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Test 3

Nutrition/rest and sleep/ immobility

The coordinated efforts of the musculoskeletal and nervous system maintain balance, posture, and body alignment. Body alignment refers to The relationship of one body part to another.
A structural curvature of the spine associated with vertebral rotation is known as Scoliosis.
Unlike arthritis, joint degeneration Involves overgrowth of bone at the articular ends.
prevent a shift in the nurse’s base of support.
Approximately what percentage of all back pain is associated with manual lifting tasks? 50%
The nurse is preparing to position an immobile patient. Before doing so, the nurse must understand that Body mechanics alone are not sufficient to prevent injuries.
The nurse is preparing to reposition a patient. Before doing so, the nurse must Assess the weight to be lifted and the assistance needed.
In planning a physical activity program for a patient, the nurse must understand that The best program includes a combination of exercises.
An active lifestyle is important for maintaining and promoting health. In developing an exercise program, the nurse understands that
The nurse is developing an exercise program for elderly patients living in a nursing home. To develop a beneficial health promotion program, the nurse needs to understand that when dealing with the elderly
The nurse is attempting to start an exercise program in a local community as a health promotion project. In explaining the purpose of the project, the nurse explains to community leaders that A sedentary lifestyle contributes to the development of health-related problems.
The patient is eager to begin his exercise program with a 2-mile jog. The nurse instructs the patient to warm up with stretching exercises. The patient states that he is ready and does not want to waste time with a “warm-up.” The nurse explains that the w
Many patients find it difficult to incorporate an exercise program into their daily lives because of time constraints. For these patients, it is beneficial to reinforce that many ADLs are used to accumulate the recommended 30 minutes or more per day of mo Daily chores should begin with gentle stretches.
The nurse is developing an exercise plan for someone diagnosed with congestive heart failure and exercise intolerance. In doing so, the nurse should Perform 6-minute walks at the patient’s pace at least 2 times a day.
Which of the following exercise activities would most likely provide the opportunity for mind-body awareness? Cool-down activity
The patient is brought to the emergency department with possible injury to his shoulder. To help determine the degree of injury, the nurse should evaluate The patient’s range of motion.
The nurse is examining a patient who is admitted to the emergency department with severe elbow pain. Of the following situations, which would cause the nurse to suspect a ligament tear or joint fracture? Joint motion is greater than normal.
The patient has been bedridden for several months owing to severe congestive heart disease. In determining a plan of care for this patient that will address his activity level, the nurse formulates which of the following nursing diagnoses? Activity intolerance related to physical deconditioning
The patient weighs 450 lbs (204.5 kg) and complains of shortness of breath with any exertion. His health care provider has recommended that he begin an exercise program. He states that he can hardly get out of bed and just cannot do anything around the ho Activity intolerance related to excessive weight
The patient is being admitted for elective knee surgery. While the nurse is admitting the patient, she will Begin to develop a discharge plan.
The patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move his right arm and leg. The nurse understands that Passive range of motion must be instituted to help prevent contracture formation.
The patient has been in bed for several days and needs to be ambulated. Before ambulation, the nurse Dangles the patient on the side of the bed.
The nurse is ambulating a patient in the hall when she notices that he is beginning to fall. The nurse should Gently lower the patient to the floor.
In assisting the patient to exercise, the nurse should Stop the exercise if pain is experienced.
The nurse is developing a plan of care for a patient diagnosed with activity intolerance. Of the following strategies, which has the best chance of maintaining patient compliance? Instructing the patient to use an exercise log to record day, time, duration, and responses to exercise activity
The nurse is working with the patient in developing an exercise plan. The patient tells the nurse that she just will not participate in a formal exercise program. The nurse then suggests that exercise activities can be incorporated into activities of dail
Bones perform five functions in the body: support, protection, movement, mineral storage, and hematopoiesis. In the discussion of body mechanics, which are the most important? (Select all that apply.) Support Movement
When assessing the activity tolerance of a patient, the nurse would evaluate which of the following? (Select all that apply.) Skeletal abnormalities Emotional factors Age Pregnancy status
In developing a nursing care plan for increasing activity tolerance in a patient, the nurse should (Select all that apply.) Consult with members of the health care team. Involve the patient and the patient’s family in designing an exercise plan. Consider the patient’s ability to increase activity level.
