Question 1

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client?

Accepted Answer

The primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client is the client's ability to assist, as using a mechanized device requires some degree of client participation and cooperation. The client's body weight, cognitive status, and age may also play a role in the decision, but the ability to assist is the most important factor to consider.

Question 2

A nurse is teaching an older woman how to move and lift her disabled husband. The woman has osteoarthritis of the hips and knees. What is the goal of the nurse's education plan?

Accepted Answer

The goal of the nurse's education plan is to minimize stress on the wife's joints. This is important because the woman already has osteoarthritis of the hips and knees, which can cause pain and stiffness. Lifting and moving her husband incorrectly can cause further damage to her joints. Teaching proper techniques for lifting and moving her husband can help prevent injury and minimize stress on her joints. The other options, providing exercise for the husband, increasing socialization with neighbors, and maintaining self-esteem of the wife, may also be important but are not the primary goal of the education plan in this case.

Question 3

While performing a physical examination on a client, the nurse observes that the client has scoliosis based on which of the following?

Accepted Answer

Scoliosis is a lateral deviation of the spine, which can be observed as a curve when viewing the spine from the back. The thoracic spine is the most common location for scoliosis to occur, so a lateral deviation of the thoracic spine would indicate scoliosis. A concave or convex curvature of the spine can also be observed with scoliosis, but these terms do not specifically indicate the lateral deviation that defines scoliosis.

Question 4

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 three times a day. Which of the following actions will be most effective to transfer the client safely into the chair?

Accepted Answer

Having the client sit on the side of the bed for several minutes before moving to the chair helps to gradually adjust the client's body to the upright position, reducing the risk of orthostatic hypotension, dizziness, or falls. Infusing an intravenous fluid bolus is not necessary for this type of transfer, and it may increase the risk of fluid overload, electrolyte imbalance, or other adverse effects. Positioning a friction-reducing sheet under the client may facilitate the movement, but it may not be sufficient to ensure safety and stability during the transfer. Obtaining a quad cane for the client may be helpful if the client has gait or balance problems, but it may not be necessary for a simple transfer from bed to chair.

Question 5

A client 86 years of age with a diagnosis of late-stage Alzheimer's disease requires full assistance with transfers to and from his bed. Which of the following nursing actions is most likely to promote safe handling of this client?

Accepted Answer

For a client with late-stage Alzheimer's disease, cognitive function is significantly impaired, making it difficult for them to process complex instructions or remember written guidelines. Providing brief, clear instructions that are phrased positively is the most effective way to communicate and ensure safe handling during transfers. This approach accommodates their cognitive limitations and helps in guiding them through the process with minimal confusion.

Question 6

A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease. The client always remains in a sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client?

Accepted Answer

Prolonged sitting can lead to pressure ulcers on bony prominences. The sacrum is a common area for pressure ulcer development in clients who spend prolonged periods in a seated position. Therefore, it is essential to frequently assess the client's sacral area for pressure ulcer development.

Question 7

Why is it important for the nurse to teach and role model proper body mechanics?

Accepted Answer

Teaching and role modeling proper body mechanics is important for promoting health and preventing injury, both for the nurse and the client.

Question 8

What function of the skeletal system is essential to proper function of all other cells and tissues?

Accepted Answer

The skeletal system produces all types of blood cells through a process called hematopoiesis, which is essential for the proper function of all other cells and tissues in the body.

Question 9

Which of the following activities is normally acquired in the toddler years? Select all that apply.

Accepted Answer

Rolling over and pulling to a standing position are typically achieved in infancy. Walking, running, and jumping are gross motor skills that are typically acquired during the toddler years.

Question 10

A nurse is assessing the activity level of an infant age 5 months. What normal findings would be assessed?

Accepted Answer

At 5 months of age, the infant should be able to sit with support and have some head control, but they are not expected to pick up small objects or progress toward running, jumping or unassisted walking yet.

Question 11

An obstetrical nurse is preparing to help a client up from her bed and to the bathroom three hours after the woman delivered her baby. Which of the following actions should the nurse perform first?

