(PrepU) Functional Ability
A nurse is evaluating the progress of a client with chronic fatigue syndrome. Which statement by the client indicates successful symptom management?
"My schedule includes yoga and a weekly club meeting." Chronic fatigue syndrome is a disorder of persistent unrelieved fatigue lasting longer than 6 months. It is managed through pacing activities, emotional support, an exercise program to regain strength, and structured activity to allow resumption of activities of daily living.
According to the U.S. Census (2010), what percentage of people are diagnosed with a disability?
20 The U.S. Census, last conducted in 2010, indicates that about 20% of people have a disability and 10% have a severe disability. The other numerical values are incorrect.
A hospitalized 7-year-old is recovering from a head injury. Occupational therapy has been ordered to assist the child in regaining eye/hand coordination. If the child cannot master this skill, what feelings may arise?
A feeling of inferiority Children who are unsuccessful in completing activities during the school-age phase, whether from physical, social, or cognitive disadvantages, develop a feeling of inferiority.
You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis?
A progressive, bilateral loss of hearing A progressive, bilateral loss of hearing is the characteristic symptom of otosclerosis. Tinnitus appears as the loss of hearing progresses; it is especially noticeable at night, when surroundings are quiet, and may be quite distressing to the client. The eardrum appears pinkish-orange from structural changes in the middle ear. The client often describes a history of having had a recent upper respiratory infection in case of otitis media, not otosclerosis.
A 76-year-old female client visits the primary care doctor for an annual physical. The client's spouse recently died and the client lives by themselves with no adult children nearby. The client's appearance is clean but disheveled and the client has lost weight since the last visit 3 months ago. The nurse is concerned about the client being able to care for themselves at home. Complete the following sentence by choosing from the lists of options. Based on the client's findings and history, the client is at risk for ______A______ and the nurse should ______B______.
A: self-neglect B: complete the Lawson Scale for Instrumental Activities of Daily Living (IADLs) The client is exhibiting early signs of self-neglect, which will likely become worse over time. The nurse should complete the Lawson Scale for Instrumental Activities of Daily Living (IADLs) to determine if the client is able to live independently and to determine what social services the client may benefit from, such as meals delivered to their home. There is no indication that the client is at risk for Alzheimer disease. Although a disheveled appearance and weight loss could be signs of elder abuse in other scenarios, there is no indication that elder abuse is occurring in this situation and the findings more directly point to self-neglect. The Katz Activities of Daily Living index assesses a client's ability to perform activities of daily living (ADLs) such as bathing, eating, toileting, and dressing independently; while there may be a concern about eating enough due the client's weight loss, the client's appearance is clean, and the main concern is whether they can live independently. The nurse should not consult a social worker before assessing the client, using the Lawson Scale.
A nurse is providing psycho-education to a client who has been admitted to the inpatient mental health unit for a manic episode. In order to ensure the teaching is effective, the nurse must first determine which regarding the client?
Ability to concentrate and process the information To best assure successful outcomes related to client education of an individual experiencing a manic episode, the nurse's initial assessment is focused on the client's ability to concentrate and process the information.
A 42-year-old client reports increasing difficulty reading the labels on packages. He states that he has to continually hold it further and further away from his face in order to see the type clearly. Which eye disorder is this client most likely experiencing?
An age-related change in accommodation. The term presbyopia refers to a decrease in accommodation that occurs because of aging. This is unrelated to UV light exposure and diabetes does not normally cause a specific decline in accommodation. Presbyopia is not the result of changes in retinal function.
A client with gastric cancer is scheduled to undergo a Billroth II procedure. The client's spouse asks how much of the client's stomach will be removed. What would be the most accurate response from the nurse?
Approximately 75% The Billroth II is a wide resection that involves removing approximately 75% of the stomach and decreases the possibility of lymph node spread or metastatic recurrence.
For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?
Attaching braces or splints to each foot and leg Attaching braces or splints to each foot and leg prevents foot drop (a lower leg contracture) by supporting the feet in proper alignment. Putting slippers on the client's feet can't prevent foot drop because slippers are too soft to support the ankle joints. Crossing the ankles every 2 hours is contraindicated because it can cause excess pressure and damage veins, promoting thrombus formation. Placing hand rolls on the balls of each foot doesn't prevent contractures because hand rolls are too soft to support and hold the feet in proper alignment.