CHP 38 Complete
The nurse is caring for a young adult patient on the medical-surgical unit. When doing midnight checks, she sees that the patient is awake and is doing a puzzle. What is the best explanation for the patient being awake? The patient’s sleep-wake cycle preference is late evening.
The nurse is providing an educational session on sleep regulation for new nurses in the Sleep Disorder Treatment Center. Which of these statements by the nurses would best indicate that learning has occurred? “If the patient has a disease process in the central nervous system, it can influence the functions of sleep.”
The nurse is caring for a patient who is having trouble sleeping. To encourage decreased stimulus to the reticular activating system and activation of the bulbar synchronizing region, which actions would the nurse implement? Encourage relaxed positions.
The nurse is caring for a patient in the sleep lab. The nurse recognizes that the patient is in stage 4 NREM from which of the following assessments? The patient is difficult to awaken
The patient shares with the nurse the vivid, full color dreams experienced by the patient last night. These data would indicate that the patient has reached what stage of sleep?
Which nursing observation of the patient in intensive care indicates that the patient is sleeping comfortably? Eyes closed, lying quietly, respirations 12, heart rate 60
The nurse is discussing with a new mother the sleep requirements of a neonate. Which of these comments would indicate that the patient has an understanding of the neonate’s sleeping pattern?
The nurse is discussing lack of sleep with a middle-aged adult. The nurse recognizes that insomnia in this age group is commonly due to Anxiety.
A single dad is discussing with the nurse the sleep needs of a preschooler. Which of the following directions would be most helpful to the parent? “The preschooler may have trouble settling down after a busy day.”
The nurse is having a conversation with an adolescent regarding the need for sleep. The adolescent states that it is common to stay up with friends several nights a week. Which nursing action should the nurse take? Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness.
The nurse is completing an assessment on an older patient who is having difficulty falling asleep. Which factor has the potential to contribute to this difficulty? Depression
The nurse is caring for an adolescent who is complaining of difficulty falling asleep. Which intervention would be most appropriate? Encourage the discontinuation of soda and chocolate nightly snack.
Which of the following would be most important for the nurse to monitor in a patient who has obstructive sleep apnea? Respiratory status
The patient has just been diagnosed with narcolepsy. The nurse provides an educational session and teaches the patient to avoid Sitting in hot, stuffy rooms.
The nurse is caring for a patient who has been in holding in the emergency department for 24 hours. The nurse is concerned about the patient experiencing sleep deprivation. What would be the best action for the nurse to take? Expedite the process of obtaining a medical-surgical room for the patient.
The nurse is completing a sleep assessment on a patient. The nurse utilizes which of the following tools to complete the assessment? Visual Analogue Scale
The nurse is beginning a sleep assessment on a patient. Which of the following would be the most appropriate question to ask? “How are you sleeping?”
The nurse assigns a nursing diagnosis of ineffective breathing pattern. Which of the following sleep conditions would support this diagnosis? Obstructive sleep apnea
The nurse is caring for a postpartum patient. The patient’s labor has lasted over 28 hours within the hospital; the patient has not slept and is disoriented to date and time. What is the most appropriate nursing diagnosis? Sleep deprivation
The patient presents to the clinic with reports of irritability, being sleepy during the day, not being able to fall asleep, and being tired. Select the most appropriate nursing diagnosis. Insomnia
The nurse is preparing an older patient’s evening medications. Which of the following does the nurse recognize as relatively safe for difficulty sleeping? Lorazepam
The nurse is caring for a patient on the medical-surgical unit who is experiencing an exacerbation of asthma. Which of the following interventions would be most appropriate to help the patient sleep? Bed placed in semi-Fowler’s position
A young mother has been hospitalized for an irregular heartbeat (arrhythmia). The night nurse comes in to see the patient awake. What would be the most appropriate nursing intervention? Take time to sit and talk with the patient about her inability to sleep.
The nurse is evaluating outcomes for the patient with the nursing diagnosis of Insomnia. During this process, the nurse recognizes that The patient is the best evaluator of sleep.
A patient has received a nursing diagnosis of sleep deprivation. Which of the following statements by the patient would indicate that outcomes are being met? “I feel rested when I wake up in the morning.”
The older patient is visiting the clinic after a fall during the night. Which of the following data points obtained most likely would contribute to this fall? The patient has been taking Benadryl (diphenhydramine).
