Functional Ability
The volume of air inhaled and exhaled with each breath is termed which of the following?
Tidal volume
A client with right sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity?
Turn him regularly.
A client with end-stage dementia is admitted to the orthopedic unit after undergoing internal fixation of the right hip. How should the nurse manage the client's postoperative pain?
Administer analgesics around the clock.
A client is diagnosed with Alzheimer's disease. While assessing the client, the nurse notes that the client has trouble identifying objects such as a key and spoon. The nurse would document this as what?
Agnosia
Which of the following is not a secondary problem of functional ability? A. Disease B. Age C. Down's syndrome D. Trauma
C. Down's syndrome
An elderly client is becoming progressively confused due to Alzheimer's disease. The family can no longer manage the client at home due to wandering. Which of the following living arrangements could the nurse recommend?
Extended-care facility
The nurse is planning care with an older adult who is at risk for falling because of postural hypotension. Which intervention will be most effective in preventing falls in this client?
Instruct the client to sit, obtain balance, dangle legs, and rise slowly.
Which of the following is an inaccurate clinical manifestation of a fracture?
Lengthening
The nurse is caring for an adolescent who has been admitted several times with uncontrolled type 1 diabetes. The child is now stabilized and is preparing for discharge. Which of the following should be the priority focus for the nurse when conducting discharge teaching?
Management of the therapeutic regimen
Which of the following terms refers to failure of fragments of a fractured bone to heal together?
Nonunion
Older adults, who are more subject to falls, may fracture one or more ribs and be more susceptible to which of the following after a rib fracture?
Pneumonia
Within the acute care facility where you practice nursing, you have cared for hundreds of clients who have suffered neurologic deficits from various causes, including cerebrovascular accident and closed head injury. While caring for these clients, what was an important nursing goal that motivated you to offer the best care possible?
Prevent complications, which may interfere with recovering function.
During an assessment of a patient's functional health pattern, which question by the nurse directly addresses the patient's thyroid function?
"Do you experience fatigue even if you have slept a long time?"
A nurse is teaching an elderly client's family about the causes of mental impairment. The nurse sees that the teaching has been effective when the family says which of the following?
"Sundowning is a common problem of dementia."
A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate?
"The most common cause of dementia in the elderly is Alzheimer's disease."
The nurse observes that a client is very sad and dejected after a myocardial infarction. What is the best response to the statement, "Life will never be the same"?
"You're very concerned when you think about how this will change your life."
An 18-year-old is highly dependent on her parents and fears leaving home to attend college. Shortly before the fall semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits the woman to the psychiatric unit, where she is diagnosed with functional neurologic symptom disorder. She asks the nurse, "Why has this happened to me?" What is the nurse's best response?
"Your problem is real but, there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened."
The nurse is planning community education on the prevalence and incidence of disabilities in the United States. The nurse includes that according to the U.S. Census (2010), what percentage of people are diagnosed with a disability?
20
Which client is most likely to be at risk for drug dependence and difficulties with withdrawal?
A woman who has been taking lorazepam for several months after witnessing a traumatic motor vehicle accident
The two basic categories of functional ability are basic activities of daily living and instrumental activities of daily living. A. True B. False
A. True
A 76-year-old man is recovering from a myocardial infarction. In regards to his recovery, it is important for the nurse to
Address any questions about sexuality
The nurse identifies a nursing diagnosis of self-care deficit, bathing related to motor impairment and decreased cognitive function for a client with cerebral metastasis. Which outcome would the nurse most likely identify on this client's plan of care?
Client participates in daily hygiene activities with assitive devices.
A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize?
Depressed deep tendon reflexes
A graduate nurse is assigned to care for a client with an acute exacerbation of chronic obstructive pulmonary disease. The client also has Down syndrome. During the shift, the nurse discovers that the clent lives alone and holds a full-time job. Which type of disability would the nurse state the client has?
Developmental
This type of disability represents one that occurs any time from birth to 22 years and results in impairment of physical or mental health, cognition, speech, language, or self-care.
Developmental
A client who suffers an injury in a local high school hockey game presents with left shoulder pain. The client cannot move the left arm, and the left shoulder is lower than the right shoulder. The nurse recognizes the client most likely has a:
Dislocated shoulder
Through which mechanism is Duchenne muscular dystrophy acquired?
Heredity
A nurse is interviewing an elderly client who has experienced a drastic weight loss following a CVA (cerebrovascular accident). The client states, "I have trouble getting groceries since I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis?
Imbalanced nutrition: less than body requirements related to difficulty in procuring food
The client demonstrates stair climbing using a quad cane. What type of outcome is this an example of?
Psychomotor outcome
The nurse is assisting an elderly client with dementia to get dressed after morning care. Which statement would be most beneficial to the patient?
Put your arm in this sleeve.
What is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?
Regain orientation to time and place.
Which milestone would you expect an infant to accomplish by 8 months of age?
Sitting without support
The nurse is providing discharge instructions for a patient following laryngeal surgery. The nurse instructs the patient to avoid which of the following?
Swimming
The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?"The nurse is correct to instruct on the action of which system?
