Fundamentals I E2

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Which of the following signs or symptoms in an opioid-naïve client is of greatest concern to the nurse when assessing the client 1 hour after administering an opioid?

A) Respiratory rate of 10 breaths per minute
B) Oxygen saturation of 95%
C) Pain intensity rating of 5 on a scale of 10
D) Difficulty arousing the client

D) Difficulty arousing the client

Sedation always occurs before respiratory depression, so the nurse should monitor for sedation or difficulty arousing the client. A pain intensity rating of 5 on a scale of 10 means that the client probably needs a higher dose of medication. The oxygen saturation and respiratory rate are probably acceptable but should be compared with the client's baseline values for vital signs.

A physician wrote the following order for an opioid-naïve client who has returned from the operating room after total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." Based on this order, the nurse takes which of the following actions?

A) Calls the physician and questions the order
B) Applies the patch on the third postoperative day
C) Applies the patch as soon as the client reports pain
D) Places the patch as close to the hip dressing as possible

A) Calls the physician and questions the order

The nurse calls the physician and questions this order. Onset of pain relief can take 18 to 36 hours after a fentanyl patch is applied. Fentanyl patches are used for long-term management of severe pain, so this is not an appropriate order for this client, who needs immediate, short-term relief. The patch should not be applied until the order is clarified and confirmed by the physician after short-term relief is started.

A client is being discharged to home with an order for an around-the-clock opioid for relief of chronic back pain. Because of this drug regimen, for which class of medication does the nurse request an order?

A) Stool softener
B) Stimulant laxative
C) H2 receptor blocker
D) Proton pump inhibitor

B) Stimulant laxative

All clients receiving opioid therapy should also be placed on a bowel program to ensure that constipation related to opioid use is avoided. The other medications are not required with around-the-clock opioid use.

An intern new to the service writes an order for OxyContin SR 10 mg by mouth every 12 hours as needed. Which part of the order does the nurse question?

A) The dose
B) The drug
C) The time interval
D) The route

C) The time interval

OxyContin SR is a long-acting opioid that requires regular dosing to be effective. This medication should be prescribed for regular use and a short-acting medication provided for as-needed dosing for breakthrough pain. The rest of the elements in the drug order are correct.

After returning from vacation, the nurse notices that the client has been receiving Percocet, 2 tablets by mouth every 3 hours for the past 3 days. The nurse is most concerned about which of the following?

A) Risk for gastrointestinal bleeding
B) Client's level of pain
C) Potential for addiction
D) Amount of acetaminophen received daily

D) Amount of acetaminophen received daily

The maximum dosage of acetaminophen is 4 g every 24 hours. This client is receiving 5.6 g, which could cause liver damage. A check of the client's level of pain to assess the need for the high dose of acetaminophen could indicate that the client requires a different medication. The potential for addiction if the client is taking the medication as prescribed is minimal. Gastrointestinal bleeding is usually associated with the use of nonsteroidal antiinflammatory drugs.

A client with chronic low back pain who has been receiving an opioid around the clock for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this client is experiencing symptoms of:

A) Addiction
B) Tolerance
C) Pseudoaddiction
D) Physical dependence

D) Physical dependence

Physical dependence results after a client has been taking a medication for a period of time. This is not addiction, which occurs when an individual takes medication for reasons other than its intended use. This also is not pseudoaddiction or tolerance.

After a client receives 0.2 mg of naloxone via intravenous push, the client's respiratory rate and depth are within normal limits. The nurse now plans to implement which of the following actions?

A) Discontinue all ordered opioids.
B) Close the room door to allow the client to recover.
C) Administer the remaining naloxone over 4 minutes.
D) Assess the client's vital signs every 15 minutes for 2 hours.

D) Assess the client's vital signs every 15 minutes for 2 hours.

Clients who receive naloxone should be reassessed every 15 minutes for 2 hours after drug administration because of the risk of renarcotization and the return of respiratory depression. The nurse should not close the door to the room or leave the client where the client cannot be observed quickly. If the dose was effective, there is no need to give a further dose unless the client shows signs of renarcotization. The type and dosages of opioids should be reevaluated

Which of the following instructions is it crucial for the nurse to give to both the client and family members when the client is about to be started on morphine delivered via a patient-controlled analgesia (PCA) device?

A) The PCA button should not be pushed until the pain is severe.
B) Only the client should push the PCA button.
C) The nurse should be notified when the button is pushed.
D) The PCA system prevents overdoses from occurring.

B) Only the client should push the PCA button.

Only the client should push the PCA button, because the client should be the one to decide when medication is needed. The client should use the button whenever there is pain and should not wait until the pain is severe. The nurse does not need to be notified when the button is pushed unless the medication is not relieving pain. The PCA system does prevent accidental overdoses, but the most important feature is that the client controls the analgesia.

A client with a history of a stoke that left her confused and unable to communicate has returned from the interventional radiology department after placement of a gastrostomy tube. The physician's order reads: "Vicodin 1 tablet, per tube, every 4 hours as needed." Which is the best action by the nurse?

A) Take no action because the order is appropriate.
B) Request to have the order changed to around-the-clock administration for the first 48 hours.
C) Begin the Vicodin when the client shows nonverbal signs of pain.
D) Ask for a change of medication to meperidine (Demerol) 50 mg by intravenous push every 3 hours as needed.

B) Request to have the order changed to around-the-clock administration for the first 48 hours.

This client is nonverbal and cannot communicate her pain level. Changing the client's medication to around-the-clock administration for 48 hours allows the client to receive some continual pain relief. If the client begins to show nonverbal symptoms of pain, this approach needs to be reconsidered. Meperidine is typically not used in more than a single dose.

The results of many diagnostic tests performed to identify the cause of a client's chronic low back pain come back negative. This indicates to the physician and nurse that the client's pain is:

A) Psychological
B) Overestimated
C) Currently idiopathic
D) Caused by low pain tolerance

C) Currently idiopathic

The fact that a cause for pain cannot be identified through laboratory or diagnostic tests does not mean that the pain is not real. It may indicate that the current tests are not sophisticated enough to detect the abnormality.

Just before friends visit, a client reports to the nurse that his pain level is 7 out of 10. The nurse returns to the room with the ordered analgesic and finds the client laughing and joking with the friends. The nurse decides to:

A) Administer the analgesic immediately.
B) Record the pain intensity as 2 out of 10.
C) Make a note that the client's behaviors do not indicate pain.
D) Withhold the analgesic until the client requests it again.

A) Administer the analgesic immediately.

Pain is what the client says it is. There is no single way in which pain manifests itself. Clients may be temporarily distracted from their pain when friends are visiting. Clients in pain may not want their friends and family members to know how much pain they are experiencing. In addition, laughing with friends or family members may be a distraction that diverts attention from the pain. Pain rated at 7 out of 10 requires immediate treatment.

When setting goals for a client with chronic pain, the nurse should begin by doing which of the following?

A) Identifying the cause of the pain
B) Asking "What pain rating is acceptable to your family?"
C) Asking "What does your pain prevent you from doing that you used to do?"
D) Getting an idea of what pain intensity will allow the client to perform the activities of daily living (ADLs)

C) Asking "What does your pain prevent you from doing that you used to do?"

Understanding what the pain prevents the client from doing that is important helps in establishing a goal that the nurse can measure. This also assists in identifying what is important to the client. A pain rating that is acceptable to the client is more important than one that is acceptable to family members. An acceptable pain rating is unique and individual to the client. Clients may perform ADLs even though they are in pain because ADLs are often necessary for survival. Although identifying the cause of pain is important, it is not essential in establishing goals.

A client describes the pain radiating down the leg as sharp, shooting, and electric-like. The nurse recognizes this as indicative of:

A) Somatic pain
B) Visceral pain
C) Idiopathic pain
D) Neuropathic pain

D) Neuropathic pain

Neuropathic pain is usually described as burning, shooting, or electric-like. It is important to report these characteristics to the physician, because neuropathic pain may not respond as well to opioids. Visceral and somatic pain are often described as "aching," "throbbing," and "pounding." Idiopathic pain does not have specific descriptive terms.

Which of the following are myths regarding pain and pain treatment in older adults? (Select all that apply.)

A) Pain is an inevitable part of aging.
B) Older clients are unable to tolerate opioids.
C) The pain center in older adults diminishes over time.
D) Older adult clients are at greater risk for the development of conditions that are painful.

A, B, and C

Pain is not an inevitable part of aging. Older adult clients can tolerate opioids, although these drugs are best begun at a low dosage and the dosage gradually increased as needed. There is no one pain center in the brain, and the components of the nervous system associated with pain transmission do not diminish over time. It is true that as one ages, one is at greater risk for the development of painful conditions.

Which of the following are important adverse effects of nonsteroidal antiinflammatory drugs (NSAIDs) for which the nurse continually assesses older adult clients receiving long-term NSAID therapy? (Select all that apply.)

A) Diarrhea
B) Liver failure
C) Renal insufficiency
D) Gastrointestinal (GI) bleeding

C and D

Renal insufficiency and GI bleeding are frequent adverse effects of long-term NSAID use in older clients. The normal aging process results in decreased renal function, and the addition of NSAIDs may accelerate this process. NSAIDs are common over-the-counter drugs, and as a result, clients may believe these drugs are safe in high dosages. Liver failure can occur with consumption of acetaminophen. Diarrhea is not usually an adverse effect of NSAID use.

The vital functions associated with survival, which include heart rate, blood pressure, and respiration, are controlled by which of the following?

A) Cerebral cortex
B) Pituitary gland
C) Medulla oblongata
D) Reticular formation

C) Medulla oblongata

The medulla oblongata controls the heart rate, blood pressure and respirations. These are not controlled by the other portions of the brain.

While assessing a person for effects of the general adaptation syndrome, the nurse should be aware that:

A) Heart rate increases in the resistance state.
B) Blood volume increases in the exhaustion stage.
C) Vital signs return to normal in the exhaustion stage.
D) Glucose level increases during the alarm reaction stage.

D) Glucose level increases during the alarm reaction stage.

Glucose levels increase during the alarm stage. Heart rate decreases and stabilizes during the resistance stage. During the exhaustion stage, the physiological response has intensified and the ability to adapt to stress diminishes.