The nurse is caring for a client in the hospital with chronic heart failure who has marked limitations in his physical activity. The client is comfortable when resting in the bed or chair, but when ambulating in the room or hall, the client becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)?
Class III (Moderate) This client is comfortable at rest, but has "marked limitations" on physical activity. Merely walking down the hall causes fatigue and dyspnea. Therefore, this client is in Class III (moderate). With Class I (mild), ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea, and the client does not experience any limitation of activity. With Class II (mild), the client is comfortable at rest, but the ordinary physical activity of daily living results in fatigue, heart palpitations, or dyspnea; the client's activity is only slightly limited. With Class IV (severe), symptoms of cardiac insufficiency occur at rest, and discomfort increases if any physical activity is undertaken.
A nurse is caring for an older adult who has experienced damage to the frontal lobe after an automobile accident. The nurse anticipates that the client will have difficulty with which function?
Concept formation Working memory is an important aspect of frontal lobe function. The nurse can anticipate that the client will have difficulty with concept formation, insight, judgment, and reasoning. The temporal lobes contain the primary auditory and olfactory areas. Wernicke's area, located at the posterior aspect of the superior temporal gyrus, is primarily responsible for receptive speech.
A nurse is preparing to medicate an older adult client with an opioid analgesic. Which information will the nurse obtain first to decide about administering the medication?
Determining if the client is able to communicate pain verbally or nonverbally The nurse should ascertain the level and intensity of the client's pain. The family is not able to give adequate information about the client's pain. Taking the client's vital signs can be of value as a baseline. A client may share indication of pain other than verbally, such as a grimace or moaning. Each client may exhibit different behaviors when in pain. This is not a reliable indicator as to a client's pain level.
Colles fracture occurs in which area?
Distal radius A Colles fracture is a fracture of the distal radius (wrist). It is usually the result of a fall on an open, dorsiflexed hand.
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?
Dyspnea on exertion Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of arterial blood and respiratory symptoms. Many clients notice unusual fatigue with activity. Some find exertional dyspnea to be the first symptom. An increase in urinary output may be seen later as fluid accumulates. Hypotension would be a later sign of decompensating heart failure as well as tachycardia.
The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention?
Encourage the client to provide as much self-care as possible. The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.
A client who is legally blind had orthopedic surgery 3 days ago and wants to urinate. She is using a walker for ambulation. It would be best for the nurse to
Guide the client's hand to the armrest on the bedside commode prior to the client sitting on the commode. When the nurse offers seating to a client with low vision or blindness, the nurse should place the client's hand on the arm of the chair. This helps to guide the client in sitting. Though placing the bedside commode next to the bed is a good idea, it is not the best choice. The nurse will encourage the client to use the bedside commode, not the bedpan, for better emptying of the urinary bladder.
The nurse is caring for a client admitted to home care after total knee replacement surgery. Which home health care goal for the client will be the nurse's priority?
Help the client regain mobility and independence The essential components of home health care include the client, the family, and health care professionals from various disciplines. The priority goal of nursing care in the home after knee surgery is to help the client regain mobility and independence. Respiratory function is not typically affected by knee replacement surgery; if there were concerns, such as pneumonia, they would be addressed while the client is still in the hospital. Reducing the risk of infection is not a specific goal of home health care. The client may have bowel complaints related to pain medication use, but the priority goal is regaining mobility and independence.
The nurse is performing an admission assessment to a rehabilitation unit. Which assessment tools should she utilize to determine an alert client's normal activities, perceived level of activity tolerance, or level of fatigue?
Human Activity Profile The Human Activity Profile (HAP) is a paper and pencil test in which participants describe their normal activities, their perceived level of activity tolerance, or their level of fatigue. The Fatigue Severity Scale only assesses the fatigue and not the normal activities or tolerance. The ergometry and the Mini-Mental Examination are not directly related to assessing fatigue.
Which type of fracture occurs when a bone fragment is driven into another bone fragment?
Impacted An impacted fracture is one in which a bone fragment is driven into another bone fragment. An oblique fracture occurs at an angle across the bone. A spiral fracture is one that twists around the shaft of the bone. A transverse fracture is one that is straight across the bone shaft.
A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?
