ramont2e rev tif ch23

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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank

Chapter 23Question 1

Type: MCSA

The nurse is caring for a client who requires frequent repositioning, and determines that proper alignment is

obtained when which of the following is achieved?

1. There is little strain on the musculoskeletal system

2. The client is in a supine position

3. The client says she is properly aligned

. There are pillows under all e!tremities

Corre!t "ns#er: "

Rationa$e 1# Alignment is achieved when the client is positioned in a way that takes strain off of the muscles,

$oints, tendons, and ligaments Clients cannot be consistently maintained in a supine position because it will caus

skin breakdown and become uncomfortable Clients might not be aware of when they are aligned, or they mightnot be able to voice when they are comfortable %illows can help the nurse achieve alignment, but are not require

under every e!tremity, and should only be placed where they are needed

Rationa$e 2# Alignment is achieved when the client is positioned in a way that takes strain off of the muscles,

$oints, tendons, and ligaments Clients cannot be consistently maintained in a supine position because it will causskin breakdown and become uncomfortable Clients might not be aware of when they are aligned, or they might

not be able to voice when they are comfortable %illows can help the nurse achieve alignment, but are not require


Rationa$e 3# Alignment is achieved when the client is positioned in a way that takes strain off of the muscles, $oints, tendons, and ligaments Clients cannot be consistently maintained in a supine position because it will caus

skin breakdown and become uncomfortable Clients might not be aware of when they are aligned, or they might

not be able to voice when they are comfortable %illows can help the nurse achieve alignment, but are not requireunder every e!tremity, and should only be placed where they are needed

Rationa$e # Alignment is achieved when the client is positioned in a way that takes strain off of the muscles, $oints, tendons, and ligaments Clients cannot be consistently maintained in a supine position because it will caus

skin breakdown and become uncomfortable Clients might not be aware of when they are aligned, or they mightnot be able to voice when they are comfortable %illows can help the nurse achieve alignment, but are not require


%$o&a$ Rationa$e:

&amont, 'iedringhous, Comprehensive Nursing Care (nd )dition *pdate Test +ank

Copyright ("( by %earson )ducation, -nc



Cogniti'e (e'e$: Applying

C$ient Need: %hysiological -ntegrity

C$ient Need )u&:

Nursing*+ntegrated Con!epts: 'ursing %rocess# )valuation

(earning ut!ome: .escribe basic elements of normal movement

Question 2

Type: MCSA

The nurse is teaching a group of clients at a mental health clinic about mobility and $oint care /ne client asks the

nurse what effect depression has on a person0s mobility The nurse responds with which of the following?

1. Many depressed clients are catatonic, and e!perience $oint stiffness as a result

2. The depressed client in a mental hospital does not get enough e!ercise

3. .epression saps energy and the ability to e!ercise, affecting mobility and posture

. The depressed client does not drink enough fluids, which affects the $oints

Corre!t "ns#er: 1

Rationa$e 1# The depressed client has no energy for e!ercise, and may affect a slumped posture )!ercise not onl

affects the quality of mobility, but also is directly related to mental health %sychiatric facilities schedule

recreational and e!ercise times for their clients The depressed client does not e!perience catatonia There is noinformation about the amount of fluids that the client is drinking


affects the quality of mobility, but also is directly related to mental health %sychiatric facilities schedulerecreational and e!ercise times for their clients The depressed client does not e!perience catatonia There is noinformation about the amount of fluids that the client is drinking


affects the quality of mobility, but also is directly related to mental health %sychiatric facilities schedulerecreational and e!ercise times for their clients The depressed client does not e!perience catatonia There is no

information about the amount of fluids that the client is drinking

Rationa$e # The depressed client has no energy for e!ercise, and may affect a slumped posture )!ercise not onl

affects the quality of mobility, but also is directly related to mental health %sychiatric facilities schedule

recreational and e!ercise times for their clients The depressed client does not e!perience catatonia There is noinformation about the amount of fluids that the client is drinking

%$o&a$ Rationa$e:



C$ient Need )u&:





