the first time after surgery. The client tells the nurse, "I feel faint." Which is the best action by the nurse? 1.Find another nurse for help. 2.Return the client to her room as quickly as possible. 3.Tell the client to take rapid, shallow breaths. 4.Assist the client to a nearby chair.

4.Assist the client to a nearby chair. Rationale: Placing the client in a safe position is the best maneuver. Leaving the client creates unsafe conditions because the client may faint before being able to return to her room (options 1 and 2). Rapid, shallow breathing (hyperventilation) may increase the dizziness (option 3).

A nurse is teaching a client about active range-of-motion (ROM) exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following? 1.Exercises past the point of resistance. 2.Performs each exercise one time. 3.Performs each series of exercises once a day. 4.Uses the same sequence during each exercise session.

4.Uses the same sequence during each exercise session. Rationale: When the client performs the movements systematically, using the same sequence during each session, the nurse can evaluate that the teaching was understood and is successful. When performing active ROM the client should exercise to the point of slight resistance, but never past that point of resistance in order to prevent further injury (option 1). The client should perform each exercise at least three times, not just once (option 2). The client should perform each series of exercises twice daily, not just once per day (option 3).