A client avoids emotional conflict by refusing to consciously acknowledge anything that might cause intolerable emotional pain. The client is using the defense mechanism of:

A) Denial
B) Conversion
C) Dissociation
D) Displacement

A) Denial

Denial is avoiding emotional conflicts by refusing to consciously acknowledge anything that cause intolerable pain. Conversion is unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms. Dissociation is experiencing a subjective sense of numbing and reduced awareness of one's surroundings. Displacement is transferring emotions, ideas, thoughts, and wishes from a stressful situation onto a less anxiety-producing substitute.

When performing an assessment of a young woman who was in an automobile accident 6 months before, the nurse learns that the woman has vivid images of the crash whenever she hears a loud, sudden noise. The nurse recognizes this as:

A) Social phobia
B) Acute anxiety
C) Posttraumatic stress disorder
D) Borderline personality disorder

C) Posttraumatic stress disorder

Posttraumatic stress disorder can include flashbacks to a trauma or recurrent recollections of the event. Social phobias are typically not related to a trauma. Acute anxiety is a short-term anxiety. The information given does not indicate a borderline personality disorder.

A man is adjusting to chronic illness. This is an example of:

A) Critical thinking
B) Response to a situational factor
C) Response to a maturational factor
D) Response to a sociocultural factor

B) Response to a situational factor

Situational stressors are stressors confined to a specific situation, such as adjusting to a chronic illness. Maturational factors are the stressors that occur with different life stages. Sociocultural factors are specific to the client's social and cultural group. Critical thinking is a nursing skill.

A child who has been in a house fire comes to the emergency department with her parents. The child and parents are upset and tearful. During the nurse's first assessment of the child for stress, the nurse should say what to the child?

A) "Tell me whom I can call to help you."
B) "Tell me what bothers you the most about this experience."
C) "I will contact someone who can help get you temporary housing."
D) "I will sit with you until other family members can come help you get settled."

B) "Tell me what bothers you the most about this experience."

Trying to get the child to talk about the event may be comforting to the child. Because the client in this case is a child, the client may not have the resources to tell the nurse whom to call.

The nurse is evaluating the coping success of a client experiencing stress from being newly diagnosed with multiple sclerosis and psychomotor impairment. The nurse realizes that the client is coping successfully when the client says:

A) "I'm going to learn to drive a car so I can be more independent."
B) "My sister says she feels better when she goes shopping, so I will go shopping."
C) "I have always felt better when I go for a long walk. I will do that when I get home."
D) "I'm going to attend a support group to learn more about multiple sclerosis and what I will be able to do."

D) "I'm going to attend a support group to learn more about multiple sclerosis and what I will be able to do."

Option D shows successful coping. The other options do not demonstrate appropriate coping skills for a client with psychomotor impairment.

A client newly diagnosed with type 2 diabetes exhibits denial when she says, "My blood sugar was just a little high. I don't have diabetes." The nurse responds with:

A) "Let's talk about something cheerful."
B) "Do other members of your family have diabetes?"
C) "I can tell that you feel stressed to learn that you have diabetes."
D) Silence. The nurse understands that the denial is a defense mechanism that assists in coping with a shock.

D) Silence. The nurse understands that the denial is a defense mechanism that assists in coping with a shock.

Denial is a protective mechanism and helps the client to begin to deal with a stressor. Silence can be very helpful in allowing the client to begin to think about the new diagnosis. After a period of silence, depending on the client, beginning to discuss the diagnosis is then appropriate.

A staff nurse is talking with her nursing supervisor about the stress she feels on the job. The supervising nurse recognizes that:

A) Nurses who feel stress usually pass the stress along to their clients.
B) Nurses who feel stress are ineffective as nurses and should not be working.
C) Nurses who talk about feeling stress are unprofessional and should calm down.
D) Nurses frequently experience stress with the rapid changes in health care technology and organizational restructuring.

D) Nurses frequently experience stress with the rapid changes in health care technology and organizational restructuring.

Nursing can be a stressful profession, and the fields of nursing and technology are rapidly changing. This creates stress for all individuals. The other options are incorrect.

Increased blood volume, heart rate, blood glucose levels, and mental alertness occur during which part of the general adaptation syndrome (GAS)?

A) Alarm reaction
B) Resistance stage
C) Exhaustion stage
D) Situational crisis

A) Alarm reaction

The GAS is divided into a three-stage reaction to stress. The first stage is the alarm reaction. It is characterized by an increase in hormone levels leading to the initiation of a fight-or-flight reaction. During the resistance stage of the GAS, the body stabilizes itself and responds in a manner opposite to that in the alarm reaction stage. It is during this time that the body repairs any damage that may have occurred. However, if stress continues and there is no adaptation, the client will enter the third or exhaustion stage. The exhaustion stage is reached when the body can no longer resist the effects of the stressor and when the energy necessary to maintain adaptation is depleted. The body can no longer defend itself against the impact of stressful events, and if this situation continues, death may result. A situational crisis is not part of the GAS.

A client comes to an outpatient psychiatric unit complaining of frequent flashbacks and nightmares. The nurse listens attentively to the client as he describes vividly his military duties during the Vietnam War. This information leads the nurse to believe the client is experiencing which of the following?

A) Bipolar disorder
B) Chronic depression
C) Developmental crisis
D) Posttraumatic stress disorder

D) Posttraumatic stress disorder

Posttraumatic stress disorder is a psychiatric disorder caused by exposure to a very traumatic event the effects of which may last well after the event ends. It may have a delayed onset longer than 4 weeks after the event and persists longer than 1 month. A bipolar disorder is characterized by episodes of mania and depression. It is not typically initiated by a traumatizing event. Chronic depression is an emotional condition characterized by feelings of hopelessness and inadequacy that continue over a long period. A developmental crisis is associated with changing developmental levels and is not the result of a traumatizing event.

A client's effort to manage psychological stress is known as:

A) Coping
B) Distress
C) Primary appraisal
D) Secondary appraisal

A) Coping

Coping is a client's ability to take action to change a stressful situation and successfully deal with the pressure of stress. Secondary appraisal is the tool a client uses to identify the appropriate coping strategy for stress that is already present. Primary appraisal is the ability of the client to evaluate an event for its personal meaning and determine how the stress will affect the body in the long term. Distress is not associated with coping; it is a type of damaging stress.

The theory of nursing that views the person, family, or community as constantly changing in response to the environment and stressors is known as:

A) Situational crisis theory
B) Neuman's systems model
C) Pender's health promotion model
D) Hans Selye's general adaptation syndrome

B) Neuman's systems model

Neuman's systems model is based on the concepts of stress and reaction to stress. Pender's health promotion model focuses on increasing the level of well-being of an individual or group by encouraging stress reduction strategies. Situational crisis theory does not exist as a formal theory; however, a situational crisis is described as a situation in which a person faces a turning point in life. Hans Selye's general adaptation syndrome is a three-stage reaction of the body in response to stress.

To adequately interview a client, the nurse must first establish which of the following?

A) Coping strategy
B) Judgmental attitude
C) Defense mechanism
D) Trusting relationship

D) Trusting relationship

Development of a trusting relationship with a client is imperative. This allows the client to feel comfortable and more open to verbalizing concerns about his or her stress. Defense mechanisms are used to regulate emotional distress and give a person protection from anxiety and stress. Coping strategies are dependent on the individual's needs, and the nurse can assist the client in developing strategies to better cope with the client's stress. If the nurse adopts a judgmental attitude when obtaining a health history from the client, the client may feel threatened and may not disclose vital information important for proper diagnosis and treatment of his or her problem.

The anterior pituitary gland is stimulated to secrete a substance that in turn stimulates the adrenal gland to release cortisol. What is the substance secreted by the pituitary gland?
A) Parathyroid hormone (PTH)
B) Follicle-stimulating hormone (FSH)
C) Thyroid-stimulating hormone (TSH)
D) Adrenocorticotrophic hormone (ACTH)

D) Adrenocorticotrophic hormone (ACTH)

The hypothalamus releases corticotropin-releasing hormone, which stimulates the pituitary gland to secrete ACTH. This, in turn, stimulates the adrenal gland to secrete cortisol. If a problem arises during this sequence of events, the adrenal gland may shut down, so that no cortisol is released. This can be detrimental to a client's health, especially during a stressful situation, because cortisol assists the body in combating stress. Thyroid-stimulating hormone is not categorized as a stress hormone. It is responsible for stimulating the thyroid gland. Parathyroid hormone is not associated with stress. Although follicle-stimulating hormone is secreted by the pituitary gland, it is not associated with stress; it stimulates the testes in the male and the ovaries in the female.

Which of the following systems recognizes bacteria as a threat or stress to the body and attacks them?

A) The immune system
B) The circulatory system
C) The reproductive system
D) The gastrointestinal system

A) The immune system

The immune system is involved in the stress response. Physiological responses to stress include immunological responses, and research has shown that when the body is in a prolonged state of stress, illness ensues. The gastrointestinal system is not a part of the stress response. The reproductive system is not typically affected by the stress response. The circulatory system is affected by the stress response during the alarm reaction stage of the general adaptation syndrome.

Physiological signs of stress that occur during the early stage of the general adaptation syndrome (GAS) include all of the following except:

A) Impaired mentation
B) Increased pulse rate
C) Increased blood pressure
D) Increased respiratory rate

A) Impaired mentation

Impaired mentation is not considered an early physiological response to stress; rather, mental alertness increases during the early stage. Blood pressure and respiratory rate rise during the alarm stage of the GAS. The medulla oblongata sends messages throughout the body to increase and decrease vital functions such as blood pressure and respiratory rate as necessary. The pulse rate increases during the alarm stage of the GAS. Again, the medulla oblongata is responsible for this reaction.

The nurse assists a client in connecting a stressful event with the client's reaction to the event. This approach is known as:

A) Evaluative care
B) Problem solving
C) Crisis intervention
D) Situational intervention

C) Crisis intervention

Crisis intervention aims to return the client to a precrisis level of functioning and to promote growth. Evaluative care is not a method of intervention; however, evaluation is a means of determining if the goals and expected outcomes of care set forth by the nurse and client are being achieved. Problem solving is not an appropriate answer; however, the nurse may assist the client in finding ways of coping with problems. Situational intervention is not an appropriate term; crisis intervention is a specific type of brief psychotherapy with prescribed steps.