Nursing*+ntegrated Con!epts: 'ursing %rocess# -mplementation

(earning ut!ome: 'ame factors affecting body alignment and mobility

Question 3

Type: MCMA

The nurse is caring for a client who has been on bedrest for two days, and anticipates which of the following as a

result? Select all that apply

)tandard Te-t: Select all that apply

1. %ostural hypotension when the client stands for the first time

2. Muscle weakness

3. -ncreased risk for pneumonia

. +oredom

. 2acial edema

Corre!t "ns#er: ",(,1

Rationa$e 1# The immobile client is at increased risk for postural hypotension, muscle weakness, and pneumonia

+oredom depends on the client0s health status )dema is more likely to occur in dependent areas

Rationa$e 2# The immobile client is at increased risk for postural hypotension, muscle weakness, and pneumonia+oredom depends on the client0s health status )dema is more likely to occur in dependent areas

Rationa$e 3# The immobile client is at increased risk for postural hypotension, muscle weakness, and pneumonia


Rationa$e # The immobile client is at increased risk for postural hypotension, muscle weakness, and pneumonia+oredom depends on the client0s health status )dema is more likely to occur in dependent areas

Rationa$e # The immobile client is at increased risk for postural hypotension, muscle weakness, and pneumonia


%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: -dentify effects of immobility on body systems

Question





Type: MCSA

The nurse is caring for an alert client who has been in bed for three days 3hen performing a focused assessment

the nurse checks the skin of the legs and feet for which of the following?

1. .ependent edema

2. 2oot drop

3. 4aricose veins

. Cyanosis

Corre!t "ns#er: "

Rationa$e 1# The feet and legs should be checked for dependent edema, which can increase the risk for skin

breakdown 2oot drop is more likely to occur in the client with reduced level of consciousness, who is not movin

the foot 4aricose veins and cyanosis would not be an anticipated risk of immobility unless other problems e!ist

Rationa$e 2# The feet and legs should be checked for dependent edema, which can increase the risk for skin

breakdown 2oot drop is more likely to occur in the client with reduced level of consciousness, who is not movin


Rationa$e 3# The feet and legs should be checked for dependent edema, which can increase the risk for skin breakdown 2oot drop is more likely to occur in the client with reduced level of consciousness, who is not movin


Rationa$e # The feet and legs should be checked for dependent edema, which can increase the risk for skin

breakdown 2oot drop is more likely to occur in the client with reduced level of consciousness, who is not movinthe foot 4aricose veins and cyanosis would not be an anticipated risk of immobility unless other problems e!ist

%$o&a$ Rationa$e:

Cogniti'e (e'e$: Analy5ing


C$ient Need )u&:


(earning ut!ome: -dentify effects of immobility on body systems

Question Type: MCSA

3hen teaching the client how to use a straight cane, the nurse would include which of the following?

1. 6old the cane with the hand on the weak side

2. &emove all scatter rugs from the home





3. Move the cane "( inches ahead of the foot

. 7eep the elbow straight when moving the cane forward

Corre!t "ns#er: (

Rationa$e 1# Scatter rugs can cause a client with a cane to fall, as the rug moves easily and does not provide a

stable surface for the client %revention of falls would be the priority teaching for this client The cane is held inthe hand on the strongest side, moved forward 8 inches, and the elbow should be slightly bent

Rationa$e 2# Scatter rugs can cause a client with a cane to fall, as the rug moves easily and does not provide astable surface for the client %revention of falls would be the priority teaching for this client The cane is held in

the hand on the strongest side, moved forward 8 inches, and the elbow should be slightly bent

Rationa$e 3# Scatter rugs can cause a client with a cane to fall, as the rug moves easily and does not provide a

stable surface for the client %revention of falls would be the priority teaching for this client The cane is held inthe hand on the strongest side, moved forward 8 inches, and the elbow should be slightly bent

Rationa$e # Scatter rugs can cause a client with a cane to fall, as the rug moves easily and does not provide astable surface for the client %revention of falls would be the priority teaching for this client The cane is held in

the hand on the strongest side, moved forward 8 inches, and the elbow should be slightly bent

%$o&a$ Rationa$e:


C$ient Need: Safe )ffective Care )nvironment

C$ient Need )u&:


(earning ut!ome: .escribe assistive devices used to support mobility

Question /

Type: MCSA

The nurse is reinforcing instructions about crutch walking received from physical therapy, and includes which of

the following?

