WorksheetsReview For Exam 4
Total questions: 40
Worksheet time: 3600secs
. While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has:
Paralysis of the legs
Weakness affecting on half of the body
Paralysis affecting on half of the body
Paralysis of the arms and legs
A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but the care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?
Fowler
Low Fowler
Protective Supine
Semi Fowlers
Why is it important for the nurse to teach and role model proper body mechanics?
To ensure knowledgeable client care
To promote health and prevent illness
To prevent Unnecessary insurance claims
To demonstrate knowledge and skills
The home health nurse is placing a client in the Fowler's position in an adjustable bed in the client's home. What information should the nurse teach the family about the Fowler's position?
"Use at least two big pillows to support the client's head."
"Cross the client's arms over the abdomen when moving the client."
"Avoid bending the mattress at the knee level."
"Keep the hands lower than the rest of the body."
13. The nurse cares for a newly admitted client who will soon need to be taken to the radiology department for a CT scan. The client has a body mass index (BMI) of 52. Which of the following strategies to transport the client is most appropriate?
A. obtaining a mechanical lateral transfer device to move the client onto a stretcher
B. enlisting the aid of two other staff members and pulling the client across the bed and onto a stretcher
C. positioning a friction-reducing sheet under the client before attempting the transfer
D. transporting the client to the radiology department in the hospital bed
The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair 3 times per day. Which action will be most effective to transfer the client safely into the chair?
A. having the client sit on the side of the bed for several minutes before moving to the chair
B. infusing an intravenous fluid bolus 15 minutes before transferring the client into the chair
C. positioning a friction-reducing sheet under the client
D. obtaining a quad cane for the client to use as a transfer aid
The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial action by the nurse is appropriate?
A. Firmly grasp the client's gait belt.
B. Support the client's body against yours and gently slide the client onto the floor.
C. Ask the client to lean against the wall while you obtain a wheelchair.
D. Apply oxygen and wait several minutes for the weakness to pass.
E. Ask the client, "When was the last time you ate?"
Which client would be the most appropriate candidate to move by using a powered stand-assist device?
A. a comatose client who is being taken for x-rays
B. an alert client after knee-replacement surgery who is being assisted to ambulate
C. an obese client who has Alzheimer disease and is being escorted to the shower room
D. a car accident victim with fractures in both legs who is being moved to another room
When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the client. What is the rationale for using a transfer board in this procedure?
A. to lift the client off the bed
B. to slide the board with the client onto the stretcher
C. to reduce friction as the client is pulled laterally onto the stretcher
D. to protect the client's head from hitting the headboard
The nurse is leading an exercise class for a group of adults aged 65 years and older. The nurse incorporates isotonic, isometric, and isokinetic exercises into the class. Which activity is an isometric exercise?
A. sitting in a chair with a low weight on the ankle and lifting the knee to the seat level of the chair
B. walking single file at a rate of 3 miles (5 km)/hour around a racetrack two times
C. contracting the gluteal muscles while holding a simple yoga pose
D. carrying an air-filled ball while wading through the water across the width of a pool
On a previous clinic visit a month ago, an overweight client reported shortness of breath with activity and constipation. The client was diagnosed as having osteoporosis and noted to have an elevated triglyceride level. The primary care provider prescribed an exercise program. The nurse is assessing for the effects of exercise. What are the expected outcomes for this client? Select all that apply.
A. The client reports no shortness of breath with activity.
B. The client's blood triglyceride level is increased.
C. The client reports regular and formed bowel movements.
D. The client's weight is maintained or lessened.
E. The client reports joint pain with movement.
The middle-aged client asked the nurse about developing an exercise program to help lose weight and improve health. What instructions would the nurse include? Select all that apply.
A. Obtain a medical evaluation by the primary care provider first.
B. Include warm-up and cool-down activities.
C. Participate in activities that you consider fun.
D. Continue exercising even when you become tired.
E. Plan your activities and do not deviate in your plan.
An older adult client is scheduled to receive passive range-of-motion (ROM) exercises. The family is present to learn how to do the exercises for the client at home. What interventions would the nurse include? Select all that apply.