Stress that is considered damaging is known as:

A) Crisis
B) Eustress
C) Distress
D) Fight-or-flight response

C) Distress

Distress is considered damaging stress with which a client may have problems coping. Eustress is defined as stress that leads to motivating energy, such as happiness, hopefulness, and purposeful movement. Crisis is a turning point in life that may be developmental or situational. The fight-or-flight response is arousal of the sympathetic nervous system.

Socialization of a 6-year-old child from Mexico into the Mexican culture is best described as:

A) Assimilation
B) Biculturalism
C) Enculturation
D) Acculturation

C. Enculturation is socialization into one's own culture. Acculturation is the process of adopting a new culture. Assimilation results when an individual gradually adopts and incorporates the characteristics of the dominant culture. Biculturalism occurs when an individual identifies equally with two or more cultures.

A 46-year-old woman from Bosnia came to the United States 6 years ago. Although she did not celebrate Christmas when she lived in Bosnia, she celebrates Christmas with her family now. This woman has experienced assimilation into the culture of the United States because she:

A) Chose to be bicultural
B) Adapted to and adopted the American culture
C) Had an extremely negative experience with the American culture
D) Gave up part of her ethnic identity in favor of the American culture

B. Assimilation results when the individual adopts and incorporates the characteristics of the dominant culture, such as celebrating holidays of the dominant culture. There is not enough information to consider the other options.

For a nursing student to enhance cultural awareness, the student will need to make an in-depth self-examination of:

A) Motivation and commitment to caring
B) Social, cultural, and biophysical factors
C) Engagement in cross-cultural interactions.
D) Background, including recognition of biases and prejudices

D. Cultural awareness is an in-depth self-examination of one's own background, including recognizing one's biases and prejudices and assumptions about other people.

Cultural competence is the process of:

A) Learning about the large number of cultures
B) Developing motivation and commitment to caring
C) Influencing the treatment and care of clients
D) Acquiring specific knowledge, skills, and attitudes

D. Cultural competence is the process of acquiring specific knowledge, skills, and attitudes that ensure delivery of culturally congruent care. The other options are incorrect.

Ethnocentrism is the root of:

A) Cultural beliefs
B) Biases and prejudices
C) Meanings by which people make sense of their experiences
D) Individualism and self-reliance in achieving and maintaining health

B. Ethnocentrism is the cause of biases and prejudices that associate negative characteristics with people who are different from a valued group. These are individual beliefs, not cultural beliefs, and do not help people make sense of their experiences.

When action is taken on one's prejudices:

A) Discrimination occurs.
B) Effective intercultural communication develops.
C) Delivery of culturally congruent care is ensured.
D) Sufficient comparative knowledge of diverse groups is obtained.

A. Discrimination occurs when one acts on one's prejudices. These actions do not allow for the delivery of culturally competent care, and they create barriers for effective intercultural communication and the ability to learn about different groups.

Which activity would not be expected by the nurse to meet the cultural needs of the client?

A) Developing the structure and process for meeting cultural needs on a regular basis and means to avoid overlooking these needs in clients
B) Expecting the client's family to keep an interpreter present at all times day and night to assist in meeting the communication needs of the client while hospitalized
C) Promoting and supporting attitudes, behaviors, knowledge, and skills to respectfully meet the client's cultural needs despite the nurse's own beliefs and practices
D) Ensuring that the interpreter understands not only the client's language but also the feelings and attitudes behind cultural practices to make sure an ethical balance can be achieved

B. It is not the family's responsibility to assist in the communication process. Many families will leave someone to help at times, but it is the hospital's legal obligation to find an interpreter to provide continued understanding of the client and to ensure that the client is fully informed and comprehends in his or her primary language. The nurse should respect and recognize cultural needs in every client to be able to give holistic care to every client. The nurse should not use as interpreter a person who barely speaks the language, because many elements in language communication involve more than just saying the right words. Ongoing assessment and planning for incorporating cultural needs into the larger picture of health care will allow the client to feel fully cared for while in the hospital.

Culture strongly influences pain expression and need for pain medication. However, cultural pain:

A) Is not expressed verbally or physically
B) Is expressed only to others of like culture
C) Is more intense, thus necessitating more mediation
D) May be suffered by a client whose valued way of life is disregarded by practitioners

D. Clients suffer cultural pain when health care providers disregard their valued way of life. Cultural pain may or may not be intense and may or may not be expressed, and the individual and his or her culture will choose to whom the client expresses this pain.

The dominant values in American society of individual autonomy and self-determination:

A) Do not have an effect on health care
B) Rarely have an effect on those of other cultures
C) May be in direct conflict with the values of diverse groups
D) May hinder the ability to gain admission to hospice programs

C. Individual autonomy and self-determination are not societal values in all cultures, so what is valued by most Americans may not be valued in other cultures. These values do have an affect on health care, will not hinder the ability to gain admission to hospice programs, and will affect those of other cultures.

The best explanation of what Title VI of the Civil Rights Act mandates is the freedom to:

A) Pick any physician and insurance company despite one's income.
B) Enjoy equal access to all health care regardless of race and religion.
C) Receive free medical benefits as needed within the county of residence.
D) Receive basic care under a sliding scale payment plan from all health care facilities.

B. Title VI mandates that no person in the United States, regardless of race, color, or national origin, shall be excluded from participation in, denied benefits of, or be subjected to discrimination under any program receiving federal funding. The act does not say that care must be given at no charge but that the services or health care must be offered equally to all without bias. Payment guidelines are not the focus of the act; private and public organizations such as medical institutions can charge according to their own policies and are not regulated by the federal government.

The role of the nurse in planning care for a culturally diverse population can best be described as:

A) Focusing only on the needs of the client, ignoring the nurse's beliefs and practices
B) Including care that is culturally congruent with the nursing staff based on predetermined criteria
C) Providing care while remaining aware of one's own bias and focusing on the client's individual needs rather than the staff's practices
D) Blending the values of the nurse that are for the good of the client and minimizing the client's individual values and beliefs during care

C. Unless the nurse understands his or her own beliefs and values, a bias or preconceived belief of the nurse could create an unexpected conflict or an area of neglect in the plan of care for a client (who might be expecting something totally different from the care). Basing care on predetermined criteria that may or may not reflect the individual client's needs does not allow for individualization of care based on the client's culture. The nurse is still providing too much input if the plan is a blend of the nurse's and client's values. The focus of care is not to benefit the nurse but to meet specific needs of the client. The nurse in this description becomes the "guardian figure" who dictates what the "nurse believes" to be in the best interest of the client and does not include the client's own preferences or beliefs.

Which of the following statements related to cultural conflicts is an accurate definition?

A) Cultural ignorance is a refusal to accept another person's beliefs.
B) Ethnocentrism is a belief that one's own way of life is inferior to that of others.
C) Cultural blindness is the ability to see that there are differences among people.
D) Discrimination is bias against people because of age, gender, color, race, or beliefs.

D. A person who discriminates against others recognizes that there are differences among people and relies on his or her own values or beliefs about others to interpret their behaviors. Ethnocentrism is the belief that one's own value system and beliefs are superior not inferior to those of others. Cultural ignorance is failure to recognize or acknowledge that others have different values or beliefs that affect their behavior. Cultural blindness is a refusal to accept that there are differences among individuals based on beliefs, practices, and values. The culturally blind may see the difference but not give it value as a part of the focus of the individual's needs for care.

The nurse addressing cultural needs during the postpartum period knows that which of the following statements is correct?

A) Hindu mothers prefer bathing and sitz baths to feel clean after delivery and prefer liquid diets for several days after delivery.
B) In Western medicine it is common practice to perform religious rituals, such as a cleansing bath, before sexual relations are resumed after delivery.
C) Members of non-Western cultures have fewer problems with postpartum depression because attention is given to the mother's recovery for a longer period of time.
D) Eastern cultures, such as the Chinese, encourage activity and exercise by the mother soon after the delivery and a return to social involvement as soon as possible.

C. Americans are often more autonomous and have fewer friends and relatives who come for extended times to assist in the recovery period. Hindu beliefs call for bathing rituals that are performed only after bleeding has stopped, because blood is associated with pollution. Dietary practices do not call for consuming only liquids; rather, foods that are thought to balance the mother after delivery are recommended. In Eastern cultures the practice is to allow the mother to rest and be waited upon for at least a month. Ritualistic cleansing is an Eastern cultural practice, not an American or Western practice.

Which factors are least significant during assessment when gathering information about cultural practices?

A) Biocultural needs
B) Language, timing
C) Touch and eye contact
D) Pain perception and pain management expectations

A. Cultural practices do not influence biocultural needs, because biocultural needs are inborn risks that are related to a biological characteristic and not a learned cultural belief or practice. Language and timing do have an impact on how practices are shared with the health care provider. Touch and eye contact can be interpreted differently in other cultures. Pain is interpreted as having a variety of causes depending on culture. Pain can be perceived as punishment from God, a consequence of a past life, or something to be endured with or without the aid of certain behaviors.

Transcultural nursing involves:

A) Working in another culture to practice nursing within the limitations of that culture
B) Ignoring all cultural differences to provide the best generalized care to all clients
C) Combining all cultural beliefs into a practice that takes a nonthreatening approach to minimize cultural barriers and achieve equality of care for all clients
D) Using a comparative study of cultures to understand similarities and differences across human groups to provide specific individualized care that is culturally appropriate

D. Transcultural care means that the nurse understands and learns about specific cultural practices so that the nurse can integrate these practices into the plan of care for a client who adheres to these beliefs or practices in order to meet the client's needs in a holistic way. Transcultural nursing can be practiced anywhere; the nurse does not have to work within the given country under its practice limitations. Even if the nurse combines all cultural beliefs, the nurse still may not meet the belief needs of a specific client. The nurse cannot ignore needs and expect the plan of care to be satisfying or beneficial for an individual client. Taking a holistic approach to health care means meeting all of the physical, social, psychological, and spiritual needs of the client.

According to the Nurse Practice Act (NPA), how are cultural needs addressed?

A) There are no references to culture or ethnicity of clients in the NPA.
B) Knowledge of cultural aspects is to be incorporated into the plan of care to meet each client's unique needs.
C) Cultural needs can be ignored when the client is very ill and about to die, because physical needs are more important at this time.
D) Only scientifically based methods of treatment are to be used in nursing; use of other methods or therapies is not the role of the nurse.

