VN wk 4 Fundamentals

95. The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include?

"Picture yourself with good posture standing; that is how good lying posture works."

29. Which teaching will the nurse include when educating a client about stump socks?

"Stump socks can be made of cotton or wool."

A client asks the nurse how cortisol works. What is the appropriate nursing response?

"it suppresses the immune response."

high Fowler position. When following this guideline, the nurse would elevate the client's 97. A client's plan of care specifies that the client should spend the majority of time in a head at:

60 to 90".

82. The nurse is caring for four clients. Which client does the nurse identify as the highest risk for social readjustment concerns?

77-year old whose spouse just died

80. The nurse is caring for a client diagnosed with terminal cancer who wishes to use meditation and prayer to be cured. What is the appropriate nursing action?

Advocate for the client's choice.

89. A nurse is caring for a client who is an investment banker. The client is stressed because of the sudden fall of share prices in the stock exchange. Which stress-reduction technique should the nurse use with this client?

Advocate on behalf of the client to others.

74. The nurse is caring for an older adult client who reports feeling dizzy when moving from sitting to standing. What teaching will the nurse provide?

Allow extra time to move from sitting to standing.

46. A client who tends to volunteer to complete major assignments (but forgets to complete his own work) is stressed because of this. The nurse suggests that the client prioritize the work, complete the difficult part of the work first, and delegate the rest of the work to colleagues. In this case, what technique is the nurse asking the client to follow?

Alternative behaviors

42. The nurse is caring for a client who will be raised via a tilt table. Which intervention the nurse perform first?

Apply antiembolism stockings.

44. An older adult has been admitted to a long-term care facility after unsuccessful attempts to continue living independently. The nurse's admission assessment reveals the presence of long, ingrown toenails that appear to contribute to the resident's unsteady gait and decreased mobility. How should the nurse follow up this assessment finding?

Arrange for the client to be seen by a podiatrist.

should the nurse prioritize? (Select all that apply.) disuse syndrome. When assessing this client for disuse syndrome, what assessments 114. A nurse is working with an elderly client who possesses numerous risk factors for

Assess the client's current level of mobility Assess the client's skin integrity. Assess the client's cognition. Assess the client's bowel elimination patterns

nursing guideline should be followed during client transfer? 37. A client with a fractured leg and arm needs to be transferred to the x-ray unit. Which

Assess the client's strength and mobility.

41, A nurse is caring for a client with muscle spasms due to bad sitting posture. The nurse wants to teach the client correct sitting posture. Which sitting position is good for the client?

Buttocks and upper thighs should become the base of support.

8. After experiencing an ST-wave elevation myocardial infarction, a 64-year-old man has been admitted to the cardiac unit of the hospital for care. The nurse has completed a comprehensive assessment and is creating a plan of care that is holistic in its focus. How can the nurse best integrate the principles of holism into the client's care?

By integrating each of the various dimensions of the client's identity into his care

76. The nurse is educating a client and family about home safety. Which teaching will the nurse include? (Select all that apply.)

Consider adding grab bars to shower or tub. Assess for adequate lighting so client can see clearly when walking. Replace rubber tips on cane as soon as they become wom or dirty.

55. A nurse is trying to calm an upset client who has been involved in an accident. The client escaped with minor bruises from the accident. What should the nurse do in order to calm the client?

Explain that things could have been worse.

11. A child has been admitted to the medical center with severe depression and stress, and has been avoiding going to school for these reasons, How should the nurse attempt to treat the child?

Find the factors that have caused stress and depression.

2. A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?

Fowlers'

13. A nurse has become involved in political efforts to ensure that a greater percentage of Americans have access to affordable health care, regardless of their individual circumstances. This view of health is reflective of what belief?

Health is a right.

111. The nurse is teaching a client who is recovering from surgery about using a walker. Which teaching will the nurse include?

Hold the walker at the padded handgrips.

period. What sign or symptom may be attributable to the parasympathetic effects of stress? accident and is experiencing major physiological and psychological stressors during this 113. A client has been admitted to the emergency department following a motorcycle

Ihcreased bronchoconstriction

45. A nurse is showing a group of cllents the correct way to move their body parts during their daily exercise regimen at a health care facility. Which effect occurs when a person adheres to proper body mechanics?