Ischial tuberosity For a client who sits for prolonged periods, such as in a wheelchair, the ischial tuberosity would be highly susceptible to pressure ulcer development. Areas such as the greater trochanter and lateral malleolus would be susceptible for clients lying on their side. The scapula would be considered a high risk area for clients lying on their back.
The diagnosis of multiple sclerosis is based on which test?
Magnetic resonance imaging (MRI) The diagnosis of MS is based on the presence of multiple plaques in the central nervous system observed on MRI. Electrophoresis of CSF identifies the presence of oligoclonal banding. Evoked potential studies can help define the extent of the disease process and monitor changes. Neuropsychological testing may be indicated to assess cognitive impairment.
Which classic symptom will the nurse assess for to detect the development of plantar fasciitis?
Morning heel pain Plantar fasciitis is characterized by heel pain.
Which of the following disorders is characterized by an increased autoantibody production?
Systemic lupus erythematosus (SLE) SLE is an immunoregulatory disturbance that results in increased autoantibody production. Scleroderma occurs initially in the skin but also occurs in blood vessels, major organs, and body systems, potentially resulting in death. Rheumatoid arthritis results from an autoimmune response in the synovial tissue, with damage taking place in body joints. In polymyalgia rheumatic, immunoglobulin is deposited in the walls of inflamed temporal arteries.
A patient was recently diagnosed with a cortical cataract in his left eye. His wife asks the nurse for information about his diagnosis. The nurse explains that:
The cataract should have little or no effect on his vision. A cortical cataract involves the anterior, posterior, or equatorial cortex of the lens. A cataract in the equator or periphery of the cortex does not interfere with the passage of light through the center of the lens and has little effect on vision. Cortical cataracts progress at a highly variable rate. Vision is worse in very bright light.
During a mental status exam, what conclusion should the nurse draw when the client is able to complete fewer than half of tasks accurately?
The client's cognitive deficit is significant The fewer tasks the client competes accurately, the greater the cognitive deficit. None of the other options provide a plausible conclusion.
The nurse is performing an assessment on a 8-month-old infant. The infant's medical history notes that he was born at 32 weeks' gestation. The infant is progressing normally. At what adjusted age should the nurse expect the infant's developmental accomplishments?
The infant will most likely present with developmental skills consistent with a 6-month-old infant. When assessing the growth and development of a premature infant, the nurse will use the infant's adjusted age to determine expected outcomes. To determine adjusted age, the nurse subtracts the number of weeks that the infant was premature from the infant's chronological age. The infant who was born at 32 weeks' gestation was 8 weeks (or 2 months) premature. To determine the adjusted age, the nurse subtracts 2 months from the chronological age of 8 months: 6 months.
The nurse is working in the emergency department when a physician asks for help as the client is performing a Romberg test. In which position would the nurse stand to be most helpful?
The nurse would stand laterally to the client, opposite side to where the physician is standing. The Romberg test is used to evaluate a person's ability to sustain balance. The client stands with the feet together and arms extended. In the event that the client begins to sway (an abnormal result), the nurse is most helpful to stand on the lateral side of the client, opposite side to where the physician is standing to ensure that the client does not fall.
A client with somatic symptom disorder tells the nurse that they are sick so often that the client's spouse has not been able to travel for work. Which secondary gain is the client seeking?
The spouse's attention and having emotional needs met Secondary gains are the external or personal benefits received from others because one is sick, such as attention from family members and comfort measures. The client is receiving a secondary gain from having the spouse's undivided attention. A primary gain is the direct external benefits that being sick provides, such as relief from anxiety from issues such as marital discord, fear of abandonment, and fear of dying.
A client is color blind. The nurse understands that this client has a problem with:
cones Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isn't involved with color perception.
A client with Down syndrome is admitted to the pediatric unit with asthma. The client does not enunciate words well and holds onto furniture when walking. The nurse should ask the caregiver
how the client's condition today differs from their normal condition. The nurse should ask how the client's condition differs from their normal condition in order to identify the chief complaint. Asking how long the client has been like this may be interpreted poorly by the caregiver. The nurse shouldn't ask if the client can walk without holding onto furniture because focusing on what the client can do — not on what the client can't do — preserves the family's self-esteem. Focusing on negative aspects of the client's behavior, such as constant drooling, is inappropriate.