B. Assessment and implementation of care must consider the total needs of the client, and cultural needs are one of the major areas of assessment. In the Standards of Professional Practice, the nurse is directed to follow all federal, state, and local laws governing the practice of registered nurses, and to provide nursing services without discrimination, regardless of the national origin, race, religion, or health problems of the client served. Cultural needs are incorporated, especially at the time of death, when many religious beliefs and practices of the client and family affect what care is expected from the health care team. A care activity does not have to have a scientific basis for it to be performed. If the client believes that a certain practice will help him or her get better and no harm is expected from the practice, the nurse is expected to support it for the betterment of the client.

Which of the following statements about culture is correct?

A) Subcultures are cultures that are inferior to others.
B) Culture is not inherited but is a result of socialization.
C) Cultural needs are the same as racial needs because they originate from biological traits that are unique to that group.
D) Cultural conflict is the inability of a person to decide which cultural pathway to follow when exposed to multiple cultures.

B. The process of gaining culture is a process of learning through exposure and incorporation of cultural elements into one's own belief system. Racial traits are genetically passed on and include such things as bone structure, tendencies to develop various disorders, and recognizable characteristics (texture of hair, shape of nose, etc.). Cultural concepts are not genetic but are learned and do not depend on biological traits. Subcultures are smaller recognizable groups within a larger societal group that have their own unique characteristics. Cultural conflict is the conflict between two values or beliefs that a person might have.

Which of the following should the nurse do when planning nursing care for a client with a different cultural background?

A) Identify how these cultural variables affect the health problem.
B) Speak slowly and show pictures to make sure the client always understands.
C) Allow the family to provide care during the hospital stay so that all rituals or customs are carried out.
D) Explain how the client must adapt to hospital routines to be effectively cared for while in the hospital.

A. Without assessment and identification of the client's cultural needs, the nurse cannot begin to understand how these might influence the health problem or health care management. Although the family can assist if they desire to do so, the nurse is legally responsible for giving care based on current assessments, for documenting problems, and for following current physician orders.

An emergency department nurse is caring for a client who was severely injured in a car accident. The client's family is in the waiting room. They are crying softly. The nurse sits down next to the family, takes the mother's hand, and says, "I can only imagine how you are feeling. What can I do to help you feel more at peace right now?" In this example, the nurse is demonstrating:

A) Prayer
B) Presence
C) Coaching
D) Instilling of hope

B. Behaviors that establish the nurse's presence include giving attention, answering questions, listening, and having a positive and encouraging (but realistic) attitude. This nurse is not coaching, offering prayer, or instilling hope.

A client states that he does not believe in the existence of God. This client most likely is:

A) An agenic
B) An atheist
C) An agnostic
D) An anarchist

B. An atheist does not believe in the existence of God. An agnostic believes that ultimate reality is unknown and probably unknowable. Anarchist and agenic are not terms related to spirituality.

As the nurse cares for a client in an outpatient clinic, the client remarks that he recently lost his position as a volunteer coordinator at a local community center. He expresses anger toward his former boss and toward God. The nurse knows that the priority at this time is to assess the client's spirituality in relation to his:

A) Vocation
B) Life satisfaction
C) Fellowship and community
D) Connectedness with his family and co-workers

A. This client is concerned about the loss of his position, and it is important to determine whether this was a job or a vocation, which has spiritual implications.

A client who is hospitalized with congestive heart failure says that she sees her illness as an opportunity and a challenge. Despite her illness, she is still able to see that life is worth living. This is an example of:

A) Hope
B) Faith
C) Values
D) Connectedness

A. Hope is a feeling that provides comfort during challenges. Faith is a relationship with a divinity or power that incorporates beliefs and values. Values provide a foundation for faith. Connectedness is the sense of being connected to a higher power.

A client expresses the desire to learn how to meditate. What does the nurse need to do first?

A) Answer the client's questions.
B) Help the client get into a comfortable position.
C) Select a teaching environment that is free from distractions.
D) Encourage the client to meditate for 10 to 20 minutes 2 times a day.

C. The nurse should first select an environment free of distractions, then help the client to get into a comfortable position. Next, the nurse should encourage the client to mediate for 10 to 20 minutes twice a day. Then the nurse should answer the client's questions.

A mother frequently prays for a child to change behaviors that lead to legal complications. This is an example of the use of spirituality to:

A) Reduce tension by balancing control.
B) Demonstrate that one is a caring parent.
C) Achieve a sense of individuation for the family.
D) Illustrate spiritual wellness to provide a child with a model for his or her own behavior.

A. Humans try to reduce the effect of tension in their lives by balancing control with spirituality. There is not enough information to determine whether the mother is a caring parent. Individuation is human's striving to connect and become a part of something outside of oneself. The question provides insufficient information regarding the spiritual wellness of the mother.

Religion is best defined as:

A) A highly personal and unique system of individuality
B) A source of comfort and motivation to achieve when a person is faced with a loss
C) A system of organized beliefs and worship that a person practices to outwardly express spirituality
D) A relationship with a higher power or authority that enables action and gives purpose and meaning to life

C. Religion is defined as a highly organized system of beliefs and worship that a person practices to outwardly express spirituality. Spirituality is a highly personal and unique system of individuality. Faith is a relationship with a higher power or authority that enables action and gives purpose and meaning to life. Hope provides comfort and motivation to achieve when a person is faced with a loss.

For nurses to develop knowledge about spirituality they must:

A) Realize that the focus is on the client only.
B) Experience an event that promotes incoherence.
C) Assume the role of spiritual leader during the client's spiritual crisis.
D) Gain insight about their own spirituality by understanding their own beliefs and values.

D. According to Friedemann, nurses develop their own spirituality through self-exploration to understand their own beliefs and values.

The nurse can apply the nursing process to address a client's spiritual needs by:

A) Consulting pastoral care personnel for interventions
B) Communicating through presence and touch
C) Simply assessing the client's choice of religious patterns
D) Assisting the client in using the nurse's methods of spiritual expression

B. Communication through presence and touch helps in the development of trust and rapport, which are necessary for spiritual care. Knowing the client's religious patterns and practices is not intervention and application of care. It is unethical of the nurse's to require a client to share the nurses beliefs and values. Consulting pastoral care personnel for interventions can represent avoidance of the need to intervene.

During assessment of a spiritually distressed client a nurse must establish trust and rapport. A key to the success of spiritual care is to:

A) Administer the JAREL spiritual well-being scale as an assessment tool.
B) Continuously offer reassurance that the crisis will work to the client's benefit.
C) Perform the assessment early to discover the client's choice of religious practices.
D) Conduct ongoing assessments over the course of the client's stay in the health care setting.

D. A key to success for spiritual intervention is to conduct ongoing assessments over the course of the client's care the health care setting. Early assessment is helpful but does not offer follow-up and consistency in care delivery. Performing the JAREL assessment tool is part of assessment and evaluation but does not ensure success in spiritual intervention. Telling the client that a crisis will work to the client's benefit is giving false reassurance.

When a client is in acute spiritual distress, the nurse focuses care on:

A) Relieving symptoms to provide the client with a sense of control
B) Advising the client to consult with others who have similar problems
C) Describing personal experience of a similar crisis to display sympathy
D) Discussing how the nurse's personal religious practices and beliefs will benefit the client

A. A client's spiritual health is closely tied to his or her physical and psychological well-being. When a client is in acute distress, the nurse focuses care on the relief of symptoms to provide the client with a sense of control. Advising the client to consult others with similar problems is avoidance and threatens the nurse's effectiveness as a partner in the nurse-client relationship. Explaining personal experiences demeans the client's own situation. Requiring a client to adopt the nurse's beliefs and religious practices is unethical.

Older adult clients become more aware of physical decline and inevitable losses. This awareness allows older clients to:

A) Plan for hospitalization and chronic illnesses.
B) Begin the process of grieving for their decline in health status.
C) Bargain with their higher power to prevent further decline.
D) Find meaning to balance the developmental conflict of ego integrity versus despair.

D. There is an association between an older adult's spirituality and the ability to adjust to or cope with illness. Older adults become more aware of physical decline and inevitable losses, which allows them to find meaning to balance the developmental conflict of ego integrity versus despair. There is not enough evidence for the need of the grieving process in this situation. Hospitalization and chronic illnesses are not considered an inevitable part of aging. Bargaining is a step of the grieving process, and, as noted, there is insufficient evidence of the need for grieving for physical decline in older adults.

Many religions forbid the consumption of certain foods. Pork is omitted from the diets of clients practicing which religions?

A) Hinduism, Islam, and Judaism
B) Buddhism, Islam, and Mormonism
C) Christianity, Islam, and Mormonism
D) Jehovah's Witness faith, Christianity, and Islam

A. Hinduism, Islam, and Judaism forbid any consumption of pork or pork products. The other religions allow pork consumption.

In assessment of a client's spiritual health, it is most important for the nurse to:

A) Notify the chaplain.
B) Establish trust and rapport.
C) Determine the client's religion.
D) Use the B-E-L-I-E-F assessment tool.

B. Establishing trust and rapport makes conversations more meaningful and assessment more successful. Determining the client's religion is not an assessment of the client's spirituality. Notifying the chaplain does not help the nurse determine a client's spiritual health. The B-E-L-I-E-F assessment tool is only one tool that can be used to complete an assessment.

The purpose of spiritual assessment tools is to:

A) Help clarify values and assess spirituality.
B) Identify the religious convictions of the client.
C) Help nurses avoid difficult spiritual discussions.
D) Give the nurse information to communicate to the chaplain.

A. Spiritual assessment tools clarify values and assess spirituality. Spiritual assessments may or may not identify religious values, depending on the client's beliefs. Spiritual assessment tools can assist the nurse in performing a spiritual assessment or having spiritual discussions with the client, but they do not allow the nurse to avoid the assessment. The purpose of these tools is not to obtain information to communicate to the chaplain, although this may be done.

The client is a Jehovah's Witness. He is most likely to refuse:

A) Meat
B) Medication
C) Blood products
D) Medical intervention

C. A Jehovah's Witness is likely to refuse blood products. Medications, meat, and medical intervention are typically acceptable to members of this religion.