The nurse is caring for a patient who has not been able to sleep well while in the hospital. The nurse recognizes that lack of sleep can manifest in which of the following signs and symptoms? (Select all that apply.) Changes in physiological function such as temperature Decreased appetite and weight loss Anxiety, irritability, and restlessness Impaired judgment
The nurse is caring for a patient in the intensive care unit who is having trouble sleeping. The nurse explains the purpose of sleep and its benefits. What points should the nurse include in her teaching? (Select all that apply.) NREM sleep contributes to body tissue restoration. Restful sleep preserves cardiac function. Sleep contributes to cognitive restoration. REM sleep decreases cortical activity.
The patient and the nurse discuss the need for sleep. After the discussion, the patient is able to state factors that hinder sleep. Which statements indicate that the patient has a good understanding of sleep? (Select all that apply.) “Drinking coffee at 7 PM could interrupt my sleep.” “Worry about work can disrupt my sleep.” “Staying up late for a party can interrupt sleep patterns.” “Exercising 2 hours before bedtime can decrease relaxation.”
A community health nurse is providing an educational session at the senior center on how to promote sleep. Which practices should the nurse recommend? (Select all that apply.) Sleep where you sleep best. Use sedatives as a last resort. Decrease fluids 2 to 4 hours before sleep. Get up if unable to fall asleep in 15 to 30 minutes.
Chapter 42 Complete
What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? Ask the patient to rate the level of pain.
A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient’s blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. “What would you like to try to alleviate your pain?”
Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain? “Meditation controls pain by blocking pain impulses from coming through the gate.”
A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student’s knowledge? “It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient’s response to the medication.”
The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patie Meaning of pain
The nurse anticipates administering an opioid fentanyl patch to which patient? A 50-year-old patient with prostate cancer
What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia? Labeling the tubing that leads to the epidural catheter
A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? Relaxation and guided imagery
Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective? “I feel less anxiety about the possibility of overdosing.”
A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management? “We should work together to create a regular schedule of medications that does not allow for breakthrough pain.”
A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient i The patient’s culture is possibly influencing the patient’s experience of pain.
A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide? “You need to drink plenty of fluids and eat a diet high in fiber.”
A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health Softly plays music that the patient finds relaxing
A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing educatio “You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot.”
A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, “The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the Visceral pain
A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA? The patient rates pain at an acceptable level of 3 on a 0 to 10 scale.
The nurse recognizes that which of the following is a modifiable contributor to a patient’s perception of pain? Anxiety and fear
The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controllin The patient’s need for analgesic medication decreases during the dressing changes.
A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal antiinflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works? “Ibuprofen helps to decrease the production of prostaglandins.”
A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic? “Would you like medication to be given for dressing changes on top of your regularly scheduled medication?”
A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as n Ask the health care provider to verify the dosage and frequency of the medication.
The nurse knows that which technique is best for assessing pain in a child who is 4 years of age? Use the FACES scale.
Which statement made by a nursing educator best explains why it is important for nurses to determine a patient’s medical history and recent drug use? “This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief.”
A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management? “I need to reassess the patient’s pain 1 hour after administering oral pain medication.”
The nurse is assessing how a patient’s pain is affecting mobility. Which assessment question is most appropriate? “What activities, if any, has your pain prevented you from doing?”
The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding? “Pain assessment scales determine the quality of a patient’s pain.”
The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? The patient who is experiencing 8/10 pain and has a STAT order for pain medication
The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse’s assessment? Increasingly higher doses of opioid are needed to control pain.
A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient’s social history is the nurse most concerned about? Patient drinks 1 to 2 glasses of wine every night.
The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse’s first priority? Ask the patient to rate and describe the pain.
The nurse is caring for a patient who recently had surgery to repair a hernia. The patient’s pain was 7 out of 10 before receiving pain medication. One hour after receiving an oral opioid, the patient ranks his pain at 3 out of 10. The patient asks the nu “It can take 2 hours for oral pain medication to work, and your pain is going down. Let’s try boosting you up in bed and putting an ice pack on the incision to see if that helps.”
Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis? Give medications around-the-clock.
The nurse is caring for an infant in the intensive care unit. Which of the following is the most accurate description of factors that will influence the perception and management of pain for this patient? Infants respond behaviorally and physiologically to painful stimuli.