Increased muscle effectiveness

6. A nurse is assessing an obese teenager who is unhappy and stressed out because she modeling intervention for stress management for the client. Which action should the nurse has not lost weight despite working out at the gym. The physician asks the nurse to try the perform when adhering to the modeling intervention?

Introduce the client to someone with a positive attitude.

22. A nurse is caring for a clent with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease?

It has a gradual onset and lasts for a long time. /

25. A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate?

Limit the family visits to once daily

117. A client who is a drug addict visits a health care facility for treatment. During counseling, he discloses that he took to drugs because it helped him deal with stressful his stress-related problems. What kind of strategy has the client used in this case? situations. The nurse explains that he is not using the correct coping strategy to overcome

Nontherapeutic coping strategy

77. The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?

Nurses and unit assistants use tele phones with handsets.

78. A client at a health care facility is to undergo amputation of the left leg due to gangrene. The client will be fitted with an immediate post-operative prosthesis (IPOP) after the surgery. What is the function of the IPOP?

Promotes intact body image

19. A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects tertiary level of prevention?

Provide care transition at discharge for speech therapy.

40. A nurse needs to change the soiled linen and body position of a client who is confined to bed and has developed bedsores. Which general principle of positioning should the nurse follow?

Raise the bed to the height of the caregiver's elbow.

18. A nurse is reading the goals stated in the Healthy People 2020 report. Which goal is targeted in the Healthy People 2020 report?

Reducing infections caused by key food-borne pathogens

53. A nurse is observing a client who is lying on an oscillating bed. Which pressure- relieving action does an oscillating bed offer?

Relieve skin pressure.

47. A client visits a health care facility reporting work-related stress that alters his mood when he comes home. The nurse suggests that the client make changes to his home décor to include vibrant colors and bright lighting, and listen to soothing music when he returns home. Which stress-reducing technique is the nurse following in this case?

Sensory manipulation technique

3. A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea?

Sit with the client and ask them about their feelings.

development of gangrene. The client uses crutches to ambulate and is waiting to be fitted 21. A nurse is a caring for a diabetic client whose right leg had to be amputated due to the with a prosthetic leg What gait should the nurse observe in this client?

Swing-through

81. When discussing his problem, a client tells the nurse that he is always doing small, petty jobs for everyone and he is not happy about it. Because of this, he is feeling stressed and has been getting into fights with his wife. What should the nurse suggest to help the client overcome this problem?

Take control of the situation.

15. A nurse is referring a client with a preferred provider organization (PPO) to a specialist. Which statement made by the nurse to the client demonstrates proper knowledge of PPOS?

The specialist should be in-network."

100. A client visits a health care facility after his spouse's death. The client is quite depressed and feels very lonely. The nurse asks him to confront the reality and be emotionally strong. What type of strategy is the nurse following in this case?

Therapeutic coping strategy

69. A UAP asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

To prevent the legs from rotating outward."

115. A nurse is caring for a client with impaired mobility. What is the purpose of the trochanter roll?

To prevent the legs from turning outward

104. The nurse is delegating ambulation of a client with generalized weakness to the unlicensed assistive personnel (UAP). Which teaching will the nurse provide? (Select that apply.)

When available, use parallel bars for support. Utilize a gait belt around the client's waist.

94. Which nursing activity reflects care given on the tertiary level of healthcare delivery?

assisting with transplant surgery

59. A nursing student is engaging in a conversation with a nursing instructor that the student intensely dislikes. Which nursing student behavior is consistent with reaction formation?

being extremely nice to the nursing instructor

110. Which ambulatory aid could a nurse suggest to assist a client who has weakness in one side of his body?

cane

91. A nurse is explaining A1C diagnostic testing to a client with diabetes. What level of healthcare delivery does this test suggest?

primary

14. A public health nurse has been asked to participate in an initiative that is aimed at promoting the use of ergonomics. What is the most likely goal of this initiative?

promote comfort and health in workplace settings

1. The nurse is caring for a client with multiple areas of skin breakdown on the back. In which position will the nurse choose to place the client to improve arterial oxygenation?

prone

122. A nurse is caring for a client with cardiac dyspnea. The nurse assists the client into Fowler position. Which advantage does Fowler's position offer a client with dyspnea?

relieves pressure on the diaphragm, allowing easy breathing. /

106. The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select?

risk for impaired skin integrity

75. A nurse is assessing the home environment of an elderly client with limited mobility. What recommendation by the nurse would most likely increase the client's confidence in ambulation in the home environment?

strategically placed handrails

63. A nurse is assisting a neurologist, who is assessing the norepinephrine (noradrenaline) level of a client who is reporting stress. Which function does norepinephrine (noradrenaline) perform?

heightens arousal and increases energy

39. A client, while driving, hits a small child crossing the road. The child survives with some minor bruises and cuts. The client feels very stressed and is depressed when thinking of the child's injury. Which technique should the nurse implement in this case?