1. )!ercise both legs on a regular basis

2. 9oing up and down stairs in the home is good e!ercise

3. %erform arm:strengthening e!ercises daily

. Support weight with the a!illa

Corre!t "ns#er: 1





Rationa$e 1# The client using crutches needs the strength in the arms to help support the body, so arm e!ercisesshould be encouraged The client should be taught stair:walking, but should be cautioned against using the stairs

unless it is unavoidable )!ercising the legs is often discouraged in a client with a leg in$ury requiring crutches

3eight should be supported on the arms, not the a!illa, as this can cause nerve damage

Rationa$e 2# The client using crutches needs the strength in the arms to help support the body, so arm e!ercisesshould be encouraged The client should be taught stair:walking, but should be cautioned against using the stairs

unless it is unavoidable )!ercising the legs is often discouraged in a client with a leg in$ury requiring crutches3eight should be supported on the arms, not the a!illa, as this can cause nerve damage

Rationa$e 3# The client using crutches needs the strength in the arms to help support the body, so arm e!ercises

should be encouraged The client should be taught stair:walking, but should be cautioned against using the stairs



Rationa$e # The client using crutches needs the strength in the arms to help support the body, so arm e!ercises

should be encouraged The client should be taught stair:walking, but should be cautioned against using the stairs



%$o&a$ Rationa$e:



C$ient Need )u&:



Question 0

Type: MCSA

3hen planning care for the immobile client, the nurse includes which of the following?

1. Assess for complications resulting from immobility

2. %lan for the client to obtain eight hours of uninterrupted sleep without repositioning

3. -mplement repositioning every hour

. )valuate the client0s ability to perform passive &/M

Corre!t "ns#er: "

Rationa$e 1# The nurse uses the nursing process to care for the immobile client and assesses for complicationsresulting from lack of mobility 3hile sleep is important, the client who is unable to reposition themselves must

be repositioned every two hours, not hourly The client performs active, not passive, &/M





Rationa$e 2# The nurse uses the nursing process to care for the immobile client and assesses for complicationsresulting from lack of mobility 3hile sleep is important, the client who is unable to reposition themselves must

be repositioned every two hours, not hourly The client performs active, not passive, &/M

Rationa$e 3# The nurse uses the nursing process to care for the immobile client and assesses for complications

resulting from lack of mobility 3hile sleep is important, the client who is unable to reposition themselves must be repositioned every two hours, not hourly The client performs active, not passive, &/M

Rationa$e # The nurse uses the nursing process to care for the immobile client and assesses for complications

resulting from lack of mobility 3hile sleep is important, the client who is unable to reposition themselves must be repositioned every two hours, not hourly The client performs active, not passive, &/M

%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: 'ursing %rocess# Assessment

(earning ut!ome: )!plain how the nursing process relates to clients with immobility

Question

Type: MCSA

The nurse assists the client with emphysema admitted because of a respiratory infection to assume what position

to reduce the effort of breathing and improve gas e!change?

1. ;eft Sims0 position

2. 2owler0s position

3. 6igh 2owler0s position

. /rthopneic position

Corre!t "ns#er: <

Rationa$e 1# This client, also with increased work of breathing, should be placed in the orthopneic position

because it allows for the greatest chest e!pansion and makes breathing easier The client is placed at a =:degree

angle leaning on an over:bed table to achieve this position The second best position would be the high 2owler0s

or 2owler0s position, but it is not as effective as the orthopneic position, because the pressure on the back reduceschest e!pansion Sims0 position is side:lying, and would likely increase the client0s respiratory distress, as chest

e!pansion would be reduced on the side she is lying on




or 2owler0s position, but it is not as effective as the orthopneic position, because the pressure on the back reduces





chest e!pansion Sims0 position is side:lying, and would likely increase the client0s respiratory distress, as cheste!pansion would be reduced on the side she is lying on



angle leaning on an over:bed table to achieve this position The second best position would be the high 2owler0sor 2owler0s position, but it is not as effective as the orthopneic position, because the pressure on the back reduces

chest e!pansion Sims0 position is side:lying, and would likely increase the client0s respiratory distress, as cheste!pansion would be reduced on the side she is lying on

Rationa$e # This client, also with increased work of breathing, should be placed in the orthopneic position



or 2owler0s position, but it is not as effective as the orthopneic position, because the pressure on the back reduceschest e!pansion Sims0 position is side:lying, and would likely increase the client0s respiratory distress, as chest

e!pansion would be reduced on the side she is lying on

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: ;ist and compare different body positions

Question

Type: MCSA

The nurse is caring for a client who has had a below:the:knee amputation and is positioned in bed with theaffected knee on a pillow To prevent hip and knee contractures, the nurse plans to do which of the following at

least once a shift?