A. ask the assistive personnel to perform the exercises and teach the family
B. provide slow and gentle movements while supporting the extremity
C. perform the exercise to the point of resistance
D. massage the client's leg if the client reports sudden sharp pain in the leg during exercise
E. perform the range-of-motion exercises once a day
A client with a fractured right tibia is prescribed axillary crutches to prevent weight bearing on the extremity. The nurse is reinforcing instructions for using axillary crutches and crutch walking. The nurse determines that additional teaching is needed based on which client statement?
A. "It is important that I support my body weight on my underarm area."
B. "When standing, the top of the crutches should be 1 to 2 in (2.5 to 5 cm) below my armpits."
C. "The handgrips should be even with my hips."
D. "The crutches should be no closer than 12 in (30 cm) from my feet."
A client age 71 years has recently integrated large amounts of blueberry and pomegranate juice into the diet, touting their antioxidant properties that mitigate the effects of separated high-energy electrons. The client's actions reflect which of the following theories of aging?
A. Free radical theory
B. Genetic theory
C. Cross-linkage theory
D. Immunity theory
.According to Erikson, the stage of development of the middle adult is generativity versus stagnation. What happens to the middle adult if developmental tasks are not achieved?
A. Denies changes in the body that are related to aging
B. Becomes more concerned about own health needs
C. Is more motivated to learn new material
D. Has an increased awareness of own mortality
While conducting a health assessment with an older adult, the nurse notices it takes the person longer to answer questions than is usual with younger clients. What should the nurse do?
A. Stop asking questions so as not to confuse the client.
B. Slow the pace and allow extra time for answers.
C. Realize that the client has some dementia.
D. Ask a family member to answer the questions.
A nurse educates adults in preventive measures to avoid problems of middle adult years. Which of the following are the major health problems during the middle adult years?
A. Cardiovascular disease, cancer
B. Upper respiratory infections, fractures
C. Communicable diseases, dementia
D. Sexually transmitted infections, drug use
The adult child of an older adult calls the nurse practitioner to report that the parent is becoming very confused after dark. What is this type of confusion named?
A. Night-time confusion
B. Sundowning syndrome
C. Alzheimer's disease
D. Cognitive dysfunction
There are myths associated with aging and older adults. Which of the following statements is true of the older adult population?
A. Old age begins at 65 years of age.
B. Most older adults live in nursing homes.
C. Older adults are not interested in sex.
D. Incontinence is not a part of aging.
Which of the following are physical changes that occur in middle adulthood? Select all that apply.
A. Body fat is redistributed.
B. The skin is more elastic.
C. Cardiac output begins to increase.
D. Muscle mass gradually decreases.
E. There is a loss of calcium from bones.
. A nurse is working as a member of a group tasked with developing a plan to reduce the risk of delirium in older adult clients admitted to the facility. Which intervention(s) is appropriate for the group to include in this plan? Select all that apply.
A. promoting adequate amounts of sleep at night
B. encouraging activity levels within the client's functional abilities
C. ensuring clients are reoriented once daily
D. having assistive devices within the client's reach
E. limiting fluid intake to one liter per day
Which natural chemical does the body produce at night to decrease wakefulness and promote sleep?
A. melatonin
B. serotonin
C. endorphins
D. dopamine
A client reports that their naps after lunch often stretch to 3 hours in length and that the family has great difficulty arousing the client after a nap. This condition is termed as:
A. hypersomnia.
B. insomnia.
C. parasomnia.
D. sleep apnea.
A nurse working the night shift assesses a client's vital signs at 4 a.m. (0400). What would be the expected findings, based on knowledge of NREM sleep?
A. Decreased TPR and BP
B. Increased TPR and BP
C. No change from daytime readings
D. Highly individualized, cannot predict
A middle-age adult client has just started an exercise program. What would the nurse teach the client about timing of exercise and sleep?