Sympathetic nervous system
Which of the following disorders is characterized by an increased autoantibody production?
Systemic lupus erythematosus (SLE)
A nurse refers an HIV-positive patient to a local support group. This is an example of what level of preventive care?
Tertiary
The nurse is caring for an infant who exhibits the above characteristics. When planning care, which would be the best long term client goal? (Child appears to have Down's in picture)
The client will reach his/her optimal level of functioning.
A 5-month-old infant being assessed was born at 32 weeks. The nurse doing the well-child check-up should compare the baby to what norms?
The development of a 3-month-old
A nurse is caring for a client with delirium. The nurse assesses the client's activities of daily living on a daily basis. What is the most likely reason for assessing these so frequently?
To assess for fluctuation in the client's capabilities
instrumental activities of daily living
complex skills needed for independent examples: meal preparation, shopping for food, doing laundry, housekeeping, transportation, and handling financial matters
The nurse is caring for an infant born to a mother who abused cocaine during her pregnancy. The nurse would likely notice that this infant:
cries when touched.
A woman with severe preeclampsia is receiving magnesium sulfate. The woman's serum magnesium level is 9.0 mEq/L. Which finding would the nurse most likely note?
diminished reflexes
When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:
elevate the head of the bed 90 degrees during meals.
A nurse is planning care for an elderly client with cognitive impairment who is still living at home. Which action should the nurse identify as a priority for safety in planning care for this client?
ensuring the removal of objects in the client's path that may cause him to trip
A nurse is caring for a veteran, who exhibits signs and symptoms of posttraumatic stress disorder (PTSD). Signs and symptoms of posttraumatic stress disorder include:
hyperalertness and sleep disturbances.
Which is a priority goal for the client with chronic obstructive pulmonary disease (COPD)?
maintaining functional ability
examples of basic activities of daily living
self-care activities that the patient must accomplish each day to meet personal needs examples: personal hygiene/bathing, dressing/grooming, feeding, and toileting
The nurse has been teaching the client about how to use a walker safely. The nurse knows the teaching has been effective when the client:
steps into the walker when walking.
Which goal is the most realistic for a client diagnosed with Parkinson's disease?
to maintain optimal body function
A nurse is caring for a woman who has just been diagnosed with uterine prolapse. Which symptoms may interfere with her daily activities? Select all that apply.
urinary frequency low back pain pelvic pressure
An elderly client had a thrombotic cerebrovascular accident and now has flaccid hemiplegia of the right side. When planning care for this client, the nurse understands that rehabilitation begins:
when the client is admitted to the hospital.
The nurse is a member of the multidisciplinary team in a large primary healthcare setting. The nurse understands that which healthcare team member is responsible for a client's swallow evaluation following a CVA (cerebral vascular accident)?
Speech pathologist
The nurse is working with a client with schizophrenia who has cognitive deficits. It is time for the client to get up and eat breakfast. Which statement by the nurse would be most effective in helping the client prepare for breakfast?
"First, wash your face and brush your teeth. Then put your clothes on."
The parent brings a child to the clinic after discharge from the hospital for Guillain-Barré syndrome. Which statement by the parent indicates that the discharge plan is being followed?
"I take her to the pool where she can exercise with other children."
The client has various sensory impairments associated with type 1 diabetes. The nurse determines that the client needs further instruction when the client says:
"I will avoid kitchen activities."
Which client exhibits the characteristics that are typical of the prodromal phase of schizophrenia?
A 20-year-old is experiencing a gradual decrease in the ability to concentrate, be productive, and sleep restfully.
All of the following are antecedents to functional ability except which: A. Developmental milestones B. Acquisition of learning skills C. Learning D. Capacity to perform
D. Capacity to perform
Which of the following is not a domain of functional ability? A. Psychological domain B. Social domain C. Cognitive domain D. Spatial domain
D. Spatial domain
The nurse is educating the spouse of a client with a somatic symptom disorder about how to best help the client. Which strategy should the nurse suggest?
Empathize about physical discomfort but encourage independence.
The nurse is planning care for a client admitted for vascular dementia. Which action is most appropriate in assisting the client with activities of daily living?
Encourage client to complete as many activities as possible, and provide ample time to complete them.
A client with a subdural hematoma needs a feeding tube inserted due to inadequate swallowing ability. How would the nurse best explain this to the family?
Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia.
A patient who is blind is said to be experiencing:
Sensory deficit
A client is having an increasing amount of difficulty caring for herself in her home alone. She states to the nurse, "I need more help. What am I going to do?" It would be important for the nurse to have the
Social worker visit to discuss care options
A college student who was the victim of an attempted sexual assault has sought care due to anxiety that is affecting every aspect of the client's life. Which characteristic of the client's situation and the client's anxiety would suggest a diagnosis of posttraumatic stress disorder (PTSD) rather than acute stress disorder?
The attack took place several months ago, and the client's anxiety has been continuous.
A nurse is caring for a child with attention deficit hyperactivity disorder (ADHD). The child is given medication and behavioral modification therapy to treat the condition. Which outcome achieved within 3 days would indicate successful therapy?
The child is able to complete assignments or tasks with assistance.
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should:
stay with the client and encourage him to eat.
