Chapter 27, 33, 36 Book Questions
An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints?
Identifying his door with his picture and a balloon
A nurse is evaluating a patient following the adminis tration of an enteral feeding . Which findings are normal and are criteria that indicate patient tolerance to the feeding ? Select all that apply . a Absence of nausea , vomiting b . Weight gain c. Bowel sounds within normal range d . Large amount of gastric residue e. Absence of diarrhea and constipation f . Slight abdominal pain and distention
A C E
The nurse moves a person's arm from an outstretched position to a position at the side of the patient's body . What is the term used to describe this type of body movement ?
Adduction
A nurse nutritionist is collecting assessment data for a patient who complains of " tiredness " and appears malnourished . The nurse orders tests for hemoglobin and hematocrit . What condition might these tests confirm ?
Anemia
A nurse is caring for patients with alterations in mobility . Which nursing interventions are recommended for these patients ? a . For increased cardiac workload , instruct the patient to lie in the prone position . b . For ineffective breathing patterns , encourage shallow breathing and coughing . c . For orthostatic hypotension , have the patient sleep sitting up or in an elevated position . d . For impaired physical mobility , perform ROM exercises every 2 hours . e . For constipation , increase fluid intake and roughage . f . For impaired skin integrity , reposition the patient in correct alignment at least every 1 to 2 hours .
C E F
Which exercises would the nurse recommend when planning isometric exercise for a patient ? a . Jogging b . Range - of - motion exercises c. Contracting the quadriceps d Kegel exercises e . Bicycling f. Contracting and releasing the gluteal muscles
C, D, F
T or F? In the older adult population one out of five falls causes a serious injuries such as broken bones or a head injury, with fall being the most common cause of traumatic brain injuries.
True
True or dalse? Body dynamics are the efficient use of the body as a machine and as a means of locomotion .
True
True or false? It is a nerve impulse that stimulates muscles to contract.
True
True or false? Ligaments are tough , fibrous bands that bind joints together and connect bones and cartilage.
True
A nurse is teaching a patient how to walk with mended guidelines for this crutches Which teaching points are recom activity ? a Keep elbows close to sides . b. Prevent crutches from getting closer than 3 inches to the feet . c . Use the four - point gait for patients who may bear weight on both feet . d . Use the swing - to gait for patients who may bear weight on one foot . e . Use the two - point gait for patients who may not bear weight on either foot f . When climbing stairs , advance the unaffected leg past the weight on the crutches then advance the crutches , then place affected leg and then the crutches .
A B C
A nurse is evaluating patients to determine their need for parenteral nutrition ( PN ) . Which patients would be the best candidates for this type of nutritional support ? a . A patient with irritable bowel syndrome who has intractable diarrhea b . A patient with celiac disease not absorbing nutrients from the GI tract c . A patient who is underweight and needs short - term nutritional support d . A patient who is comatose and needs long - term nutritional support e . A patient who has anorexia and refuses to take foods via the oral route f . A patient with burns who has not been able to eat adequately for 5 days
A B F
Which body system effects would the nurse state as occurring due to immobility ? a . Increased cardiac workload b . Increased depth of respiration c . Increased rate of respiration d . Decreased urinary stasis e . Increased risk for renal calculi f . Increased risk for electrolyte imbalance
A E F
Which patient would the nurse place in a protective prone position ?
A patient prone to hyperextension of the spine
What consideration should the nurse keep in mind regarding the use of side rails for a patient who is confused?