The client, just diagnosed with breast cancer, is depressed, is angry with God, and is asking why she was ever born. She is demonstrating a nursing diagnosis of:

A) Spiritual distress
B) Dysfunctional grieving
C) Risk for spiritual distress
D) Readiness for enhanced spiritual well-being

A. Defining characteristics for the diagnosis of Spiritual distress include patterns that reflect the client's actual dispiritedness. This client does not demonstrate Readiness for enhanced spiritual well-being. The description shows that she already has dispiritedness, and therefore Risk for spiritual distress is not an appropriate diagnosis. She does not show Dysfunctional grieving at this time.

The client experienced a traumatic below-knee amputation. The central focus of the nurse's healing relationship with this client is:

A) Mobilizing hope
B) Assessing spirituality
C) Identifying barriers to spirituality
D) Locating spiritual resources in the community

A. Mobilizing hope is central to the healing relationship. Identifying barriers and assessing spirituality do not develop a healing relationship, nor does locating spiritual resources.


A) Intrapersonal
B) Interpersonal
C) Transpersonal

Intrapersonal - within one's self.
Interpersonal - with others and the environment.
Transpersonal - with an unseen higher power.

When repositioning an immobile client, the nurse notices redness over a bony prominence. When the area is assessed, the red spot blanches with fingertip touch, indicating:

A) A local skin infection requiring antibiotics
B) A stage III pressure ulcer needing the appropriate dressing
C) Sensitive skin that calls for the use of special bed linen
D) Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area

This observation is indicative of reactive hyperemia. This is not a local skin infection or a stage III pressure ulcer. Not enough information is given to determine whether the client has sensitive skin.

Which type of pressure ulcer consists of an observable pressure-related alteration of intact skin that may show changes in skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), and/or sensation (pain, itching) compared with an adjacent or opposite area on the body?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

A. In stage I the ulcer appears as a defined area of persistent redness in lightly pigmented skin and as a darker red, blue, or purple area in darker pigmented skin, with no open skin areas. The skin will be warmer or cooler than other areas, with a change in consistency and sensation. A stage II ulcer is characterized by partial-thickness skin loss involving the epidermis and possibly the dermis. In stage III the ulcer appears as a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. In stage IV the ulcer shows as a full-thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

When a wound specimen is obtained for culture to determine whether infection is present, the specimen should to be taken from:

A) Necrotic tissue
B) Wound drainage
C) Drainage on the dressing
D) The wound after it has first been cleansed with normal saline

D. The wound should be cleaned with saline, then a culture specimen should be obtained from the wound. Necrotic tissue, drainage on the dressing, and old wound drainage can harbor old bacteria that may not necessarily be infecting the wound.

Postoperatively a client with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the nurse sees that the sutures are open and that pieces of small bowel are visible at the bottom of the now opened wound. The correct intervention would be to:

A) Allow the area to be exposed to air until all drainage has stopped.
B) Place several cold packs over the area, with care taken to protect the skin around the wound.
C) Cover the area with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.
D) Cover the area with sterile gauze; place a tight binder over the areas; ask the client to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly.

C. In wound evisceration, the bowel extrudes from the body. The nurse should cover the visible bowel with sterile saline-soaked towels and notify the surgical team. The area should not be allowed to be exposed or to dry out. Cold packs and binders are not acceptable options.

Serous drainage from a wound is defined as:

A) Fresh bleeding
B) Thick and yellow drainage
C) Clear, watery plasma
D) Beige to brown and foul-smelling drainage

C. Serous drainage is clear, watery plasma. Bleeding is not serous. A thick, yellow drainage or beige to brown drainage is indicative of an infection.

For a client who has a muscle sprain, localized hemorrhage, or hematoma, application of which of the following helps to prevent edema formation, control bleeding, and anesthetize the body part?

A) Binder
B) Ice bag
C) Elastic bandage
D) Absorptive diaper

B. The application of cold will help constrict blood vessels, which will reduce swelling that occurs with bleeding and edema formation in a muscle sprain. It also provides a numbing effect. Binders and elastic bandages are not initial treatments for a sprain. A diaper would not be used for a muscle sprain.

Which of the following interventions is most appropriate in managing fecal and urinary incontinence in a client?

A) Keeping the buttocks exposed to air at all times
B) Applying a large absorbent diaper that is changed when completely saturated
C) Using an incontinence cleanser, followed by application of a moisture barrier ointment
D) Cleansing frequently, applying an ointment, and covering the areas with a thick absorbent towel

C. The use of an incontinence cleanser followed by application of a moisture barrier helps protect the skin when a client is incontinent. A diaper should be used to collect the feces and urine; however, the diaper should be changed as soon as it is wet—the nurse should not wait until the diaper is completely saturated. The client's dignity should be maintained by keeping the client covered.

Which of the following is the best description of a hydrocolloid dressing?

A) A dressing containing a seaweed derivative that is highly absorptive
B) Premoistened gauze placed over a granulating wound
C) A dressing containing a débriding enzyme that is used to remove necrotic tissue
D) A dressing that forms a gel which interacts with the wound surface

D. The wound contact layer of a hydrocolloid dressing forms a gel as fluid is absorbed and maintains a moist healing environment. It does not contain a débriding enzyme, a seaweed derivative, or premoistened gauze.

Placement of a binder around a surgical client with a new abdominal wound is indicated for:

A) Collection of wound drainage
B) Reduction of abdominal swelling
C) Reduction of stress on the abdominal incision
D) Stimulation of peristalsis (return of bowel function) from direct pressure

C. The binder helps support the abdominal muscles and prevent stress on the incision. It should be used with proper dressings that will collect wound drainage. A binder will not reduce swelling and will not stimulate peristalsis.

Application of a warm compress is indicated:

A) To relieve edema
B) For a client who is shivering
C) To improve blood flow to an injured part
D) To protect bony prominences from pressure ulcers

C. Warm compresses are used to improve blood flow to an affected part. Warm compresses are typically not used for edema relief. A warm compress will not necessarily help with shivering; extra blankets should be used instead. A warm compress will not protect from pressure ulcers.

Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, which results in tissue ischemia and ultimately tissue death. There are four stages of pressure ulcer formation. The nurse observes partial-thickness skin loss involving the epidermis and possibly the dermis. What stage of ulcer will the nurse document?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

B. Partial-thickness skin loss involving the epidermis and possibly the dermis is classified as a stage II ulcer. In stage I the ulcer appears as a defined area of persistent redness in lightly pigmented skin or a darker red, blue, or purple area in darker pigmented skin, with no open skin areas. In stage III the ulcer appears as a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. In stage IV the ulcer appears as a full-thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

There are three phases of wound healing. The nurse observes granulation tissue in a client's pressure ulcer. What phase of wound healing is represented by granulation tissue?

A) Maturation phase
B) Hemostasis phase
C) Proliferative phase
D) Inflammatory phase

C. Tissue granulation occurs in the proliferative phase. Maturation is the final stage of wound healing. Hemostasis occurs during the inflammatory phase.

The nurse observes all wounds closely. At what time is the risk of hemorrhage the greatest for surgical wounds?

A) Between 48 and 60 hours after surgery
B) Between 60 and 72 hours after surgery
C) During the first 24 to 48 hours after surgery
D) 7 days after surgery, when the client is more active

C. The risk is highest during the first 24 to 48 hours after surgery because of the possibility of poor clot formation, slipped surgical suture, or trauma to a blood vessel by a foreign object. The more time that passes after surgery, the greater the amount of healing, which lessens the risk of hemorrhage.

The autolytic, mechanical, chemical, and surgical methods that are often used during wound management are all methods of accomplishing what?

A) Wound dressing
B) Wound cleansing
C) Wound débridement
D) Stimulation of growth factors

C. Methods of débridement include mechanical, autolytic, chemical, and surgical methods. All of these methods share the common objective of removing nonviable, necrotic tissue. Dressing, cleansing and stimulation of growth factors are not part of débridement.

Several instruments are available for assessing clients who are at high risk for developing a pressure ulcer. The Braden Scale is the most commonly used. What risk factors are assessed using the Braden Scale?

A) Infection, hemorrhage, dehiscence, evisceration, and fistulas
B) Physical condition, mental condition, activity, mobility, and incontinence
C) Sensory perception, moisture, activity, mobility, nutrition, friction, and shear
D) Nutrition, tissue perfusion, infection, age, shear force and friction, and moisture

C. The Braden Scale measures the following risk factors: sensory perception, moisture, activity, mobility, nutrition, friction, and shear. The Norton Scale measures five risk factors: physical condition, mental condition, activity, mobility, and incontinence. Infection, hemorrhage, dehiscence, evisceration, and fistulas are the complications of wound healing. The factors that influence pressure ulcer formation and wound healing are nutrition, tissue perfusion, infection, age, shear force and friction, and moisture.

A 40-year-old client is a new paraplegic. The client is about to be discharged from the rehabilitation center. Prevention of pressure ulcers has been an important part of the client's education. In providing this education, the nurse should have included which of the following guidelines?

A) The client should sit in chair for no longer than 3 hours.
B) The client should use a donut-shaped chair cushion.
C) The client should use a rigid cushion for full support.
D) The client should shift the weight in a chair every 15 minutes.

D. Shifting weight frequently prevents prolonged pressure that may lead to pressure ulcer formation. The guideline for sitting up in a chair is to sit for 2 hours or less, but it is only a guideline. The nurse should individualize activity for each client. Sitting on rigid or donut-shaped cushions is contraindicated because they reduce blood supply to the area, which increases the area of ischemia.

During the skin assessment of an older adult client who had a stroke, the nurse noted a reddened area over the coccyx. The next actions of the nurse for this client should include:

A) Massaging the reddened area and repositioning the client
B) Placing the client in Fowler's position and returning in 2 hours
C) Inserting a urinary catheter to prevent accumulation of moisture from urinary incontinence
D) Repositioning the client off the coccygeal area and reassessing the area in 1 hour

D. Repositioning the client and reassessing the area in 1 hour is the most appropriate action for the nurse. When pressure is relieved from an area, the blood flow returns and the redness will disappear if no damage has occurred. This is the appropriate assessment. Placement in Fowler's position would only increase pressure on the coccyx. Massaging of a reddened area is not recommended because it could cause further injury if the tissue is already compromised. Insertion of a urinary catheter will not relieve pressure on the coccyx.

