Review For Exam 4

. While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has:

 

• Paralysis of the legs

• Weakness affecting on half of the body

• Paralysis affecting on half of the body

• Paralysis of the arms and legs

Answer explanation

Answer: A

 

Rationale: Paraplegia is paralysis of the legs, and quadriplegia is paralysis of the arms and legs. Hemiparesis refers to weakness of one-half of the body, and hemiplegia is paralysis of one-half of the body.

Question format: Multiple Choice

Chapter 34: Activity

Cognitive Level: Understand

Client Needs: Physiological Integrity: Physiological Adaptation

Integrated Process: Nursing Process

Reference: p. 1259

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

• Fowler

• Low Fowler

• Protective Supine

• Semi Fowlers

Answer explanation

Answer: A

 

Rationale: Fowler position optimizes cardiac function and respiratory function in addition to being the best position for eating. The client's risk of aspiration would be extreme in a supine position. Low Fowler and semi-Fowler are synonymous, and this position does not aid swallowing as much as a high Fowler position.

Question format: Multiple Choice

Chapter 34: Activity

Cognitive Level: Apply

Client Needs: Physiological Integrity: Basic Care and Comfort

Integrated Process: Nursing Process

Reference: p. 1270

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

• To ensure knowledgeable client care

• To promote health and prevent illness

• To prevent Unnecessary insurance claims

• To demonstrate knowledge and skills

Answer explanation

Answer: B

 

Rationale: The correct use of body mechanics is a part of health promotion and illness prevention. The nurse has a major responsibility to teach good body mechanics, both directly and indirectly, by example.

Question format: Multiple Choice

Chapter 34: Activity

Cognitive Level: Understand

Client Needs: Safe, Effective Care Environment: Safety and Infection Control

Integrated Process: Nursing Process

Reference: p. 1245-1247

 

The home health nurse is placing a client in the Fowler's position in an adjustable bed in the client's home. What information should the nurse teach the family about the Fowler's position?

 

• "Use at least two big pillows to support the client's head."

• "Cross the client's arms over the abdomen when moving the client."

• "Avoid bending the mattress at the knee level."

• "Keep the hands lower than the rest of the body."

Answer explanation

Answer: C

 

Rationale: When the client is in the Fowler's position, avoid bending the knee of the bed and, thus, the knee of the client. Bending the knee causes pressure on the popliteal space, impairs circulation to the lower extremity, and increases the risk of clot formation. Allow the head to rest against the mattress or use only a small pillow. Support the forearms on pillows, with the hand slightly elevated above the forearm. Do not bend the mattress at the knee level.

Question format: Multiple Choice

Chapter 34: Activity

Cognitive Level: Apply

Client Needs: Physiological Integrity: Basic Care and Comfort

Integrated Process: Teaching/Learning

Reference: p. 1270-1272

13. The nurse cares for a newly admitted client who will soon need to be taken to the radiology department for a CT scan. The client has a body mass index (BMI) of 52. Which of the following strategies to transport the client is most appropriate?

• A. obtaining a mechanical lateral transfer device to move the client onto a stretcher

• B. enlisting the aid of two other staff members and pulling the client across the bed and onto a stretcher

• C. positioning a friction-reducing sheet under the client before attempting the transfer

• D. transporting the client to the radiology department in the hospital bed

Answer explanation

Answer: A

 

Rationale: The combined weight of the bed and client will be difficult to move safely. Mechanical lateral-assist devices include specialized stretchers and eliminate the need to slide the patient manually. A portion of the device moves from the stretcher to the bed, sliding under the patient, bridging the bed and stretcher. The device is then returned to the stretcher, effectively moving the patient without any pulling by staff members. The other options do not address the need to transfer the client onto, and off, equipment in the radiology department.

Question format: Multiple Choice

Chapter 34: Activity

Cognitive Level: Apply

Client Needs: Safe, Effective Care Environment: Safety and Infection Control

Integrated Process: Nursing Process

Reference: p. 1267

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair 3 times per day. Which action will be most effective to transfer the client safely into the chair?

• A. having the client sit on the side of the bed for several minutes before moving to the chair

• B. infusing an intravenous fluid bolus 15 minutes before transferring the client into the chair

• C. positioning a friction-reducing sheet under the client

• D. obtaining a quad cane for the client to use as a transfer aid

Answer explanation

Answer: A

 

Rationale: Having the client sit at the side of the bed minimizes the risk for blood pressure changes (orthostatic hypotension) that can occur with position change.

Question format: Multiple Choice

Chapter 34: Activity

Cognitive Level: Apply

Client Needs: Physiological Integrity: Reduction of Risk Potential

Integrated Process: Nursing Process

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial action by the nurse is appropriate?

• A. Firmly grasp the client's gait belt.

• B. Support the client's body against yours and gently slide the client onto the floor.

• C. Ask the client to lean against the wall while you obtain a wheelchair.

• D. Apply oxygen and wait several minutes for the weakness to pass.

• E. Ask the client, "When was the last time you ate?"

Answer explanation

Answer: B

 

Rationale: Assessing for the potential causes of the weakness should occur after the client's safety is assured.

Question format: Multiple Choice

Chapter 34: Activity

Cognitive Level: Apply

Client Needs: Safe, Effective Care Environment: Safety and Infection Control

Integrated Process: Nursing Process

Reference: p. 1278-1279

Which client would be the most appropriate candidate to move by using a powered stand-assist device?

• A. a comatose client who is being taken for x-rays

• B. an alert client after knee-replacement surgery who is being assisted to ambulate

• C. an obese client who has Alzheimer disease and is being escorted to the shower room

• D. a car accident victim with fractures in both legs who is being moved to another room

Answer explanation

Answer: B

 

Rationale: Powered stand-assist devices can be used with clients with weight-bearing ability on at least one leg who can follow directions and who are cooperative. Clients who are unable to bear partial weight or full weight or who are uncooperative should be transferred with a full-body sling lift.

Question format: Multiple Choice

Chapter 34: Activity

Cognitive Level: Analyze

Client Needs: Safe, Effective Care Environment: Safety and Infection Control

Integrated Process: Nursing Process

Reference: p. 1267

 

When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the client. What is the rationale for using a transfer board in this procedure?

• A. to lift the client off the bed

• B. to slide the board with the client onto the stretcher

• C. to reduce friction as the client is pulled laterally onto the stretcher

• D. to protect the client's head from hitting the headboard

Answer explanation

Answer: C

 

Rationale: The transfer board or other lateral-assist device reduces friction, easing work load to move the client. It is positioned partially under the client, across the space between the bed and stretcher.

Question format: Multiple Choice

Chapter 34: Activity

Cognitive Level: Understand

Client Needs: Physiological Integrity: Reduction of Risk Potential

Integrated Process: Nursing Process

Reference: p. 1294-1295

The nurse is leading an exercise class for a group of adults aged 65 years and older. The nurse incorporates isotonic, isometric, and isokinetic exercises into the class. Which activity is an isometric exercise?

• A. sitting in a chair with a low weight on the ankle and lifting the knee to the seat level of the chair

• B. walking single file at a rate of 3 miles (5 km)/hour around a racetrack two times

• C. contracting the gluteal muscles while holding a simple yoga pose

• D. carrying an air-filled ball while wading through the water across the width of a pool

Answer explanation

Answer: C

 

Rationale: An example of an isometric exercise is contracting the gluteal muscles while holding a simple yoga pose. Examples of isotonic exercise are walking around the track and wading across the pool. Lifting a leg that has a weight attached is an example of isokinetic exercise.

Question format: Multiple Choice

Chapter 34: Activity

Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching/Learning

Reference: p. 1251-1253