A person of small stature is at increased risk for injury from entrapment
A nurse is performing a safety assessment in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a patient for safety? A. A person with a history of falls is likely to fall again B. Some people are more prone to have accidents than others C. Fires are responsible for most hospital incidents D. Between 15-25% of falls result in fractures and soft tissue issues E. A medication regimen that include diuretics and analgesics place a person at risk for falls
A, B, E
A nurse is applying restraints to a confused patient who has threatened the safety of a roommate. Which actions would the nurse perform when properly applying restraints to a patient? A. Check facility policy for application of restraints and secure a health care provider order B. Choose the most restrictive type of device allowing for least amount of mobility C. Pad bony prominences D. Fasten the restraint to the side rail E. Remove the restraint at least every two hours or according to facility policy and patient need
A, C, E
A nurse is promoting body movements for a patient during range - of - motion exercises Which movements provide for flexion ? a Bending the hand or foot backward and forward b . Turning the sole of the foot toward the midline , then turning the sole of the foot outward C. Bending the leg and bringing the heel toward the back of the leg and then returning the leg to the straight position d . Curling the toes downward and then straightening them out e . Moving the head from side to side , thenbringing the chin toward each shoulder
A, C, E
The nurse is assessing an ambulatory patient for gait Which documentation describes this mobility status ?
Arms swing freely in alternation with legs .
A nurse is assessing a patient's mobility status . What data would the nurse document as nor mal findings ? a . Increased joint mobility b. Independent maintenance of correct align ment c . Scissors gait d . Head , shoulders , and hips aligned in bed e . Full range of motion f . Fasciculations
B D E
A nurse is teaching a patient about the benefi cial effects of exercise on his body . Which teaching point would the nurse include in the plan ? a . Exercise increases resting heart rate and blood pressure b. Exercise increases intestinal tone c. Exercise increases efficiency of metabolic system . d. Exercise increases blood flow to kidneys . e . Exercise decreases appetite . f . Exercise decreases rate of carbon dioxide excretion .
B, C, D
A nurse is teaching the RACE acronym to a student nurse as a guide for a fire safety plan. Which statements accurately reflect steps? A. R-Race to the front of the building to call for help B. R-Rescue anyone in immediate danger C. A-Activate the fire code system and notify appropriate person D. C-Check if the fire is contained or spreading E. C-Confine the fire by closing doors and windows F. E-Extinguish the fire with an appropriate fire extinguisher
B, C, E
The nurse caring for patients in a long term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? A. A patient who is older than 50 B. A patient who has fallen twice C. A patient who is taking antibiotics D. A patient who expresses postural hypotension E. A patient with nausea from chemotherapy F. A 70 year old who is transferred from LTC
B, D, F
A nurse orients an older adult to the safety features in her hospital room. What is a priority component of this admission routine?
Explain how to operate the call bell
A nurse is caring for a patient who is on bed rest fol lowing a spinal injury . In which position would the nurse place the patient's feet to prevent footdrop ?
Dorsiflexion
A nurse is promoting exercise and activities for an older adult patient . Which teaching point would be appropriate for this patient ?
Encourage the patient to warm up before beginning exercises and to cool down after exercising
A nurse should lift an object to be moved to reduce the energy needed to overcome the pull of gravity .
False
T or F? Asphyxiation may occur in any age group but the incidence is greatest among older adults.
False
T or F? For school age children, the focus of parental responsibility is on childproofing the environment.
False
True or false? The cerebral motor cortex integrates semivol untary movements such as walking , swim ming , and laughing.
False
ing . The nurse most appropriately assists him into pneumonia and is experiencing some difficulty breath A nurse is caring for a patient who is hospitalized with which position to promote maximal breathing in the thoracic cavity ?
Fowler's position
Which nursing diagnosis would be most appropriate for a patient with a body mass index ( BMI ) of 18 ?
Imbalanced Nutrition Less Than Body Requirements
Based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse's priority intervention to prevent trauma when caring for older adults in a nursing home?
Making sure patient rooms are decluttered
A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small - bore nasogastric tube . Fol lowing placement of the tube , which nursing action would the nurse initiate to ensure correct placement of the tube ?
Obtain an order for a radiograhic examination of the tube .
The nurse is assessing a patient who is bedridden. For which condition would the nurse consider this patient to be at risk?