The nurse is to collect a specimen for culture after assessing the client's wound drainage. The best technique for obtaining the culture is to:

A) Cleanse the wound first.
B) Send the soiled dressing to the laboratory.
C) Swab from the outside skin edge inward.
D) Collect the specimen from accumulated drainage.

A. Cleansing the wound first and swabbing the granulation tissue will provide a culture specimen that will show a more accurate picture of any causative organisms of wound infection. Sending a soiled dressing and collecting a specimen from accumulated drainage are not appropriate, because old and new drainage are mingled, and the drainage is possibly growing organisms of its own and may not provide a true reflection of the wound flora. Swabbing from the outer edge of the skin inward may introduce organisms into the wound and contaminate the culture specimen.

The nurse applies a hydrogel dressing to a client with radiation-damaged skin. Why is a hydrogel dressing the best choice for this client?

A) It provides a wicking action.
B) It permits the nurse to view the wound.
C) It is soothing and reduces pain in the wound.
D) It can be used as a preventative dressing for high-risk friction areas.

C. Hydrogel dressings are gauze or sheet dressings impregnated with a water- or glycerin-based amorphous gel. They are very useful in managing painful wounds because they are very soothing to the client and do not adhere to the wound bed, so that dressing removal causes little trauma. A hydrocolloid dressing may be used as a preventative dressing for clients with high-risk friction areas. A self-adhesive, transparent film dressing allows for viewing of the wound. The oldest and most common wound dressing is the gauze sponge, which is especially useful in wicking away wound exudates.

The nurse places an aquathermia pad on a client with a muscle sprain. The nurse informs the client that the pad should be removed in 30 minutes. Why will the nurse return in 30 minutes to remove the pad?

A) A local response occurs.
B) A systemic response occurs.
C) Reflex vasodilation occurs.
D) Reflex vasoconstriction occurs.

D. If heat is applied for 1 hour or longer, blood flow is reduced by reflex vasoconstriction. Vasoconstriction is the opposite of the desired effect of heat application. Reflex vasodilation occurs when an application of cold is left on too long. Reflex vasodilation is the opposite of the desired effect of cold application. Systemic response and local response are general and vague terms.

A client's personal preferences for hygiene are influenced by a number of factors. The nurse must recognize that:

A) The nurse is in charge of the care.
B) Hygiene care is a routine procedure.
C) Hygiene has no influence on client outcomes.
D) No two individuals perform hygiene in the same manner.

D) No two individuals perform hygiene in the same manner.

Each individual performs personal hygiene in his or her own manner, and the nurse should respect the client's wishes. Hygiene can be a routine procedure, but the routine changes with client preferences. Hygiene can influence client outcomes.

The Healthy People 2010 initiative included recommendations to improve:

A) Dental health
B) Skin care in the elderly
C) Medication management in the elderly
D) The American diet, by adding more carbohydrates

A) Dental Health

The Healthy People 2010 initiative (see Chapter 6) includes recommendations to improve the dental health of the population of the United States. The goals for oral health are to decrease tooth loss caused by tooth decay or periodontal disease for people aged 35 to 44; reduce the number of older adults who have lost their natural teeth; reduce the prevalence of gingivitis; and reduce destructive periodontal disease among individuals aged 35 to 44.

The clients most in need of perineal care are those at greatest risk of:

A) Dying
B) Falling
C) Acquiring an infection
D) Needing to be institutionalized

C) Acquiring an infection

Absence of perineal care can put a client at risk for an infection. Those at greatest risk of infection should receive appropriate perineal care. The other options involve populations that are also at risk for infections.

Clients will experience conditions that threaten the integrity of the oral mucosa; therefore:
A) No mouth care is needed.
B) Less oral hygiene is needed.
C) No antiinfective agents are needed.
D) More frequent mouth care is needed.

D) More frequent mouth care is needed

Clients with conditions that pose greater risk to the integrity of the oral mucosa need more frequent mouth care to ensure that the mouth is clean and free of infection.

The priority when providing oral hygiene to an unconscious client is to:

A) Prevent aspiration.
B) Prevent mouth odor.
C) Prevent dental caries.
D) Prevent mouth ulcerations.

A) Prevent aspiration.

When providing oral hygiene to an unconscious client, the nurse should position the client appropriately and use suction to ensure that there is no risk of aspiration. Good oral hygiene is still necessary to prevent mouth odor, dental caries, and ulcerations.

Depending on the client's age and physical condition, the room temperature should be maintained between:

A) 20° and 23.3° C (68° and 74° F)
B) 23.9° and 25° C (75° and 77° F)
C) 25.6° and 26.7° C (78° and 80° F)
D) 18.3° and 21.1° C (65° and 70° F)

A) 20° and 23.3° C (68° and 74° F)

A comfortable room temperature should be maintained for the client, about 20° to 23.3° C (68° to 74° F), depending on the client's comfort

A client with head and neck cancer has begun receiving radiation therapy to the right side of the neck. Because of the radiation treatments, the nurse includes which of the following interventions in the client's plan of care?

A) Gargling with mouthwash every 8 hours
B) Lemon glycerin swabs to the mouth every 2 hours
C) Mouth care every 4 hours with a nondrying mouthwash
D) Nothing by mouth (NPO) status during radiation therapy treatments

C) Mouth care every 4 hours with a nondrying mouthwash

Radiation therapy to the head and neck can impair the secretion of saliva. Routine and frequent mouth care is essential. The nurse does not want to use mouth care products that contribute to further drying of the mucous membranes of the mouth. There is no reason that clients must remain NPO during radiation therapy. In fact, offering fluids is important during this time to assist in hydrating the mucous membranes. The products in options 1 and 2 are very drying and irritating to the mucous membranes of the mouth and should be avoided.

A nurse working in a nursing home decides to implement a stringent mouth care protocol. The most important reason to establish this protocol is that proper oral care:

A) Prevents the formation of caries
B) Improves the client's self-image
C) Minimizes the occurrence of halitosis
D) Can reduce the incidence of pneumonia in the elderly

D) Can reduce the incidence of pneumonia in the elderly

Proper oral care reduces the bacterial count in oral secretions, which decreases the risk of bacterial pneumonia if oral secretions are aspirated. The other options are all true; however, they are not the most important reason for adequate mouth care, although they are additional positive outcomes

After performing a home assessment, a home care nurse might make which of the following safety recommendation to a family who will be caring for an older adult mother after discharge from the hospital?

A) Set the water heater to a temperature that is not scalding.
B) Change all the water faucets so that the mother can easily turn them on and off.
C) Relocate the mother's bedroom upstairs so that she is not bothered by the activity of other family members.
D) Place a small throw rug in the bathroom to absorb water dripping off the body so that the mother will not fall.

A) Set the water heater to a temperature that is not scalding.

Lowering the water temperature in the hot water heater will prevent accidental burning of the mother's fragile skin during bathing.

The nurse understands that providing a complete bed bath may have which of the following cardiovascular effects and thus plans for rest periods during the bath?

A) Increase in oxygen supply
B) Decrease in glucose demand
C) Increase in oxygen consumption
D) Decrease in blood supply to the skin

C) Increase in oxygen consumption

Turning during a complete bed bath and receiving back care increases oxygen demand and consumption. Thus it is important for the nurse to provide rest periods and monitor heart rate before, during, and after the bath. Blood flow to the skin should increase with gentle rubbing from the bath. Glucose demand should increase as a result of increased activity. Oxygen supply is not increased with a complete bed bath, but oxygen demand does increase.

Upon examining the feet of an older adult client with type 2 diabetes, the nurse notices long, thick nails. The client says that the nails catch on his socks and asks the nurse to cut them. The most appropriate intervention for the nurse to implement is:

A) Soaking the feet in warm water before trimming the toenails
B) Calling the physician and asking for a foot care nurse consult
C) Providing toenail cutters to the client, because nurses are not allowed to do this procedure
D) Instructing an unlicensed assistant (UAP) to cut the toenails after the morning care

B) Calling the physician and asking for a foot care nurse consult

Foot and nail care are considered part of the client's regular hygiene routine, except for clients with diabetes mellitus. Because of impaired circulation to the feet, cutting of toenails, particularly if they are thickened from long-standing fungal infections, is risky and could cause an infection. Soaking the feet of a client with type 2 diabetes is not recommended because of the increased risk for infection. A client with type 2 diabetes most likely also has impaired vision, and the client could cut the skin or break a toenail if the client attempted to cut the toenails himself or herself, which could result in a serious infection. In many institutions registered nurses are not permitted to cut the toenails of a client with type 2 diabetes; therefore, instructing the UAP to perform this task is inappropriate.

A client receiving an anticoagulant questions the nurse about mouth care. Which of the following mouth care practices would the nurse recommend?

A) Obtaining an electric toothbrush to use for teeth cleaning
B) Gargling with an alcohol-based mouthwash after each meal
C) Brushing the teeth 2 or 3 times a day using a hard-bristle brush
D) Gently flossing between the teeth once a day or more using unwaxed floss

D) Gently flossing between the teeth once a day or more using unwaxed floss

Vigorous flossing is to be avoided because it may cause the gums to bleed. Use of unwaxed floss encourages gentle flossing. Toothbrushes should be soft, not hard. Hard bristles may cause bleeding at the gums. Although an electric toothbrush is nice to have, it is not required. Many clients may not be able to afford an electric toothbrush. Alcohol is drying to the mucous membranes of the mouth. This could lead to cracking and bleeding. It is best to avoid these harsh products.

The nurse explains to a client with a new set of upper and lower dentures that the dentures should be cared for daily by doing which of the following? (Select all that apply.)

A) Removing them at night
B) Storing them in an enclosed labeled cup
C) Covering them with water when they are not being worn
D) Cleaning them with a weak bleach solution weekly

A, B, and C

Removing dentures at night allows the gums to rest and prevents bacterial buildup. Covering the dentures with water when they are not being worn prevents warping. Storing them in an enclosed labeled cup prevents accidental disposal of the dentures. Cleaning with a weak bleach solution weekly may adversely affect the matrix of the dentures. The dentist should be consulted for the best cleaning techniques for dentures.

When assessing darkly pigmented skin for bruising, the nurse is sure to do which of the following? (Select all that apply.)