A. Exercising immediately before bedtime enhances ability to sleep.
B. Exercising within 2 hours of bedtime can hinder ability to sleep.
C. The time of day does not matter; exercise facilitates sleep.
D. The fatigue from exercise may be a hindrance to sleep.
The parents of a 10-year-old child are worried about the child's sleepwalking (somnambulism). What topic should the nurse discuss with the parents?
A. sleep deprivation
B. privacy
C. schoolwork
D. safety
Which expected outcome demonstrates the effectiveness of a plan of care to promote rest and sleep?
A. verbalizes inability to sleep without medications
B. continues to read in bed for hours each night
C. identifies factors that interfere with normal sleep pattern
D. reports minimal improvement in quality of rest and sleep
A new parent is discussing their 6-month-old infant's sleep habits and expresses concern about the infant obtaining too much sleep. The parent reports the infant's circadian cycle as listed above. The best statement by the nurse is:
A. "Your infant requires more time asleep during the day hours."
B. "You need to awaken your infant during the midnight to 6 a.m. time period."
C. "Your infant is obtaining the average hours of sleep per day for an infant."
D. "Your infant is actually obtaining too little sleep for one day."
The nurse is caring for two clients on the same unit. One client states that cold temperatures and loud noises are stressors. The other client says the temperature is fine and the noises do not bother them. What is the difference between the two clients related to these stressors?
A. Although the perception is the same, the response is individualized.
B. Both individuals will respond the same, depending on the situation.
C. The perception and effects of stressors are highly individualized.
D. The internal environment of one person is more selective.
A student is preparing for the first client care assignment. The student wakes up at 4 a.m. with a pounding pulse and diarrhea. What type of adaptive response to stress is the student experiencing?
A. general adaptation syndrome
B. mind–body interaction
C. local adaptation syndrome
D. coping or defense mechanism
In what phase of the general adaptation syndrome (GAS) is a client who is using all of the physiologic adaptive mechanisms for dealing with stress leaving no defense against the distress?
A. alarm reaction stage
B. fight-or-flight stage
C. stage of resistance
D. stage of exhaustion
Which group of terms best describes anxiety?
A. cognitive, known threat, depression
B. cognitive, visible threat, anger
C. known source, prolonged, solely physical
D. unknown cause, emotional, apprehensive
A client has noticed bright red blood in their bowel movements for over a month. The client says to themselves, "Oh, it is just my hemorrhoids." What defense mechanism is the client using?
A. rationalization
B. repression
C. denial
D. compensation
Which scenario describes an example of developmental stress?
A. a newborn who needs to be fed by bottle
B. a school-age child learning to read
C. a teenager learning to drive a car
D. a middle adult accepting signs of aging
According to the Harvard University Medical School committee, what function must be irreversibly lost to define death?
A. respiratory functions
B. reflexes
C. consciousness
D. brain function
Although all of the following are factors that affect grief, which one is most likely to influence a person's expression of grief?
A. socioeconomic factors
B. cultural influences
C. religious influences
D. cause of death
A nurse is caring for a young client who is dying of renal failure. What should the nurse do when caring for the dying client's family members?
A. Inform the family that the client may soon be out of danger.
B. Request the family members not to talk about death to the client.
C. Inform the family members that it is time to bid farewell to the client.
D. Encourage the family to leave the client alone to rest quietly without people around.
A client who is terminally ill states to the nurse, "My situation is hopeless; I have no control over anything." The nurse implements which interventions to enable hope for the client? Select all that apply.
A. State to the client, "We have explored all treatment options."
B. Encourage the client to discuss feelings.
C. Sit in a chair next to the client.
D. Hold the client's hand.
E. Withhold information about disease progression.
A middle-aged client has been told they have cancer of the plasma. The client states to the health care team, "Just keep me alive until I can see my child graduate from high school." What stage of dying is this client exhibiting?
A. denial
B. bargaining
C. depression
D. acceptance