Alternative thinking

Which scenario is using a prospective payment plan to reimburse for services?

An older adult client is admitted to the hospital and treated for pneumonia. The hospital is reimbursed base on a predetermined fixed price.

48. The nurse is fitting a client for axillary crutches. Which action will the nurse perform first?

Assist the client who can support his or her own body weight to a standing position the bedside.

49. A Spanish-speaking client is admitted to the Emergency Department with a urinary tract infection and is experiencing a stress response from hospitalization. What is the priority nursing intervention?

Contact a translator.

105. A nurse at a health care facility is caring for clients using crutches to ambulate. In which client would the nurse observe a four-point walking gait?

clients with disabilities such as arthritis or cerebral palsy

116. A nurse instructs a client with cognitive impairment to get into Sims position, but the client, whose word recall is diminished, is unable to understand the instruction. What should the nurse do when instructing clients with cognitive impairment?

Demonstrate the position to convey the message.

90. A nurse is caring for a client with chronic back pain. The client attributes the pain to the client's teaching job, which involves long hours of standing in the classroom. Which position can contribute to a good standing posture and relieve the pain?

Distribute weight equally on both feet.

10. The nurse is working in an acute care setting and performs primary, secondary, and tertiary prevention Which activity performed by the nurse is classified as tertiary prevention?

Instructing a client how to use crutches

9. A nurse is planning the care of a client who will soon begin radiotherapy for the treatment of breast cancer. The nurse has been identifying interventions that are rooted in the notion of holism, which states that: local,

Interactions between the mind and the body can profoundly influence health.

70. The occupational nurse is teaching employees about maintaining good posture. Which teaching will the nurse include? (Select all that apply.)

Keep shoulders even and centered above hips. Maintain hips at an even level. Bend knees slightly to avoid straining joints.

120. A client who is an strategy to overcome his stress-related problems. What kind of strategy has the client used deal with stressful situations. The nurse recognizes that he is not using an effective coping During counseling, the client discloses that he initially took drugs because it helped him intravenous drug user visits a health care facility for treatment, in this case?

Nontherapeutic coping strategy

123. A nurse needs to document client data in the computer of a health care facility. Which ergonomic recommendation should the nurse follow when working at a computer?

O Keep the elbows flexed no more than 100° to 110°. /

57. A roller sheet has been placed under an elderly client who is receiving treatment for failure to thrive. When using a roller sheet in a client's care, the nurse must:

ensure that the roller sheet is kept dry and wrinkle-free.

68. A nurse is assessing a client with stress-related problems. Which factor Influences responses to stressors?

Social support

71. An older client has been moved from home to a skilled nursing facility. Which client behavior requires immediate nursing intervention?

The client will not use their walker.

23. An elderly client is being seen at the clinic after experiencing a fall inside his home. He appears to have suffered no ill effects of the fall but his wife has asked the nurse he might benefit from the use of a cane. The nurse should be aware of what criterion for the safe use of a cane?

The client's weakness must be primarily limited to one side of his body.

28. A nurse is caring for a child with Huntington's chorea, a hereditary condition. Which statement is true of hereditary conditions?

The condition is acquired from genes of one or both parents.

16. A 7-year-old child is admitted to a health care facility. His parents explain that the child is not able to interpret what they say and so is not able to speak clearly. The child is also not able to remember anything he is taught in school. What should the nurse conclude about the part of the brain that is affected in this case?

The cortex is affected.

31. A client arrives at a health care facility complaining of diarrhea and abdominal pain for the past 24 hours. The physician diagnoses the client with gastritis, an acute illness. Why is gastritis considered acute illness?

The onset is sudden.

50. A client arrives at a health care facility complaining of pain in the abdomen and diarrhea. The physician diagnoses the client with colitis, acute illness. Why colitis considered an acute illness?

The onset is sudden.

109. A client had an argument at work about his salary. The client has been consuming a lot of caffeine. The client suffers from insomnia and gets angry quickly. Which technique should the nurse promote to help the client?

