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A patient on bed rest for several days attempts to walk with assistance. He becomes dizzy and nauseated. His pulse rate jumps from 85 to 110 beats/min. 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 (Orthostatic hypotension)
(Signs and symptoms of orthostatic hypotension include dizziness, light-headedness, nausea, tachycardia, pallor, and even fainting.)
Which action(s) are appropriate for the nurse to implement when a patient experiences orthostatic hypotension? (Select all that apply.)
A) Call for assistance.
B) Allow patient to sit down.
C) Take patient's blood pressure and pulse.
D) Continue to ambulate patient to build endurance.
E) If patient begins to faint, allow him to slide against the nurse's leg to the floor.
A, B, C, E
(If the patient has a fainting "syncope" episode or begins to fall, assume a wide base of support with one foot in front of the other, thus supporting the patient's body weight see Fig. 38-5, A to C. Extend one leg and let the patient slide against it; gently lower the patient to the floor, protecting his or her head. Take the patient's blood pressure and pulse as soon as possible after incident.)
Which of the following best motivates a patient to participate in an exercise program?
A) Giving a patient information on exercise
B) Providing information to the patient when the patient is ready to change behavior
C) Explaining the importance of exercise when a patient is diagnosed with a chronic disease such as diabetes
D) Following up with instructions after the health care provider tells a patient to begin an exercise program
B (Providing information to the patient when the patient is ready to change behavior)
(Patients are more open to developing an exercise program when they are at a stage of readiness to change their behavior. Once the patient is at the stage of readiness, collaborate with him or her to develop an exercise program that fits his or her needs and provide continued follow-up support and assistance until the exercise program becomes a daily routine.)
Which of the following is a principle of proper body mechanics when lifting or carrying objects?
A) Keep the knees in a locked position.
B) Bend at the waist to maintain a center of gravity.
C) Maintain a wide base of support.
D) Hold objects away from the body for improved leverage.
C (Maintain a wide base of support.)
(Maintaining a wide base of support allows for proper body mechanics. Locking the knees or bending at the waist causes strain on the lower back. Holding objects close to the body helps use the center of gravity for leverage.)
Which group of patients is at most risk for severe injuries related to falls?
A) Adolescents
B) Older adults
C) Toddlers
D) Young children
B (Older Adults)
(Some older adults walk more slowly and are less coordinated. They also take smaller steps, keeping their feet closer together, which decreases the base of support. Thus body balance is unstable, and they are at greater risk for falls and injuries)
A nurse plans to provide education to the parents of school-aged children and includes which of the following result of children being less physically active outside of school?
A) An increase in obesity
B) An increase in heart disease
C) Higher computer literacy
D) Improved school attendance and grades
A (An increase in obesity)
(It is increasingly clear that children are less active, resulting in an increase in childhood obesity. Strategies for physical activity incorporated early into a child's daily routine may provide a foundation for lifetime commitment to exercise and physical fitness.)
A nursing assistive personnel asks for help to transfer a patient who is 125 pounds (56.8 kg) from the bed to a wheelchair. The patient is unable to assist. What is the nurse's best response?
A) "As long as we use proper body mechanics, no one will get hurt."
B) "The patient only weighs 125 lb. You don't need my assistance."
C) "Call the lift-team for additional assistance."
D) "The two of us can easily lift the patient."
C ("Call the lift-team for additional assistance.")
(Body mechanics alone are not sufficient to prevent musculoskeletal injuries when positioning or transferring patients see Table 38-1. Teaching the use of patient-handling equipment or the use of a lift-team in combination with proper body mechanics is more effective.)
You are transferring a patient who weighs 320 lb (145.5 kg) from his bed to a chair. The patient has an order for partial weight bearing as a result of bilateral reconstructive knee surgery. Which of the following is the best technique for transfer?
A) Use a transfer board.
B) Obtain a stand assist device.
C) Implement a three-person carry.
D) Use the ceiling-mounted lift.
D (Use the ceiling-mounted lift.)
(The use of patient-handling equipment helps prevent injury to health care workers and patients.)
Which is the correct gait when a patient is ascending stairs on crutches?
A) A modified two-point gait. The affected leg is advanced between the crutches to the stairs.
B) A modified three-point gait. The unaffected leg is advanced between the crutches to the stairs.
C) A swing-through gait.
D) A modified four-point gait. Both legs advance between the crutches to the stairs.
B (A modified three-point gait. The unaffected leg is advanced between the crutches to the stairs.)
(When ascending stairs on crutches, the patient usually uses a modified three-point gait see Fig. 38-13)
A patient recovering from bilateral knee replacements is prescribed bilateral partial weight bearing. You reinforce crutch walking knowing that which of the following crutch gaits is most appropriate for this patient?
A) Two-point gait
B) Three-point gait
C) Four-point gait
D) Swing-through gait
A (Two-point gait)
(The two-point gait requires at least partial weight bearing on each foot see Fig. 38-12. The patient moves a crutch at the same time as the opposing leg, so that the crutch movements are similar to arm motion during normal walking.)