A) Use a fluorescent lamp.
B) Look for grayish, eggplant-colored areas.
C) Compare one side of the body with the other.
D) Use the back of a gloved hand to feel for skin temperature.

B and C

Comparing sides of the body will allow the nurse to more easily see variations in skin color. Bruising will not appear red as in pink or white skin but will show variations of blue, purple, or gray. Fluorescent lamps can give the skin a bluish tone and thus hinder skin assessment in darkly pigmented skin. To accurately assess the temperature of the skin, no gloves should be used.

Hygienic care requires close contact with the client. The nurse initially uses which of the following to promote a caring therapeutic relationship?

A) Assessment skills
B) Therapeutic touch
C) Fundamental skills
D) Communication skills

A, C, and D

Because hygienic care requires close contact with the client, the nurse uses communication skills to promote a caring therapeutic relationship and to take advantage of the time with the client for teaching and counseling.

A person's body image or sense of his or her physical appearance is which type of concept?
A) Social
B) Objective
C) Subjective
D) Developmental

A, B, C, and D

A client's general appearance reflects the importance hygiene holds for that person. Body image is a person's concept of his or her body, including physical appearance, structure, and function. A person's body image includes all of the four concepts listed.

Which of the following laboratory values would the nurse expect to see for a client experiencing prolonged immobility?
A) Calcium 11.5 mg/dl
B) Sodium 142 mmol/L
C) Potassium 4.2 mmol/L
D) Hemoglobin 14.6 g/dl

A. Immobility causes the release of calcium into the circulation, whereas normally the kidneys excrete the excess calcium. However, if the kidneys are unable to respond appropriately, hypercalcemia results. Pathological fractures may occur if calcium reabsorption continues as the client remains on bed rest or continues to be immobile.

A client has been on bed rest for several days. The client stands, and the nurse notes that the client's systolic pressure drops 20 mm Hg. Which of the following should the nurse document in the medical record?
A) Rebound hypotension
B) Positional hypotension
C) Orthostatic hypotension
D) Central venous hypotension

C. Orthostatic hypotension is a drop in blood pressure when the client goes from a horizontal to a vertical position. Having the client sit for 2 minutes before standing can help prevent this. The pressure drop described is not rebound, positional, or central venous hypotension.

The nurse puts elastic stockings on a client after major abdominal surgery. The nurse teaches the client that the stockings are used after a surgical procedure to:
A) Prevent varicose veins.
B) Prevent muscular atrophy.
C) Ensure joint mobility and prevent contractures.
D) Facilitate the return of venous blood to the heart.

D. Use of elastic stockings facilitates the return of venous blood to the heart, so that clients are less likely to experience deep venous thrombosis. These stockings will not prevent varicose veins or muscular atrophy. Exercises are required to prevent muscular atrophy and ensure joint mobility.

The nurse is caring for a client who has osteoporosis. The nurse is teaching her about ways to prevent fractures. Which of the following statements by the client reflects a need for further education?

A) "I usually go swimming with my family at the YMCA three times a week."
B) "I need to ask my doctor if I should have a bone mineral density check this year."
C) "If I don't drink milk at dinner, I will eat broccoli or cabbage to get the calcium that I need in my diet."
D) "The more frequently I walk, the more likely I will be to fall and break my leg. I think I will get a wheelchair so I don't have to walk anymore."

D. Clients with osteoporosis need to get regular exercise, including weight-bearing exercise such as walking, to limit the progression of the disease. Clients who do not get exercise are at greater risk for additional pathological fractures and bone loss. The other options indicate learning by the client.

Which of the following clients is at greatest risk for developing adverse effects of immobility?

A) 3-year-old child with a fractured femur
B) 78-year-old man in traction for a broken hip
C) 48-year-old woman following a thyroidectomy
D) 38-year-old woman undergoing a hysterectomy

B. A client in traction is at the greatest risks for adverse effects of immobility. The other clients described are individuals who are still able to move around to some degree and have less immobility than the individual in traction.

A client who was in a car accident and broke his femur has been immobilized for 5 days. When the nurse gets this client out of bed for the first time, a nursing diagnosis related to the safety of this client would be:
A) Pain
B) Impaired skin integrity
C) Altered tissue perfusion
D) Risk for activity intolerance

D. This client has a risk of activity intolerance due to his 5 days of immobilization. There is no discussion of pain in the question. The client may or may not have impaired skin integrity and altered tissue perfusion.

A client had a left-sided cerebrovascular accident 3 days ago and is being given 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The client is receiving enteral feedings through a small-bore nasogastric tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately?
A) Hematuria
B) Unilateral neglect
C) Limited range of motion in the right hip
D) Coughing up of a moderate amount of clear, thin sputum

A. Because of the client's heparin injections, he is at risk for bleeding. Hematuria is a sign that the client is possibly bleeding out. Limited range of motion, the coughing up of clear, thin sputum, and unilateral neglect are not medical emergencies.

The nurse is caring for a client who has right-sided weakness. The nurse needs to help the client walk. What should the nurse do while walking with the client?
A) Hold the client's left hand while walking.
B) Hold the client's right hand while walking.
C) Put a gait belt on the client and provide support on the left side.
D) Put a gait belt on the client and provide support on the right side.

D. A gait belt helps stabilize the client and helps the client maintain the center of balance. The nurse should always stand on the client's affected side and support the client when using a gait belt. Providing support by holding the client's arm is incorrect, because the nurse cannot easily support the client's weight to lower the client to the floor if the client faints or falls. In addition, if the client falls with the nurse holding an arm, the shoulder joint may be dislocated.

The nurse suspects the client is at risk for falling. Which of the following statements made by the client would most alert the nurse to this risk?
A) "My cancer has been in remission for 5 years."
B) "I have lost 20 pounds during the past 6 months."
C) "I recently began taking medication for high blood pressure."
D) "I no longer have pain in my knee after physical therapy."

C. The ability to balance can be impaired by dizziness, which is a side effect of high blood pressure medication. Cancer in remission and slow weight loss are not something that typically causes a fall risk. The cessation of pain in a knee should decrease a fall risk, not increase it.

Fibrous tissues that bind joints together, connecting bone and cartilage, are known as:
A) Tendons
B) Ligaments
C) Skeletal muscles
D) Cartilaginous tissues

B. Ligaments are elastic and provide joint flexibility and support. Tendons are fibrous bands of tissue that connect muscle to bone. Cartilaginous tissue is nonvascular supporting connective tissue located in the joints, thorax, trachea, larynx, nose, and ear. Skeletal muscles are the working elements of movement.

The hip joint is classified as what type of joint?
A) Fibrous
B) Synovial
C) Synostotic
D) Cartilaginous

B. The hip joint, with a ball-and-socket structure, is a synovial joint that moves freely. A synostotic joint is bone joined by bone. A cartilaginous joint is a synchondrodial joint, in which there is little movement. A synovial joint is a syndesmodial joint, in which two bony surfaces are united by a ligament.

When a client is immobilized, which of the following positions is preferred to prevent skin breakdown?
A) Semi-Fowler's
B) Side-lying with knees flexed
C) Prone with upper extremities flexed
D) Supine with lower extremities extended

A. Semi-Fowler's is the preferred position because the head of bed is elevated 30 degrees. Side-lying with knees flexed will put pressure on the greater trochanter area. The supine position with lower extremities extended puts pressure on the scapula, buttocks, calf, and heels. The prone position with extremities flexed puts pressure on the anterior pelvis, knees, and elbows.

An immobilized client is at risk for:
A) Hyponatremia
B) Hypocalcemia
C) Hypernatremia
D) Hypercalcemia

D. Immobility leads to the release of calcium from bone into the bloodstream. Hypocalcemia is calcium deficiency and is not a result of immobility. Neither hypernatremia, which is an elevated sodium level, nor hyponatremia, which is a sodium deficiency, is caused by immobility.

The most significant hazard of restricted mobility is:
A) Foot drop
B) Tachycardia
C) Deep vein thrombosis
D) Orthostatic hypotension

C. Deep vein thrombosis is the most significant hazard of restricted mobility because an embolus may develop from a dislodged thrombus. Orthostatic hypertension is a drop in blood pressure when the individual moves from supine to sitting or standing. A recumbent position leads to an increase in cardiac workload, which results in tachycardia. Foot drop is a common debilitating contracture.

Which of the following nursing interventions is most important for preventing deep vein thrombosis in an immobilized client?
A) Measuring calf circumference daily
B) Dorsiflexing the foot of the extremity in which thrombosis is suspected
C) Providing passive range-of-motion exercise on every shift
D) Ensuring that compression devices are fitted correctly and pumping

D. Compression devices decrease venous stasis. Measuring calf circumference will not prevent a thrombus, only help to monitor for one. Active rather than passive range-of-motion exercise will help prevent thrombi. Dorsiflexion of an extremity suspected of having a thrombus may dislodge the thrombus.

Which of the following is the highest priority nursing diagnosis for an immobilized client?
A) Risk for disuse syndrome
B) Risk for deficient fluid volume
C) Ineffective airway clearance
D) Ineffective peripheral tissue perfusion

C. Airway is always the highest priority. Neither circulation, disuse syndrome, nor deficient fluid volume takes priority over airway.

What type of diet is most important for an immobilized client?
A) Low protein
B) Low residue
C) Restricted carbohydrate
D) High protein, high calorie

D. A high-protein, high-calorie diet provides fuel to meet metabolic needs and replace subcutaneous tissues. Neither a low-residue diet nor a low-protein diet will provide adequate fuel or help in building tissues. A restricted-carbohydrate diet will not provide adequate fuel to meet metabolic needs.

The immobilized client should be instructed to:
A) Eat a restricted-calorie diet.
B) Take in a minimum of 2000 ml of water per day.
C) Deep breathe and cough every 4 hours.
D) Quickly resume walking exercises when able.

B. Drinking 2000 ml of water per day helps keep mucociliary clearance normal. The client should cough and deep breathe every 2 hours. A restricted-calorie diet will not help meet metabolic needs. Exercises should always be resumed gradually.

Before transferring a client from the bed to a stretcher, the nurse must assess to determine which of the following? (Select all that apply.)
A) How much the client's weighs
B) Whether intravenous (IV) lines are present
C) What the client's nutritional status is
D) How cooperative the client is

A, B, and D.