Accepted Answer

The first action should be to explain to the client how the nurse will assist her. This ensures the client understands the process, which can reduce anxiety and increase cooperation, making the activity safer and more efficient.

Question 12

Which postural deformity might be assessed in a teenager?

Accepted Answer

Scoliosis is a postural deformity characterized by an abnormal lateral curvature of the spine. It often appears during adolescence and can progress if left untreated. Kyphosis may also be assessed in a teenager as it refers to an abnormal curvature of the upper spine, but it is less common in this age group compared to scoliosis. Rickets and osteoporosis are not typically assessed as postural deformities in teenagers, although they can affect bone health and lead to deformities in the long term.

Question 13

A nurse is placing a client in Fowler's position. What should she teach the family about this position?

Accepted Answer

Raising the knees with the knee gatch can increase the risk of pressure ulcers and impair circulation. In Fowler's position, the head of the bed is elevated, and the knees should not be raised unless specifically indicated.

Question 14

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 of the following initial actions by the nurse is appropriate?

Accepted Answer

Supporting the client's body against yours and gently sliding the client onto the floor is the appropriate action because it ensures that the client does not fall and sustain injury. It also allows the nurse to further assess the client's condition while awaiting further assistance. Option A, grasping the gait belt, may not provide enough support to prevent a fall. Option C, asking the client to lean against the wall, is not safe in case the client loses consciousness. Option D, applying oxygen and waiting, assumes that the client's condition is related to hypoxia, without further assessment. Option E, asking about the last meal, is important but it does not address the immediate risk of falling.

Question 15

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Accepted Answer

The Fowler's position, which involves sitting the patient upright at an angle of 45 to 60 degrees, is ideal for patients with dysphagia as it helps prevent aspiration and facilitates swallowing.

Question 16

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 which of the following?

Accepted Answer

Paraplegia refers to paralysis of the legs and lower body, typically caused by a spinal cord injury or disease. It does not affect the upper body or one side of the body.

Question 17

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?

Accepted Answer

A client with a BMI of 52 is considered morbidly obese and may require specialized equipment or assistance for safe transfer. Obtaining a mechanical lateral transfer device can help prevent injury to both the client and staff during the transfer process. Enlisting the aid of two other staff members or using a friction-reducing sheet may not provide enough support for the client's weight and can increase the risk of injury. Transporting the client in the hospital bed can be difficult and may not fit through all areas of the hospital, such as elevators or narrow doorways.

Question 18

A staff development nurse is discussing techniques to prevent back injury with a group of nursing assistants. The nurse informs the group that back stress and injury can be prevented by doing which of the following?

Accepted Answer

Spreading feet shoulder-width apart to broaden the base of support can help maintain balance and stability, reducing the risk of back injury. Using the strength of the back muscles during strenuous activities, holding the object that you are lifting or moving away from the body, and pulling equipment rather than pushing it can all increase the risk of back injury.

Question 19

A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes that which of the following conditions is likely affecting the client?

Accepted Answer

Orthostatic hypotension is a drop in blood pressure that can occur when a person stands up after being in a seated or lying position. This can cause dizziness and faintness, which are symptoms that the client is experiencing. This condition is often seen in patients who have undergone orthopedic surgery and may be worsened by pain medication or dehydration. Thrombophlebitis, anemia, and bradycardia do not typically cause these symptoms.

Question 20

The physician's admitting orders indicate that the client is to be placed in a Fowler's position. Upon positioning this client, how much will the nurse elevate the head of the bed?

Accepted Answer

Fowler's position refers to a semi-sitting position where the head of the bed is raised between 45 to 60 degrees. This position helps to reduce respiratory complications and improve oxygenation. Option B, 15 to 20 degrees, is considered a semi-Fowler's position. Option C, 30 degrees, is considered a low Fowler's position. Option D, 90 degrees, is not recommended as it is a completely upright position and can cause discomfort and complications.

Quiz 32: Activity