1. %lace the client in the lateral position with a pillow between the legs once a shift for 1 minutes

2. %lace the client in the semi:2owler0s position without pillows under the knees to promote e!tension

3. %lace the client in the prone position once a shift for 1 minutes

. %lace the client in the high 2owler0s position to fully fle! the hip

Corre!t "ns#er: 1

Rationa$e 1# The client who is positioned most of the time with the hips and knees fle!ed should be placed in the prone position to e!tend the hips and knees and prevent contractures of these $oints The lateral position continue

to fle! the hip and knees, as do both of the 2owler0s positions





Rationa$e 2# The client who is positioned most of the time with the hips and knees fle!ed should be placed in the prone position to e!tend the hips and knees and prevent contractures of these $oints The lateral position continue

to fle! the hip and knees, as do both of the 2owler0s positions

Rationa$e 3# The client who is positioned most of the time with the hips and knees fle!ed should be placed in the

prone position to e!tend the hips and knees and prevent contractures of these $oints The lateral position continueto fle! the hip and knees, as do both of the 2owler0s positions

Rationa$e # The client who is positioned most of the time with the hips and knees fle!ed should be placed in the

prone position to e!tend the hips and knees and prevent contractures of these $oints The lateral position continueto fle! the hip and knees, as do both of the 2owler0s positions

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: ;ist and compare different body positions

Question 1

Type: MCSA

The nurse is planning care for an unconscious client who is breathing on his own 3hich of the following does th

nurse plan to promote $oint mobility for this client?

1. +ack massage to promote $oint circulation

2. 6ead fle!ion and e!tension

3. Transferring the client using a 6oyer lift

. %lacing a bed cradle under the sheet

Corre!t "ns#er: (

Rationa$e 1# The nurse plans to perform passive &/M of the neck to promote $oint mobility +ack massage,

transfer using a 6oyer lift, and use of a bed cradle might be indicated, but do not promote $oint mobility

Rationa$e 2# The nurse plans to perform passive &/M of the neck to promote $oint mobility +ack massage,transfer using a 6oyer lift, and use of a bed cradle might be indicated, but do not promote $oint mobility

Rationa$e 3# The nurse plans to perform passive &/M of the neck to promote $oint mobility +ack massage,


Rationa$e # The nurse plans to perform passive &/M of the neck to promote $oint mobility +ack massage,






%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: 'ursing %rocess# %lanning

(earning ut!ome: 'ame and describe actions the nurse performs to support client mobility

Question 11

Type: MCSA

The nurse is reviewing crutch:walking with the client prior to discharge The nurse concludes that the client need

further instruction if the client states which of the following?

1. >)ach step - take with crutches should feel comfortable to me>

2. >- need to inspect the crutch tips and replace them if they are worn>

3. >- should pad the crutches well to protect my armpits>

. >- should wear running shoes to support my feet>

Corre!t "ns#er: 1

Rationa$e 1# The crutches do not need to be padded on the top, as the hands and upper arms are used for support

Allowing the armpits to bear the body weight will cause nerve damage and alignment problems The other

statements by the client are correct

Rationa$e 2# The crutches do not need to be padded on the top, as the hands and upper arms are used for supportAllowing the armpits to bear the body weight will cause nerve damage and alignment problems The other


Rationa$e 3# The crutches do not need to be padded on the top, as the hands and upper arms are used for support

Allowing the armpits to bear the body weight will cause nerve damage and alignment problems The otherstatements by the client are correct

Rationa$e # The crutches do not need to be padded on the top, as the hands and upper arms are used for support

Allowing the armpits to bear the body weight will cause nerve damage and alignment problems The other


%$o&a$ Rationa$e:



C$ient Need )u&:







Question 12

Type: MCSA

The physician has ordered ambulation for the 81:year:old client who has had surgery and has been in bed for thre

days The nurse plans to do which of the following for this client?