Before transferring the client from bed to stretcher, the nurse needs to assess the weight of the client and the client's ability to cooperate to ensure that sufficient help is available. Assessing the client's nutritional status helps the nurse to determine if special precautions are required. The nurse should always note the presence and position of IV tubing to ensure that IV lines are moved with the client during a transfer to prevent pulling them out.

Mr. Stone has been on bed rest for several days. When he attempts to walk with assistance he becomes dizzy and nauseated. These are most likely symptoms of which of the following?

A) Rebound hypertension
B) Orthostatic hypotension
C) Dysfunctional proprioception
D) Central nervous system rebound hypotension

B. Some clients experience orthostatic hypotension when changing from a horizontal to a vertical position. A client on bed rest is at greater risk for this. Rebound hypertension is a result of withdrawing medications. Dysfunctional proprioception is the inability to distinguish the location of the body in space.

What is the appropriate action for Mr. Stone when he experiences these symptoms? (Select the priority intervention.)

A) Call for assistance.
B) Allow Mr. Stone to sit down.
C) Take Mr. Stone's blood pressure and pulse.
D) Continue to ambulate Mr. Stone so he begins to build up endurance.

A. Call for assistance and allow Mr. Stone to sit down and rest for a few minutes. While he is resting, checking his blood pressure and pulse rate is a prudent thing to do. After he begins to feel better, he may again attempt to ambulate. Having the client sit on the side of the bed before walking for at least 1 to 2 minutes can help prevent orthostatic hypotension.

When a client has a right-sided cerebral hemorrhage, what may also be present?

A) Bilateral hemiplegia
B) Left-sided hemiplegia
C) Right-sided hemiplegia
D) Degenerative hemiplegia

B. The motor fibers from the right motor strip of the precentral gyrus regulate voluntary motion on the left side of the body, and the fibers on the left motor strip regulate voluntary motion on the right side of the body, so a right-sided hemorrhage is likely to create left-sided hemiplegia.

In which age groups do maturational processes produce the greatest observable change?

A) Adults and elders
B) Infants and elders
C) Adults and infants
D) Childhood and old age

D. Maturational processes cause the greatest change and have the most impact during childhood and old age. The other options are incorrect.

A client is more open to developing an exercise program if the client:

A) Is requested to exercise by a family member
B) Is at the stage of readiness to change his or her behavior
C) Has been diagnosed with a chronic disease such as diabetes
D) Has been ordered by the health care provider to begin an exercise program

B. A person is not open to developing an exercise program until the person is at the stage of readiness to change his or her behavior. Being ordered to begin a program by a health care provider or requested to do so by a family member may help motivate the client, but the client will not actually do it until the client is ready. The diagnosis of a chronic disease may be a motivator, but, again, until the client is ready, the client will not be able to begin a program.

Which of the following is a result of children's being less physically active outside of school?

A) An increase in obesity
B) An increase in heart disease
C) Greater computer literacy among children
D) Improved school attendance and grades

A. Children who are less physically active outside of school stand a greater likelihood of being obese. Later in life, this group may have a greater incidence of heart disease, but heart disease is not common during childhood. Obesity and the diseases that come with it can help increase school absences. Physical activity does not correlate with computer literacy.

Which of the following is a principle of good body mechanics when lifting or carrying objects?

A) Keeping the knees in a locked position
B) Bending at the waist to maintain a center of gravity
C) Holding objects away from the body for improved leverage
D) Maintaining a wide base of support and bending at the knees

D. Maintaining a wide base of support and bending at the knees allows for good body mechanics. Locking the knees may cause strain on the lower back, as can bending at the waist. Holding objects close to the body helps use the center of gravity for leverage.

A client begins to fall during ambulation. What should the nurse do to prevent injury to the client?

A) Call for assistance.
B) Instruct the client to sit in the nearest chair.
C) Prop the client up, and then complete the ambulation.
D) Slide the client down the nurse's body and leg to the floor.

D. The nurse should allow the client to slide to the floor while protecting the client's head from injury. This prevents injury to both the client and the nurse. After the client is seated on the floor, the nurse should call for assistance and transfer the client appropriately. Instructing the client to sit in the nearest chair may not be practical. Propping the client is an incorrect answer.

Buck's skin traction is being applied to the client's left leg because of a recent hip fracture. The client is scheduled for surgery in the morning. He is reporting pain in the left hip. The nurse should first:

A) Assess the extremity for pulses.
B) Remove the skin traction to examine the skin.
C) Assess alignment of the left leg with the pulley.
D) Determine the last time the client was given analgesics.

C. Pain may be due to incorrect alignment of the Buck's traction with the pulley. Determining when analgesics were last given should be done after alignment is evaluated, because the nonpharmacological intervention of alignment may be all that is needed to relieve the pain. A reassessment would be necessary after repositioning. Assessing for pulses is part of the neurovascular assessment and is appropriate to perform; however, it will not relieve pain. Removing the skin traction at this time might aggravate the pain.

Which of the following is something the nurse would plan to provide for a client after total hip replacement to reduce friction?

A) Trapeze
B) Fracture bedpan
C) Egg crate mattress overlay
D) Continuous passive motion machine

A. A trapeze will allow the client to lift the buttocks during linen changes, bedpan application, movement up in bed, and delivery of posterior skin care. Lifting decreases the pressure between the client and the bed. Use of a fracture bedpan would be more comfortable for the client but does not reduce friction. Placing an egg crate on the mattress will improve comfort, but it does not alleviate pressure nor does it reduce friction forces. A continuous passive motion machine is used after total knee replacements, not total hip replacements.

Before the client participates in physical therapy after total knee replacement, the nurse does which of the following?

A) Administers an analgesic 30 to 60 minutes before therapy
B) Places a heating pad over the affected knee 1 hour before therapy
C) Instructs the client to bend over and touch the toes as a warm-up exercise
D) Discontinues use of the continuous passive motion (CPM) machine 4 hours before therapy

A. Clients often experience pain during physical therapy, and thus their progress may be impeded. Administering analgesics before the therapy will help the client participate more fully. The CPM machine assists the client in maintaining mobility in the affected joint. Discontinuing it may cause the joint to become stiff and more painful during therapy. Application of heat would increase circulation to the knee and increase swelling. Application of cold would be more therapeutic. Having the client perform the described warm-up exercises may be inappropriate for this client and in fact may cause injury.

After consulting with the physician, the nurse prepares a client for crutch walking by implementing which of the following interventions to help the client increase the strength of the thigh muscles?

A) Providing a gait belt for the client to be used whenever the client ambulate to the bathroom or down the hallway
B) Placing a lift sheet under the client and instructing the client to call for the nurse whenever the client needs to be lifted to the head of the bed
C) Attaching a trapeze to the overbed frame and teaching the client to plant the foot in the bed and lift the buttocks off the bed 10 times every hour
D) Inserting a footboard at the end of the bed and encouraging the client to press the ball of the foot of the unaffected leg against the board for 10 repetitions, 4 times a day

D. Resistive isometric exercises of the foot against a footboard provide quadriceps-setting exercise, which promotes muscle strength and tone, and stress to the bone to promote bone healing. A trapeze and lift sheet help reduce friction forces when moving a client up in bed. They do not prepare muscles for crutch walking. Gait belts are an important part of safety when ambulating a client with crutches, but the belts themselves do not improve muscle strength.

The physician's orders for a client immediately after total hip replacement call for the client to engage in two-touch weight bearing only. The nurse reinforces which of the following crutch-walking techniques taught by the physical therapist?

A) Two point
B) Three point
C) Four point

B. The three-point crutch-walking technique requires the client to bear all of the weight on one foot. The weight of the affected leg is borne on both crutches and then on the uninvolved leg. The two-point technique is a "swing-through" gait, and although no weight would be placed on the affected leg, it also minimizes the amount of weight placed on the unaffected leg, which is unnecessary. This gait is usually used by clients with paralysis of both lower extremities. A four-point gait gives stability to the client but requires weight bearing on both legs.

Which structures control balance?

A) Eye and ear
B) Cerebrum and pons
C) Cerebellum and inner ear
D) Cerebral cortex and gyrus

C. The cerebellum is responsible for coordinating all voluntary movement and, along with the semicircular canals of the inner ear, controls balance. The cerebral cortex and the gyrus control major muscle movements, and the cerebrum and pons relay nervous impulses. The eye and ear are sensory organs that are involved in balance, but the eye does not control any balance functions.

A nurse working in a nursing home decides to collaborate with the physical therapists in developing an exercise program for some of the residents. In developing this program, the nurse knows that which of the following are correct? (Select all that apply.)

A) Tai chi is an excellent form of exercise for older adults.
B) Purchasing isometric exercise machines will be necessary.
C) Determining the clients' interests will be important.
D) The old-old residents (over 90 years of age) will not be able to participate in any exercise activity.

A and C

Practice of tai chi has resulted in reduced fear of falling and increased sense of well-being. It is never too late to start exercising. Although not all residents will be able to perform the same types of exercise, even simple stretching can enhance circulation. Purchasing expensive equipment is not necessary. Less expensive alternatives such as using a stretch band, lifting cans of soup, or rolling a large ball can be effective in improving circulation, muscle tone, and strength.

The nurse and an unlicensed assistant (UAP) are about to move a 200-lb client up in bed. Before lifting this client, the nurse instructs the UAP to do which of the following? (Select all that apply.)

A) Bend at the knees.
B) Stand as close to the bed as possible.
C) Face in the direction of the head of the bed.
D) Place feet close together, about 6 inches apart.
E) Bend slightly (30 degrees) at the waist toward the client.

A, B, and C

Standing close to the bed allows the weight lifted to be as close to the body as possible. This places the weight in the same plane as the lifter and close to the lifter's center of gravity for balance. By facing in the direction one is pulling the client, one avoids twisting. Bending at the knees helps the lifter maintain the center of gravity and lets the leg muscles do the work instead of the back muscles. The back should be maintained in an upright position, not bent over. This allows the stronger (leg) muscles to do the work. Body balance is achieved when a relatively low center of gravity is balanced over a wide base of support. The base of support can be widened by separating the feet to a comfortable distance, and balance is increased by bringing the center of gravity closer to the base of support.

A client is admitted with a suspected right-hemisphere stroke. The nurse anticipates that the client will most likely be paralyzed or weak on the _______ side of the body.


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