Question 1

A nurse is performing passive range of motion exercises on a client who had a lacunar cerebrovascular accident nine days ago. While moving the left arm, the affected extremity, the nurse notes muscular spasticity. What is the nurse's next action?

A)Notify the physician
B)Continue with the range of motion exercises
C)Apply gentle pressure on the spastic part
D)Administer PRN pain medication, if there is any

Apply gentle pressure on the spastic part

Accepted Answer

In case of muscle spasticity, the nurse's next action is to temporarily discontinue the exercise and continue the application of gentle pressure on the spastic part until the muscle relaxes. Range of motion exercises should be discontinued if the client reports discomfort, pain, stiffness or rigidity, and other unexpected symptoms. If these symptoms occur the physician should be notified. Pain medications are ideally given prior to exercises to gain the client's cooperation.

Question 2

Janis Long, an 88-year-old client, is in an advanced stage of dementia. On a particularly busy day, the nurse decides to fit a bed exit safety monitoring device on the client. The following statements are benefits of this device, except:

A)Safely limits the mobility of the client
B)Decreases the risk of client falls
C)Alerts the nurse if the client is attempting to get out of bed
D)Prevents nighttime wandering

Safely limits the mobility of the client

Accepted Answer

A bed exit safety monitoring device does not limit the mobility of the client. The benefits of a bed exit safety monitoring device are to decrease the risk of client falls and to immediately alert the health care team if the client is attempting to get out of the bed. It is also a device that can prevent a case of night time wandering. The nurse should explain to the client and relatives that this device does not limit, in any way, the mobility of the client. The client should be instructed to call the nurse for assistance when the client needs to get out of bed.

Question 3

A client with chronic sinusitis suffers from poor ventilation due to the narrowing or obstruction of the nasal passageways. The nurse understands that poor ventilation can lead to poor nasal drainage. The nurse does NOT include which of the following comfort care measures for this client?

A)Encourage increase oral fluid intake.
B)Apply warm wrap or compress over the sinuses.
C)Increase the humidity of the environment.
D)Encourage plenty of rest in the day.

Encourage plenty of rest in the day.

Accepted Answer

Preferably, the nurse should not encourage plenty of rest in the day to avoid lack of sleep at night. Clients with chronic sinuses complain of fatigue due to lack of sleep. Sleeping patterns are usually disrupted due to difficulty breathing, chronic headache, and periorbital pain. In the morning, nasal stuffiness is more severe. Increasing oral fluid intake and increasing the humidity promote better drainage of the sinuses. Warm compresses over the sinuses would dilate the sinuses, decreasing nasal stuffiness.

Question 4

A nurse is caring for a client with an enlarged prostate. The client has difficulty voiding. Physical assessment notes a distended bladder with residual urine. When performing intermittent catheterization, which of the following is an inappropriate technique to ease the insertion:

A)Using the smallest available catheter in stock
B)Using liberal amounts of water-based lubricant
C)Assisting the client in semi-Fowler's position with the legs spread apart
D)Instructing the client to cough or bear down while maneuvering the catheter

Accepted Answer

Assisting the client in semi-Fowler's position with the legs spread apart is an inappropriate technique. The patient must be placed in supine position with the legs spread apart as this is the easiest position to gain access for catheterization. To successfully insert the catheter with minimal trauma to the urethral lining, use the smallest available catheter possible, apply liberal amounts of lubricant, and ask the client to cough or bear down while maneuvering the catheter. Do not force the catheter since this can cause traumatic injury to the urethra.

Question 5

A nurse reviews information about different therapeutic diets. The nurse knows that which of the following statements is inaccurate?&#10;A)&#34;A low-residue diet includes foods high in carbohydrates, but excludes raw fruits, seeds, and whole grains&#34;&#10;B)&#34;A low-purine diet discourages the intake of fish like anchovies, gravies, meat extracts, organ meats, and glandular meats&#34;&#10;C)&#34;A high-calorie diet includes foods high in protein&#34;&#10;D)&#34;A diet for a client with symptomatic diverticular disease includes foods high in fiber, and excludes gas-forming foods&#34;

Accepted Answer

A diet for clients with symptomatic diverticular disease excludes foods high in fiber, as it is irritating to the bowel. Gas-forming foods like broccoli, figs, and cabbage are avoided as they are known to increase pressure on the bowel's weak spots, causing gradual development of diverticula. The other options are accurate.

Question 6

A client with sleep apnea is prone to unexplained fatigue due to poor sleep quality. A female client reports increased daytime sleepiness. During the sleep study, the physician notes that the client's chest movement and airflow cease during apneic episodes. These findings strongly suggest that the client has which type of sleep apnea?

A)Central apnea
B)Obstructive apnea
C)Mixed apnea
D)Peripheral apnea

Accepted Answer

Cessation of chest movement and airflow strongly suggest central apnea. Central apnea is believed to be a result of a defect in the respiratory center of the brain. Central apnea is commonly seen in clients with brain stem injury or muscular dystrophy. Obstructive apnea results from an obstruction in the pharynx or oral cavity. In this type of apnea, chest and diaphragmatic movements continue, but airflow is usually decreased. Mixed apnea is a combination of central and obstructive apneas. Option D is not a known type of sleep apnea.

Question 7

Tony Smith is an elderly client who suffered from a left hemisphere cerebrovascular accident two weeks ago. The nurse is assessing Mr. Smith for complications of prolonged immobility. Which of the following complications is least likely to be responsive to exercise?

A)Contractures
B)Atrophy
C)Pressure ulcer
D)Constipation

Accepted Answer

Constipation is least likely responsive to exercise. Contractures, atrophy, and pressure ulcer are more responsive to exercise. Constipation is common in immobile clients because of decreased intestinal motility. Research showed that although clients are encouraged to perform exercises, there is no evidence that exercise can relieve constipation.

Question 8

Which of the following best describes the recommended diet for the client with Meniere's syndrome?&#10;A)High in fiber&#10;B)Low in sodium&#10;C)High in iodine&#10;D)Low in fiber

Accepted Answer

A low-sodium diet is best for the client with Meniere's syndrome.

Deck 1: Basic Care