The nurse is administering ibuprofen (Advil) to an older patient. Which of the following assessment data causes the nurse to hold the medication? (Select all that apply.) Past medical history of gastric ulcer Stated allergy to aspirin
Chapter 43 Complete
The energy needed to maintain life-sustaining activities for a specific period of time at rest is known as BMR.
In general, when energy requirements are completely met by kilocalorie (kcal) intake in food Weight does not change.
In determining kcal expenditure, the nurse knows that carbohydrates and proteins provide 4 kcal of energy per gram ingested. The nurse also knows that fats provide _____ kcal per gram. 9
Some proteins are manufactured in the body, but others are not. Those that must be obtained through diet are known as Indispensable amino acids.
Knowing that protein is required for tissue growth, maintenance, and repair, the nurse must understand that for optimal tissue healing to occur, the patient must be in Positive nitrogen balance.
In providing diet education for a patient on a low-fat diet, it is important for the nurse to understand that with few exceptions Saturated fats are found mostly in animal sources.
Fats are composed of triglycerides and fatty acids. Triglycerides Are made up of three fatty acids.
The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, “How much fat should I have? I guess the less fat, the better.” The nurse needs to explain that Deficiencies occur when fat intake falls below 10% of daily nutrition.
The ChooseMyPlate program was developed to replace MyFoodPyramid as a basic guide for buying food and meal preparations. This system was developed by the U.S. Department of Agriculture.
The ChooseMyPlate program includes guidelines for Balancing calories.
The nurse is providing nutrition teaching to a Korean patient. In doing so, the nurse must understand that the focus of the teaching should be on Food preferences of the patient, including racial and ethnic choices.
When teaching a patient about current dietary guidelines for the general population, the nurse explains referenced daily intakes (RDIs) and daily reference values (DRVs), otherwise known as daily values. In providing this information, the nurse understand Have provided a more understandable format of RDAs for the public.
The nurse is teaching the patient about dietary guidelines. In discussing the four components of dietary reference intakes (DRIs), it is important to understand that The tolerable upper intake level (UL) is not a recommended level of intake.
In teaching mothers-to-be about infant nutrition, the nurse instructs patients Remember that breast milk or formula is sufficient for the first 4 to 6 months.
To counter obesity in adolescents, increasing physical activity is often more important than curbing intake. Sports and regular, moderate to intense exercise necessitate dietary modifications to meet increased energy needs for adolescents. The nurse under Ingesting water before and after exercise.
In providing prenatal care to a patient, the nurse teaches the expectant mother that Folic acid is needed to help prevent birth defects and anemia.
The patient is an 80-year-old male who is visiting the clinic today for his routine physical examination. The patient’s skin turgor is fair, but he has been complaining of fatigue and weakness. The skin is warm and dry, pulse rate is 126 beats per minute, Drink more water to prevent further dehydration.
The nurse is assessing a patient for nutritional status. In doing so, the nurse must Combine multiple objective measures with subjective measures.
The patient has a calculated body mass index (BMI) of 34. This would classify the patient as Obese.
Dysphagia refers to difficulty when swallowing. Of the following causes of dysphagia, which is considered neurogenic? Stroke
The patient is elderly and has been diagnosed with Imbalanced nutrition: less than body requirements. Her treatment regimen should include having the nurse
In determining the nutritional status of a patient and developing a plan of care, it is important to evaluate the patient according to Published standards.
In creating a plan of care to meet the nutritional needs of the patient, the nurse needs to explore the patient’s feelings about weight and food. The nurse must do this Mutually plan goals with patient and team.
The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. Given this information, which of the following tubes is appropriate for this patient? Jejunostomy tube
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, the nurse measures from the
Before giving the patient an intermittent tube feeding, the nurse should Have the tube feeding at room temperature.
At present, the most reliable method for verification of placement of small-bore feeding tubes is X-ray.
The nurse is concerned about pulmonary aspiration when providing her patient with tube feedings. The nurse should Verify tube placement before feeding.
The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. To prevent this, the nurse Checks with the pharmacy to find out if liquid forms of the medications are available.
The patient has just started on enteral feedings but is complaining of abdominal cramping. The nurse should Slow the rate of tube feeding.
The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. The most likely cause of the diarrhea would Formula intolerance.
Patients who are unable to digest or absorb enteral nutrition benefit from parenteral nutrition (PN). However, the goal to move toward use of the GI tract is constant because PN Can lead to villous atrophy and cell shrinkage.