Predisposition to renal caliculi
A patient who injured the spine in a motorcycle acci dent is receiving rehabilitation services in a short - term rehabilitation center . The nurse caring for the patient correctly tells the aide not to place the patient in which position ?
Prone
A school nurse is preparing a teaching session on safety for parents if school aged children. What would be an appropriate topic for this age group?
Providing drug, alcohol, and sexuality education
When a fire occurs in a patient's room, what would be the nurse's priority action?
Rescue the patient
A nurse is performing range - of - motion exer cises on a patient who is on bedrest . What would be the nurse's best action when the patient complains : " I'm just too tired to do these exercises today . "
Stop the exercises and reevaluate the nursing care plan .
A nurse is recommending aerobic exercise for a patient who is overweight . Which exercise might the nurse suggest ?
Swimming
A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?
The nurse details the client's response and the examination and treatment of the client after the incident
The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used?
The nurse ensures that two fingers can be inserted between the restraint and patient's ankle.
A nurse is filing a safety event report for a confused patient who fell when getting out of bed. What action is performed appropriately?
The nurse records the circumstances and effect on the patient in the medical record.
When a patient stands between the back legs of a walker , the walker should extend from the floor to the patient's hip joint; the patients elbows should hd flexed about 30 degrees
True
A nurse is assisting a patient from a bed to a wheelchair Which nursing action is appropriate ?
The nurse uses assistive devices when lifting more than 35 lb of patient weight .
Using proper ergonomics , which motions would the nurse make to move an object ?
The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stoop ing , reaching , lifting , or pulling
A nurse is assessing a patient who has been NPO prior to abdominal surgery . The patient is ordered a clear liquid diet for breakfast , to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced ?
The patient reports fullness and diarrhea after breakfast
Atelectasis is an incomplete expansion or col lapse of lung tissue .
True
In a gliding joint, the articular surfaces are flat; flexion-extension and abduction-adduction are permitted.
True
Rehabilitative exercises for knee or elbow injuries are examples of isokinetic exercises.
True
T or F? An example of a modifiable intrinsic fall risk factor is postural hypotension.
True
A patient has been admitted to the alcoholic referral unit in the local hospital . Based on an understanding of the effects of alcohol on the GI tract , which is a priority concern related to nutrition ?
Vitamin B malnutrition
A nurse is instructing a patient who is recovering from a stroke how to use a cane . Which step would the nurse include in the teaching plan for this patient ?
a . ) Support weight on stronger leg and cane and advance weaker foot forward .
A nurse is feeding an older adult patient who has dementia . Which intervention should the nurse perform to facilitate this process ?
a . Stroke the underside of the patient's chin to promote swallowing .
A nurse is caring for a newly placed gastrostomy tube of a postoperative patient . Which nursing action is performed correctly ?
a . The nurse dips a cotton - tipped applicator into sterile saline solution and gently cleans around the insertion site .
A patient who has COPD is refusing to eat . Which intervention would be most helpful in stimulating appetite in this patient ?
b . Encouraging food from home when possible .
A patient has a fractured left leg , which has been casted . Following teaching from the physical therapist for using crutches , the nurse reinforces which teaching point with the patient ?
b . Keep elbows close to the sides of the body .
A nurse is caring for a patient in a long - term care facil ity who has had two urinary tract infections in the past year related to immobility . Which finding would the nurse expect in this patient ?
b . Urinary stasis
A nurse is assisting a patient who is 2 days postopera tive from a cesarean section to sit in a chair . After assisting the patient to the side of the bed and to stand up , the patient's knees buckle and she tells the nurse she feels faint . What is the appropriate nursing action ?
c . Lower the patient back to the side of the bed and pivot her back into bed .
A nurse is feeding a patient who is experiencing dys phagia . Which nursing intervention would the nurse initiate for this patient ?
d . Provide a 30 - minute rest period prior to mealtime .