A patient with a right knee replacement is prescribed no weight bearing on the right leg. You reinforce crutch walking knowing that which of the following crutch gaits is most appropriate for this patient?
A) Two-point gait
B) Three-point gait
C) Four-point gait
D) Swing-through gait
B (Three-point gait)
(Three-point alternating, or three-point, gait requires the patient to bear all of the weight on one foot. In a three-point gait, the patient bears weight on both crutches and then on the uninvolved leg, repeating the sequence see Fig. 38-12, B)
A patient on week-long bed rest is now performing isometric exercises. Which nursing diagnosis best addresses the safety of this patient?
A) Disturbed thought processes
B) Impaired skin integrity
C) Disturbed body image
D) Risk for activity intolerance
D (Risk for activity intolerance)
(The nursing diagnosis, risk for activity intolerance, best relates to patient safety because of the potential for orthostatic hypotension associated with prolonged bed rest.)
Which of the following activities does the nurse delegate to nursing assistive personnel in regard to crutch walking? (Select all that apply.)
A) Notify nurse if patient reports pain before, during, or after exercise.
B) Notify nurse of patient complaints of increased fatigue, dizziness, light-headedness when obtaining vital signs before and/or after exercise.
C) Notify nurse of vital sign values.
D) Evaluate the patient's ability to use crutches properly.
E) Prepare the patient for exercise by assisting in dressing and putting on shoes.
A, B, C, E
(These are all correct as they are within the nursing assistive personnel activities e.g., notifying the nurse or completing assigned activities. Evaluation is within the scope of professional nursing practice and is not delegated.)
Select statements that apply to the proper use of a cane. (Select all that apply.)
A) For maximum support when walking, the
patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. The weaker leg is moved forward to the cane so body weight is divided between the cane and the stronger leg.
B) A person's cane length is equal to the distance between the elbow and the floor.
C) Canes provide less support than a walker and are less stable.
D) The patient needs to learn that two points of support such as both feet or one foot and the cane need to be present at all times.
A, C, D
(A person's cane length is equal to the distance between the greater trochanter and the floor. For maximum support when walking, the patient places the cane forward 15 to 25 cm 6 to 10 inches, keeping body weight on both legs. The patient needs to learn that two points of support i.e., both feet or one foot and the cane are present at all times.)
A patient is discharged after an exacerbation of chronic obstructive pulmonary disease (COPD). She states, "I'm afraid to go to pulmonary rehabilitation." What is your best response?
A) Pulmonary rehabilitation provides a safe environment for monitoring your progress.
B) You have to participate or you will be back in the hospital.
C) Tell me more about your concerns with going to pulmonary rehabilitation.
D) The staff at our pulmonary rehabilitation facility are professionals and will not cause you any harm.
A (Pulmonary rehabilitation provides a safe environment for monitoring your progress.)
(Pulmonary rehabilitation is beneficial in helping patients reach an optimal level of functioning. Some patients are fearful of participating in exercise because of the potential of worsening dyspnea difficulty breathing. Pulmonary rehabilitation provides a safe environment for monitoring the progress of patients.)
An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.)
A) B/P = 128/84
B) Respirations 26 per minute on room air
C) HR 114
D) Crackles heard on auscultation
E) Pain reported as 3 on scale of 0 to 10 after medication
B, C
(Patients with reduced mobility are at risk for retained pulmonary secretions, and this risk increases in postoperative patients. As a result of retained secretions, the respiratory rate increases. The heart rate also increases because the heart is trying to improve oxygen levels. These symptoms are of concern for older adults because, if left untreated, further complications such as heart failure can occur.)
A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my breath." Your first action is to:
A) Call the health care provider to report this change in condition.
B) Give the patient a paper bag to breathe into to decrease her anxiety.
C) Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen.
D) Explain that this is normal after such trauma and administer the ordered pain medication.
C (Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen.)
(These are signs of possible pulmonary emboli, which can be life threatening. You must assess your patient, be prepared to start oxygen, and have someone call the surgeon while you stay with the patient to continue to monitor her status.)
The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient 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) Promote venous return to the heart.
D (Promote venous return to the heart.)
(Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces the risk for deep vein thrombosis DVT formation in the lower extremities.)
A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education?
A) "I usually go swimming with my family at the YMCA 3 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'll eat broccoli or cabbage to get the calcium that I need in my diet."
D) "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill. "
D ("I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill.")
(Just because a multivitamin has calcium in it does not mean that the woman is receiving enough to meet her needs. She must know her requirement and make the decision based on that rather than on the value for calcium on the label.)
The patient at greatest risk for developing multiple adverse effects of immobility is a:
A) 1-year-old child with a hernia repair.
B) 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA).
C) 51-year-old woman following a thyroidectomy.
D) 38-year-old woman undergoing a hysterectomy.
B (80-year-old woman who has suffered a hemorrhagic cerebrovascular accident CVA.)
(The older the patient and the greater the period of immobility, which can be significant following a hemorrhagic stroke, the greater is the number of systems that can be affected by the immobility.)