The nurse is caring for a patient who will be receiving PN. To reduce the risk of developing sepsis, the nurse Wears a sterile mask when changing the CVC dressing
The patient is having at least 75% of his nutritional needs met by enteral feeding, so the physician has ordered the PN to be discontinued. However, the nurse notices that the PN infusion has fallen behind. The nurse should Taper the PN infusion gradually.
The patient is on PN and is lethargic. He has been complaining of thirst and headache and has had increased urination. Which of the following problems would cause these symptoms? Hyperglycemia
In providing diabetic teaching for a patient with type 1 diabetes mellitus, the nurse instructs the patient that Saturated fat should be limited to less than 7% of total calories.
The patient with cardiovascular disease must be taught how to reduce the risk of cardiovascular disease by balancing calorie intake with exercise to maintain a healthy body weight. In addition to this, the nurse instructs the patient to Limit saturated fat to less than 7%.
The nurse is providing home care for a patient diagnosed with AIDS. In preparing meals for this patient, the nurse should Provide small, frequent nutrient-dense meals.
To provide successful nutritional therapies to patients, the nurse must understand that Expectations of nurses frequently differ from those of the patient.
In measuring the effectiveness of nutritional interventions, the nurse should Evaluate outcomes according to the patient’s expectations and goals.
When expected nutritional outcomes are not being met, the nurse should Revise the nurse measures or expected outcomes.
Dietary reference intakes (DRIs) present evidence-based criteria for an acceptable range of amounts of vitamins and nutrients for each gender and age group. Components of DRIs include which of the following? (Select all that apply.) Estimated average requirement (EAR) Recommended dietary allowance (RDA) Adequate intake (AI) The tolerable upper intake level (UL)
The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient that from a nutritional point of view, the patient should (Select all that apply.) Maintain body weight in a healthy range. Choose and prepare foods with little salt. Increase physical activity.
When developing a plan of care for a patient with altered nutritional needs, the nurse must assess the patient for which of the following? (Select all that apply.) What is the condition now? Is the condition stable? Will the condition get worse? Will the disease process accelerate deterioration?
To create a new nutritional plan of care for a patient, the nurse needs to do which of the following? (Select all that apply.) Utilize the characteristics of a normal nutritional status. Design innovative interventions to meet the patient’s needs. Follow through with evaluation and counseling. Evaluate previous patient responses to nursing interventions.
What is meant by “concentric tension” of muscles? Increased muscle contraction results in movement.
Muscles that attach to bones to provide the needed strength to move an object use which of the following to obtain their objective? Leverage
Although isometric contractions do not result in muscle shortening, the nurse understands that isometric contractions Result in increased energy expenditure.
Joints are the connections between bones. The joint that is freely movable is known as the _____ joint. Synovial
The term body alignment refers to positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. A term that is similar to body alignment is Posture.
Without balance control, the center of gravity is displaced, thus creating risk for falls and subsequent injuries. Balance is enhanced by Keeping a low center of gravity
Immobilized patients frequently have hypercalcemia, placing them at risk Renal calculi.
Patients on bed rest or otherwise immobile are at risk for Altered metabolic function.
In caring for a patient who is immobile, it is important for the nurse to understand that Changes in role and self-concept may lead to depression.
Immobility is a major risk factor for pressure ulcers. In caring for the patient who is immobilized, the nurse needs to be aware that Immobilized patients can develop skin breakdown within 3 hours.
The nurse is caring for a patient who has been diagnosed with a stroke. As part of her ongoing care, the nurse should Encourage the patient to perform as many self-care activities as possible.
The nurse is assessing the way the patient walks. The manner of walking is known as the patient’s Gait.
When assessing the body alignment of a patient while he or she is standing, the nurse is aware that
The nurse is evaluating the body alignment of a patient in the sitting position. In this position Both feet are supported on the floor with ankles flexed.
The nurse is assessing body alignment for a patient who is immobilized. To do this, the nurse must Place the patient in a lateral position.
The nurse must assess the patient for hazards of immobility by performing a head-to-toe physical assessment. When assessing the respiratory system, the nurse should Auscultate the entire lung region to assess lung sounds.
The nurse is aware that patients who are immobile are at increased risk of developing deep vein thromboses (DVTs). Because of this, the nurse should Measure the calf circumference of both legs.
When assessing the skin of an immobilized patient, the nurse should Use a standardized tool such as the Braden Scale.
