Exam 2 Level 1 Review - Diversity, Sleep, Comfort, Mobility

A nurse is assisting a postoperative hip replacement patient with conditioning exercises to prepare for ambulation. The nurse correctly instructs the patient to do which actions? Select all that apply.

• a. When side-sleeping, sleep on the surgical hip to promote circulation.

• b. Breathe in and out smoothly during movement.
  
  

• c. Place the bed in the lowest position before exiting.

• d. Dangle on the side of the bed for 30 to 60 minutes.
  
  

• e. Exit the bed on the unaffected side of the body.

Answer explanation

Patients should not dangle for extended periods of time, and if they must sleep on their side they must sleep on the unaffected side. The other answers are appropriate actions.

In addition to proper positioning, which of the following would be an important nursing measure for a patient who is immobile?

• A. Encouraging a low-calcium diet to prevent kidney stones
  

• B. Limiting fluid intake so she does not have to use the bedpan as frequently
  

• C. Encouraging the patient to lie still so he does not cause a blood clot to become dislodged
  

• D. Performing a skin assessment to dependent areas at least once every shift

Answer explanation

D. Performing a skin assessment to dependent areas at least once every shift

An immobile patient is at risk for pressure-related injury to the skin, especially from the patient is incontinent or diaphoretic. Frailty (bony prominences) also increases the risk for pressure injury. Therefore, a skin assessment at least once a shift is important for the early detection of decubitus. Other responses are incorrect. A diet low in calcium will not prevent kidney stones; kidney stones develop only in susceptible people, regardless of calcium intake. Limiting the fluid intake will place the patient at risk for a urinary tract infection. Keeping extremities still will lead to increased venous pooling and risk for the development of blood clots.

The preceptor is monitoring a graduate​ nurse's assessment of a male client who recently immigrated to the United States from China. Which assessment activity by the graduate nurse indicates the need for​ follow-up regarding culturally competent​ care?

• Determine if the client has any daily spiritual practices.
  
  

• Inquire if the client speaks any English.
  
  

• Discourage use of acupuncture or cupping for pain relief.
  
  

• Ask the client about food preferences or food preparation needs.

Answer explanation

Discourage use of acupuncture or cupping for pain relief is the correct answer because potentially it does not respect the patient's cultural beliefs. The others are all supportive and correct actions.

A female patient who is having a myocardial infarction complains of pain that is situated in her jaw. The nurse documents this as what type of pain?

• a. Transient pain
  
  

• b. Superficial pain
  
  

• c. Phantom pain
  
  

• d. Referred pain

Answer explanation

Referred pain is localized away from the actual injury or insult. Transient pain comes and goes, superficial pain is shallow, and phantom pain is experienced by people who have had amputations but still sense pain from those parts of their body.

The nurse determines which patient is at the greatest risk for a spiritual crisis?

• a. A patient, whose religion opposes the use of blood products, has a severely bleeding ulcer
  

• b. A single parent who must decide to terminate life support for a terminally ill child
  

• c. A newlywed whose spouse has died in an automobile accident caused by a drunk driver
  

• d. A patient who denies the need for spiritual support when given the diagnosis of terminal cancer.

Answer explanation

A spiritual crisis may occur when religious or spiritual beliefs conflict with a necessary procedure or a treatment protocol, such as permitting a blood transfusion. Although the remaining options all present with a serious emotional situation, there is no evidence to support that the patient’s beliefs are being challenged.

An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.)

• A. B/P = 128/84
  

• B. Respirations 26 per minute on room air
  

• C. HR 114
  

• D. Crackles heard on auscultation
  

• E. Pain reported as 3 on scale of 0 to 10 after medication

Answer explanation

Respirations 26 per minute on room air
C. HR 114
D. Crackles heard on auscultation

Patients with reduced mobility are at risk for retained pulmonary secretions, and this risk increases in postoperative patients. As a result of retained secretions, the respiratory rate increases. The heart rate also increases because the heart is trying to improve oxygen levels. These symptoms are of concern for older adults because, if left untreated, further complications such as heart failure can occur.

A 68-year-old woman with a recent diagnosis of osteoporosis is admitted to the geriatric care unit. Given her heightened risk for fractures, the nurse is keen on implementing preventive measures to minimize the chances of falls. As part of the comprehensive plan of care, which nursing intervention is most appropriate to safeguard the patient against potential falls? Select all that apply. 

• • A. Encouraging the use of assistive devices for mobility.

• • B. Administering calcium supplements as ordered.

• • C. Teaching relaxation techniques to manage pain.

• • D. Installing grab bars in the bathroom and ensuring well-lit hallways.

• • E. Applying heat packs to alleviate discomfort.

Answer explanation

Using assistive devices such as canes or walkers can improve stability and prevent falls in patients with osteoporosis. Grab bars help provide stability and support for the patient, especially in areas where falls are common, like the bathroom. Additionally, well-lit hallways help the patient see clearly and navigate safely, reducing the risk of tripping or falling. The other answers have nothing to do with fall risk.

A 79-year-old man with a known history of osteoporosis is admitted to the orthopedic ward after a fall in his garden, which led to a hip fracture. Recognizing the acute nature of his injury and the associated discomfort, the nurse contemplates which intervention should take precedence to ensure optimal patient comfort and recovery. Which of the following nursing actions should be given top priority for this patient?

• • A. Promptly administering analgesic medications as prescribed by the physician.

• • B. Initiating gentle range of motion exercises for the affected limb.

• • C. Applying cold compresses to the fractured area to mitigate swelling.

• • D. Coordinating an early consultation with the physical therapy department.

Answer explanation

A. Promptly administering analgesic medications as prescribed by the physician. Pain management is crucial following a fracture, especially in the initial stages. Adequate pain control can prevent complications, reduce stress, and promote healing. It’s essential to address pain promptly to ensure patient comfort.

A nurse is conducting an assessment of an American Indian woman who has come to the clinic complaining of a headache. The patient tells the nurse that the medicines prescribed by the tribal healer have done some good. What is the appropriate response of the nurse at this time?

• A. Tell me about these medicines and how often you are using them.

• B. I advise you to refrain taking those medicines from the tribal healer.

• C. Could these medicines cause your headaches?

• D. Maybe you should increase the frequency of the healer’s medicines. 

Answer explanation

Asking the patient about the nature of these medicines and how often the client uses them allows the nurse to collect data about the medicines and their uses, to learn more about the practices used by this patient to improve her health, and to check for potential drug interaction before prescribing other medications or treatment. Option B: Advising the client to stop taking any nonprescription medicines is inappropriate until the nurse knows the details about all medicines used by the client. Option C: Suggesting the client’s headaches are caused by the healer’s medicines is inappropriate until the nurse knows details about the medicines. Option D: Telling the patient to increase the frequency of the healer’s medicines is not within the practice of a nurse.

A 57-year-old librarian with a recent diagnosis of osteoarthritis (OA) in her hands and knees attends a joint protection workshop at a local community health center. During the session, she is introduced to various strategies to minimize joint stress and prevent the exacerbation of symptoms. At the end of the teaching session, the nurse checks for the patient’s understanding of the provided instructions. Which statement by the patient indicates a need for further teaching?

• • A. "I will use assistive devices to reduce joint stress when performing tasks."

• • B. "I will alternate periods of activity with rest to prevent overuse of my joints."

• • C. "I will engage in high-impact exercises to strengthen my joints."

• • D. "I will maintain a healthy weight to reduce stress on my joints."