Therapeutic coping strategy

96. A nurse is caring for a client who had a stroke. The client is lying in a supine position and is unable to reach the foot board. What should the nurse do to prevent footdrop in the client?

Use a foot splint.

32. An 80-year-old client has been transferred from the neurological unit to a rehabilitative unit during the client's recovery from a stroke. The client's nursing care plan includes Risk for Disuse syndrome. What intervention should be performed to address this risk?

Use a pressure-reducing device on the client's bed.

121. When discussing his concerns with the nurse, the client discloses that when he comes home from work, he plays with his pet dog and this makes him feel relaxed. His friends make fun of him because of this, however. The nurse explains that this is perfectly normal and is not a cause of worry. In this case, how is the client relieving stress?

by adopting an alternative lifestyle

27. A client who tore his quadriceps muscle during a soccer match has been prescribed exercise for the quadriceps muscles. How should the client perform quadriceps-setting exercises?

by alternatively tensing and relaxing the muscles

36. A client is discharged from the hospital 2 days post-appendectomy because of diagnostic-related groups (DRGS). What should the discharge nurse be most concerned about?

continuity of care

118. A client experienced a fight or flight response Immediately following a car accident. What clinical symptoms would the nurse expect? (Select all that apply.)

decreased digestion increased heart rate pallor heightened awareness

52. A nurse is caring for an older adult client at a health care facility. What should the nurse consider to be a normal, age-related change?

decreased or unsteady mobility

20. The client is admitted to the hospital with pneumonia, along with various other signs and symptoms. Which is the priority for the nurse to manage?

difficulty breathing

5. A client with Crohn's disease in remission is admitted to the nursing unit for follow-up care. The remission state is characterized by:

disappearance of signs and symptoms associated with the disease.

101. A client is receiving treatment in the intensive care unit for sepsis, a systemic infection that poses a grave threat to the body's homeostasis. The body is adapting to numerous threats, a process that primarily involves the integration of what body systems? (Select all that apply.)

endocrine syste central nervous system Automomic nervous system

98. The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client?

exhaustion stage

33. A nurse is caring for a client who has undergone total hip replacement and is advised to undergo physiotherapy after discharge. Which level of care is the physiotherapy center?

extended care

54. A client who is disabled due to stroke is discharged from a health care unit and an LPN is assigned to provide nursing care to the client at home. This is an example of which kind of care?

extended care

79. client is admitted to the mental health center with attempted suicide, Which of the client's problems is priority for the nurse to manage?

freedom from harm

64. Which client growth needs are included in the love and belonging level of Maslows hierarchy? (Select all that apply.)

friendship intimacy family

43. A wheelchair-bound client reports the "hammock effect" each time the client sits in the wheelchair. Which device should the nurse place in the wheelchair to prevent the hammock effect?

gel and foam cushions

4. A nurse is using a mechanical lift to assist an obese client with limited mobility. Which client will benefit the most from a mechanical lift?

heavy

65. A nurse at a health care facility suggests the use of parallel bars for a client who has recently been fitted with a prosthetic limb. How would parallel bars help this client?

helping the client to practice ambulating

103. The nurse directs the UAP to assist a client with eating. Into which position will the nurse delegate the UAP to place the client?

high-Fowlers'/

30. A nurse is caring for a clilent with a strained gluteal muscle at a health care facility. The nurse should understand that the function of the gluteal muscles is to aid:

in extending the legs.

87. A client who has been dealing with numerous physical, interpersonal, and financial stressors appears to be experiencing the final stage of Selye's general adaptation syndrome (GAS). Individuals in the final stage of the GAS are likely to experience:

increased susceptibility to illness.

112. The nurse has completed proper body mechanic education for a group I unlicensed assistive personnel (UAP). Which UAP statement requires the nurse to intervene?

is easier to twist my back when moving objects from side to side."

26. A 22-year-old woman has begun using axillary crutches following open reduction and assessment finding by the nurse should suggest that the client's crutches are fitted internal fixation of an ankle fracture that she suffered during a basketball game. What correctly?

jThe client's wrist is slightly hyperextended when she stands upright and grasps her crutches.