An older adult who was in a car accident and fractured his femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time?
A) Chronic pain
B) Impaired skin integrity
C) Risk for ineffective cerebral tissue perfusion
D) Risk for activity intolerance
D (Risk for activity intolerance)
(Patients on bed rest are at risk for activity intolerance, which increases patients' risk for falling.)
A patient had a left-sided cerebrovascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore nasogastric (NG) tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately?
A) Pale yellow urine
B) Unilateral neglect
C) Slight movement noted on the R side
D) Coffee ground-like aspirate from the feeding tube
D (Coffee ground-like aspirate from the feeding tube)
(When patients are receiving medications such as heparin or enoxaparin Lovenox, you must assess for signs of bleeding. These include overt signs such as bleeding from their gums or covert signs, which can be detected by testing their stool or observing their aspirate from NG tubes for coffee ground-like matter. These are signs of bleeding in the gastrointestinal tract.)
A home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a quad-cane. Which of the following must be corrected or removed for the patient's safety? (Select all that apply.)
A) The rubber mat in the walk-in shower
B) The three-legged stool on wheels in the kitchen
C) The braided throw rugs in the entry hallway and between the bedroom and bathroom
D) The night-lights in the hallways, bedroom, and bathroom
E) The cordless phone next to the patient's bed
B, C
(Stools on wheels and braided throw rugs are hazards that put the patient at risk for falls. By planning ahead and collaborating, the home care nurse can provide a safe home environment for the patient after discharge.)
The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. The nurse would recommend which of the following menus?
A) Cream of broccoli soup with whole wheat crackers and tapioca for dessert
B) Hamburger on soft roll with a side salad and an apple for dessert
C) Low-fat turkey chili with sour cream and fresh pears for dessert
D) Chicken salad on toast with tomato and lettuce and honey bun for dessert
A (Cream of broccoli soup with whole wheat crackers and tapioca for dessert)
(The dairy and broccoli in the soup, the whole grain crackers, plus the tapioca are all great sources of calcium.)
Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.)
A) Patient's weight
B) Patient's level of cooperation
C) Patient's ability to assist
D) Presence of medical equipment
E) 24-hour calorie intake
A, B, C, D
(By assessing the patient thoroughly you make the correct decision concerning your ability to manage him or her safely, the need for additional personnel, the patient's ability or inability to assist you with the transfer, and the proper equipment to use for the transfer. The calorie intake for the past 24 hours does not affect safe transfer.)
A patient of any age can develop a contracture of a joint when:
A) The adductors muscles are weakened as a result of immobility.
B) The muscle fibers become shortened because of disuse.
C) The calcium-to-phosphorus ratio becomes disrupted.
D) There is a deficiency in vitamin D.
B (The muscle fibers become shortened because of disuse.)
(The adductor muscles are stronger than the abductor muscles; when patients are immobile and the joint is not exercised through their ROM, the adductor muscle fibers shorten, resulting in the contracture of that joint, which is usually permanent.)
Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would reduce this risk? (Select all that apply.)
A) Repositioning patient every 1 to 2 hours while awake
B) Using an objective, valid scale to assess patient's risk for pressure ulcer development
C) Using a device to relieve pressure when patient is seated in chair
D) Teaching patient how to shift weight at regular intervals while sitting in a chair
E) A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes
B, C, D, E
(Patients must be repositioned around the clock, not just when they are awake. An objective assessment scale allows the nurse to assess for pressure ulcer risk over time. Once the risk is identified, the assessment tool guides the nurse in selecting appropriate pressure-relief devices. Showing the patient how to reduce his or her risk by shifting pressure is also important. Frequent and meaningful position changes that are in concert with the patient's condition and risk factors are necessary to reduce pressure ulcer developments.)
Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher?
A) The patient is 5 feet 6 inches and weighs 120 lbs.
B) The patient speaks and understands English.
C) The patient received an injection of morphine 30 minutes ago for pain.
D) You feel comfortable handling a patient of his size and with his level of cooperation.
C (The patient received an injection of morphine 30 minutes ago for pain.)
(The morphine injection would change the patient's ability to safely follow directions and participate in the transfer; therefore additional help would be needed to safely transfer the patient from the bed to the stretcher.)
A patient with left-sided weakness asks his nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." What would be your best therapeutic response?
A) "Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you."
B) "Would you like me to walk on your right side so you feel more secure?"
C) "Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side."
D) "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.
D ("By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.)
(Walking on the affected weak side side and holding the patient around the waist or using a gait belt gives you better control if the patient starts to fall. If you were holding the patient's arm as he was falling, you might dislocate his shoulder.)
Which is an outcome for a patient diagnosed with osteoporosis?
A) Maintain serum level of calcium.
B) Maintain independence with activities of daily living (ADLs).
C) Reduce supplemental sources of vitamin D.
D) Reverse bone loss through dietary manipulation.
B (Maintain independence with activities of daily living ADLs)
(The main goal is to maintain independence in ADLs once osteoporosis is diagnosed. It is best to identify individuals at risk and work toward preventing the disease.)