The nurse is caring for an elderly patient with the diagnosis of urinary tract infection (UTI). The patient is confused and agitated. It is important for the nurse to realize that confusion in the elderly is Not a normal expectation.
In preparing to create a nursing diagnosis for a patient who is immobile, it is important for the nurse to understand that All dimensions are important to health.
The patient who is experiencing an alteration in mobility often has one or more nursing diagnoses. The nurse would use the diagnosis of Impaired physical mobility for a patient who is Not completely immobile.
The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. This diagnosis means that the nurse should Assist the patient with comfort measures.
In developing an individualized plan of care for a patient, it is important for the nurse to Establish goals that are measurable and realistic.
When creating a plan of care for a patient who is experiencing alterations in mobility, the nurse Consults other health care team members to help plan therapy
The patient is being admitted to the neurological unit with the diagnosis of stroke. The nurse should begin discharge planning At the time of admission.
Of the following nursing goals, which is the most appropriate for a patient who has had a total hip replacement?
The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. The nurse is aware that the rate of occupational injury and illness in the hospital setting Is about 4.4%.
In caring for immobile patients, the nurse understands that back injuries occur
To prevent injury, the nurse should not begin a task (e.g., moving a bed from one room to another, lifting heavy objects) until the task can be completed safely. To prevent injury Tighten abdominal muscles and tuck the pelvis.
The patient is immobilized after undergoing hip replacement surgery. Which of the following would place the patient at risk for hemorrhage? Low-molecular-weight heparin doses to prevent DVT
The nurse needs to transfer the patient from the bed to the chair. The nurse should Assess for the need of a mechanical lift and help.
The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair. The nurse opts to use a mechanical lift (Hoyer lift). The nurse understands that when this lift is used, the
The nurse is caring for a patient with a spinal cord injury and notices that the patient’s hips have a tendency to rotate externally when the patient is supine. To help prevent injury secondary to this rotation, the nurse can use A trochanter roll.
The patient is unable to move himself and needs to be pulled up in bed. For this repositioning to be done safely, the nurse must understand that Assistive devices or additional nurses should be used
The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient’s toes. One strategy that the nurse could use is A foot cradle.
In applying for a job on a nursing unit that requires frequent patient positioning, the nurse should be aware that nurses Should be aware of agency policies.
When preparing a plan of care for an immobilized patient, the nurse should Use established expected outcomes to evaluate the patient’s response to care.
The director of a nursing home has decided to institute ergonomic programs in the facility because these programs increase employee satisfaction and have been shown to Enhance recruitment.
The nurse needs to reposition a 300-lb patient. Which of the following strategies is most likely to prevent back injury Assess and obtain the number of people needed to help.
The nurse is caring for a patient who has had a stroke causing total paralysis of the right side. To help maintain joint function and to prevent contractures, passive ROM will be initiated. When should therapy begin? As soon as the ability to move is lost
The nurse is admitting a patient who has been diagnosed as having had a stroke. The physician writes orders for “ROM as needed.” The nurse understands that Further assessment of the patient is needed.
While performing passive ROM exercises, the nurse stands at the side of the bed closest to the joint being exercised and Carries out movements slowly and smoothly.
The patient is admitted to a skilled care unit for rehabilitation 10 days after the surgical procedure of fixation of a fractured left hip and has a nursing diagnosis of Impaired physical mobility related to musculoskeletal impairment from surgery and pai Assist the patient with ambulation and measure how far she walks.
The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique to keep the spinal column in straight alignment. Which of the following is the proper technique for logrolling? Obtain assistance from at least two or three other people.
Correct body alignment reduces strain on musculoskeletal structures and contributes to balance. Balance control is attained by (Select all that apply.) Maintaining a wide base of support. Keeping the body’s center of gravity low. Maintaining correct body posture.
The nurse is caring for a patient with the diagnosis of Impaired physical mobility. The nurse needs to be alert for which of the following potential complications? (Select all that apply.) Pulmonary emboli Pneumonia Impaired skin integrity
The nurse is caring for a patient who has had a recent stroke and is paralyzed on his left side. He has no respiratory or cardiac issues, but he cannot walk. He becomes extremely frustrated when he cannot button his shirt and cannot feed himself because h Physical therapy Psychology services Occupational therapy
Chapter 47 Complete
Created by: SED5111