24. A nurse is caring for a client whose legs have been amputated from above the knee due to a mountain climbing accident. The client has been fitted with an above-the-knee prosthetic limb. Which component can be found only in an above-the-knee prosthetic?

knee system

34. A nurse needs to give a bath to a client with chronic back pain. Which ergonomic hazard is the nurse likely to face when caring for the client?

lifting heavy loads

99. A nurse is caring for a client whose fractured ankle is in a cast. The client needs crutches to ambulate. What would help prepare this client for ambulation?

modified hand push-ups

17. A nurse had learned that more than 8% of Americans are currently living with diabetes mellitus. This statistic represents what epidemiological concept?

morbidity

client for the presence of stool. The murse should instruct the client 38. A nurse needs to examine the rectum of a constipated to lie in which position?

on the left side with the right knee drawn up toward the chest

92. When assisting a client with ambulation using an assistive device such as parallel bars or a walking belt, what should the nurse observe the client for?

pallor, weakness, or dizziness

83. The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?

placing the client in good alignment with joints slightly flexed

51. A nurse is working with a client whose quality of life is impacted by the presence of numerous comorbid health problems. The nurse is aware that the client's body is attempting to maintain homeostasis, a process that primarily involves:

responding appropriately to internal and external influences.

consultation. Consultation and diagnostic tests are included in which level of the health 67. A client experiencing symptoms of cold is referred to the specialist for diagnosis and care system?

secondary care

58. A client visits the medical unit with the client's father for a scheduled checkup. The client's father has been recently diagnosed with hypertension, The nurse suggests that the client get his blood pressure regularly checked to avoid possible problems. What level of prevention is the nurse following in this case?

secondary level

7. A middle-aged client is distraught at receiving a diagnosis of type 2 diabetes in spite being conscientious about her health for the majority of her adult life. The client tells the nurse, "I can't believe I no longer have my health." The nurse should be aware that the World Health Organization defines health as:

state of physical, mental, and social well-being.

66. A nurse is caring for a client who is confined to bed due to paralysis. The client has a medical history of stroke, hypertension, and diabetes mellitus for the past five years, besides having asthma since childhood. Which is a secondary illness seen in the client?

stroke

56. A nurse is caring for a client with severe back pain. The client has been lying flat on his back in bed for a long time. Which body position has the highest potential for causing footdrop in a bedridden client?

supine

35. The nurse is caring for a client with lower extremity paralysis who has been placed in bilateral leg braces. Which crutch-walking gait will the nurse teach?

swing-through

85. A client admitted for hernioplasty is discharged two days later than the calculated time due to postoperative complications. The client is insured through a capitation scheme. In the event of late discharge of the client, who is at loss?

the hospital

84. A nurse is caring for a client who underwent surgery for the amputation of the right foot. The client has been fitted with a temporary prosthetic limb. What should the nurse ensure during this period?

the wound heals and no complications develop

62. The nurse is caring for a client who sustained a severe ankle sprain while playing soccer. Which crutch-walking gait will the nurse teach?

three-point non-weight-bearing

61. A nurse is applying a leg prosthesis a client at a health care facility. Why is it important for the nurse to observe the ease or difficulty of inserting the stump into the socket when applying the prosthesis?

to check the number stump socks that are required

88. A nurse at a health care facility has been assigned the care of an elderly client. For which reason would the nurse use a tilt table when preparing this client for ambulation?

to help the client bear weight on the feet

60. A nurse is assisting a client at a health care facility dangle his legs before he ambulates. The nurse places the client in Fowler's position for a few minutes. What is a possible reason for this action?

to maintain safety should the client become dizzy or faint

12. A nurse needs to transfer a client who has polio but has strong arms and upper body muscles to the x-ray unit. Which transfer devices will be most suitable for the client?

transfer board

86. A nurse is caring for a client who is recovering from acute back pain. Which device will allow the bedridden client to maintain as much independence as possible?

trapeze

102. An elderly client with a diagnosis of osteoporosis and early stage Alzheimer disease requires the use of an assistive device that will maximize stability during ambulation. What device will best meet this client's needs?

walker

93. The right leg of a client who was involved in a motor vehicle accident needs to be amputated due to complications related to gangrene. When would a permanent prosthetic limb be constructed for this client?

when the stump size stabilizes

72. The nurse is teaching a client who had a below-the-knee amputation about a temporary prosthetic limb. Which client statement demonstrates that teaching has been effective?

will loosen the belt when I go to sleep.

108. What does the nurse identify as a goal for a client with the nursing diagnosis of impaired physical mobility related to a new prosthetic limb?

will take sixteen steps independently by Monday