1. +egin ambulation immediately after breakfast

2. %re:ambulation e!ercises

3. /btain assistance with transfer of the client

. %erform passive &/M before ambulating

Corre!t "ns#er: (

Rationa$e 1# Anticipating that the client0s muscles will be weak, the nurse will plan to help the client perform preambulation e!ercises to help regain strength in the muscles before attempting to walk the client -t would be best

to wait an hour or two after meals to ambulate %assive &/M will not help to strengthen muscles, although active

&/M will be helpful The nurse is not preparing to transfer the client, and will need to determine if assistance isrequired by the client0s pre:bedrest activity level

Rationa$e 2# Anticipating that the client0s muscles will be weak, the nurse will plan to help the client perform pre

ambulation e!ercises to help regain strength in the muscles before attempting to walk the client -t would be best

to wait an hour or two after meals to ambulate %assive &/M will not help to strengthen muscles, although active&/M will be helpful The nurse is not preparing to transfer the client, and will need to determine if assistance is

required by the client0s pre:bedrest activity level

Rationa$e 3# Anticipating that the client0s muscles will be weak, the nurse will plan to help the client perform pre

ambulation e!ercises to help regain strength in the muscles before attempting to walk the client -t would be bestto wait an hour or two after meals to ambulate %assive &/M will not help to strengthen muscles, although active

&/M will be helpful The nurse is not preparing to transfer the client, and will need to determine if assistance is


Rationa$e # Anticipating that the client0s muscles will be weak, the nurse will plan to help the client perform preambulation e!ercises to help regain strength in the muscles before attempting to walk the client -t would be best

to wait an hour or two after meals to ambulate %assive &/M will not help to strengthen muscles, although active

&/M will be helpful The nurse is not preparing to transfer the client, and will need to determine if assistance is


%$o&a$ Rationa$e:



C$ient Need )u&:






(earning ut!ome: .escribe proper procedures for assisting a client with mobility issues

Question 13

Type: MCSA

The nurse is caring for a newly admitted client with a diagnosis of pneumonia The client is in need of a bed bath

and a linen change The nurse0s priority action is which of the following?

1. Assess the client0s ability to assist with the bath and with movement in bed

2. 9ather all supplies needed for the procedure

3. /btain a 6oyer lift to move the client up in bed

. )!plain all procedures to the client

Corre!t "ns#er: "

Rationa$e 1# The nurse would assess the client0s level of need and ability to perform the bath and move in bed

There is no need to obtain a lift if the client is capable of moving independently The nurse gathers supplies and

e!plains procedures after assessing the client0s needs

Rationa$e 2# The nurse would assess the client0s level of need and ability to perform the bath and move in bedThere is no need to obtain a lift if the client is capable of moving independently The nurse gathers supplies and


Rationa$e 3# The nurse would assess the client0s level of need and ability to perform the bath and move in bedThere is no need to obtain a lift if the client is capable of moving independently The nurse gathers supplies and


Rationa$e # The nurse would assess the client0s level of need and ability to perform the bath and move in bed

There is no need to obtain a lift if the client is capable of moving independently The nurse gathers supplies ande!plains procedures after assessing the client0s needs

%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: 'ursing %rocess# %lanning(earning ut!ome: .escribe proper procedures for assisting a client with mobility issues

Question 1

Type: MCSA

The nurse is caring for a client diagnosed with pneumonia who was placed on a cardiorespiratory monitor 4ital

signs are recorded from the monitor in order to allow the client to remain undisturbed during the night The nurse





observes that the blood pressure, heart rate, and respirations are ( below baseline The nurse concludes which

of the following?

