Exam 2 Review

Which of the following are consequences or hazards of immobility? Select all that apply.

• Pressure ulcer

• Positive nitrogen balance

• Pneumonia

• Decreased cardiac workload

A patient presents to the hospital with inadequate absorption of nutrients through the intestinal tract. The patient describes symptoms of poor wound healing and weight loss. A testing of blood was done and shows deficient Vitamin B, Vitamin C, and low iron. What is most likely the cause?

• Dysphagia

• Diabetes

• Food intolerance

• Malabsorption

A nurse is assessing the skin of an elderly patient who has limited mobility using the Braden scale. The nurse knows that a score lower than what places the patient at risk for pressure injury development.

• 15

• 18

• 20

• 23

The nurse is aware the effects of immobility on the cardiac system include which of the following? (select all that apply)

• Renal calculi

• Thrombus formation

• Irregular heartbeat

• Orthostatic hypotension

The nurse is caring for a patient after surgery to repair a fractured hip. Which expected outcome is most appropriate for this patient with a nursing diagnosis of impaired physical mobility?

• The patient will ambulate 100 feet using a walker independently by the time of discharge.

• The patient will ambulate briskly to the hospital exit at discharge.

• The nurse will assist the patient to ambulate with the walker in the hall 2 times a day.

• The patient will increase mobility.

A senior student nurse delegates the task of intake and output to a new nursing assistant. The student will verify that the nursing assistant understands the task of I&O when the nursing assistant states,

• “I will not record a café mocha as intake.”

• “I will not count liquid stools as output.”

• “I will record the amount of all voided urine.”

• “I will notate perspiration and record it as a small or large amount.”

The terms leadership and management are often used interchangeably. Although these concepts are related, they are different in definition and in practice. Leadership behaviors and management skills complement each other. However,

• managers focus on relationships.

• leadership focuses on coordinating and directing others.

• a manager may not possess leadership traits.

• a manager is a visionary who sets the direction for a group.

The nurse is admitting a patient who has had several previous admissions. In order to obtain a knowledge base about the patient’s medical history, the nurse may use the:

• electronic medical record (EMR).

• the computerized provider order entry (CPOE).

• American Recovery and Reinvestment Act.

• electronic health record (EHR).

The nurse is explaining to the UAP that the patient is on a full-liquid diet. Which statement by the UAP indicates a need for reorientation?

• “I can give the patient milk.”

• “I can give the patient oatmeal.”

• “I can give the patient yogurt.”

• “I can give the patient orange juice.”

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

• Ask for at least two other assistive personnel to come to the room.

• Medicate the patient to alleviate discomfort while ambulating.

• Offer the patient a walker.

• Review the patient’s activity orders.