1. The client is about to have a cardiac arrest

2. The client is in stage ( of '&)M sleep

3. The client0s metabolic rate has increased

. The client is in stage < of '&)M sleep

Corre!t "ns#er: <

Rationa$e 1# .uring stage < sleep, the client is rela!ed, and vital signs decrease from baseline by (:1 percent

Stage ( sleep is characteri5ed by light sleep with vital signs decreasing slightly The client0s metabolic rate isdecreased in stage < A decrease in vital signs is normal during stage < sleep, and the client is not at risk for

cardiac arrest

Rationa$e 2# .uring stage < sleep, the client is rela!ed, and vital signs decrease from baseline by (:1 percentStage ( sleep is characteri5ed by light sleep with vital signs decreasing slightly The client0s metabolic rate is

decreased in stage < A decrease in vital signs is normal during stage < sleep, and the client is not at risk for

cardiac arrest

Rationa$e 3# .uring stage < sleep, the client is rela!ed, and vital signs decrease from baseline by (:1 percentStage ( sleep is characteri5ed by light sleep with vital signs decreasing slightly The client0s metabolic rate is


cardiac arrest

Rationa$e # .uring stage < sleep, the client is rela!ed, and vital signs decrease from baseline by (:1 percentStage ( sleep is characteri5ed by light sleep with vital signs decreasing slightly The client0s metabolic rate is


cardiac arrest

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: .escribe the stages and functions of sleep

Question 1

Type: MCSA

The elderly client reports difficulty sleeping at night, fatigue, and lack of energy The nurse suggests which of the

following as a possible cause of the client0s sleep problems?





1. 'apping during the day

2. )vening walks with her spouse

3. Moderate food intake at the evening meal

. 3arm bath before bedtime

Corre!t "ns#er: "

Rationa$e 1# Seniors can have a tendency to nap in the daytime when they get tired, and this can cause them to

have trouble falling asleep or staying asleep at night Taking an evening walk, eating moderate nighttime meals,and taking a warm bath before bedtime are all ways to promote sleep

Rationa$e 2# Seniors can have a tendency to nap in the daytime when they get tired, and this can cause them to

have trouble falling asleep or staying asleep at night Taking an evening walk, eating moderate nighttime meals,

and taking a warm bath before bedtime are all ways to promote sleep

Rationa$e 3# Seniors can have a tendency to nap in the daytime when they get tired, and this can cause them tohave trouble falling asleep or staying asleep at night Taking an evening walk, eating moderate nighttime meals,

and taking a warm bath before bedtime are all ways to promote sleep

Rationa$e # Seniors can have a tendency to nap in the daytime when they get tired, and this can cause them to

have trouble falling asleep or staying asleep at night Taking an evening walk, eating moderate nighttime meals,and taking a warm bath before bedtime are all ways to promote sleep

%$o&a$ Rationa$e:


C$ient Need: %hysiological -ntegrityC$ient Need )u&:


(earning ut!ome: -dentify factors that affect sleep, and variables related to age or stage of development

Question 1/

Type: MCMA

The client who is about to be discharged asks the nurse for suggestions on how to improve the quality of sleep to

wake feeling refreshed in the morning The nurse makes which of the following suggestions? Select all that apply


1. Ad$ust the temperature in the room to a comfortable level

2. Change the time of aerobic e!ercise to one hour prior to sleep

3. A cup of tea before bed is rela!ing





. ;imit the use of alcohol to early in the evening

. .o not smoke before bedtime

Corre!t "ns#er: ",<,@

Rationa$e 1# A comfortable room temperature will promote sleep Alcohol interferes with &)M sleep, and should

be limited well before bedtime 'icotine is a stimulant, and could prevent the client from falling asleep )!erciseclose to bedtime acts as a stimulant, and can cause the client to be unable to sleep Tea contains caffeine, which isa stimulant The nurse could suggest non:caffeinated tea before bedtime unless this causes the client to wake

during the night to urinate

Rationa$e 2# A comfortable room temperature will promote sleep Alcohol interferes with &)M sleep, and should

be limited well before bedtime 'icotine is a stimulant, and could prevent the client from falling asleep )!erciseclose to bedtime acts as a stimulant, and can cause the client to be unable to sleep Tea contains caffeine, which is

a stimulant The nurse could suggest non:caffeinated tea before bedtime unless this causes the client to wake


Rationa$e 3# A comfortable room temperature will promote sleep Alcohol interferes with &)M sleep, and should be limited well before bedtime 'icotine is a stimulant, and could prevent the client from falling asleep )!ercise

close to bedtime acts as a stimulant, and can cause the client to be unable to sleep Tea contains caffeine, which is

a stimulant The nurse could suggest non:caffeinated tea before bedtime unless this causes the client to wakeduring the night to urinate

Rationa$e # A comfortable room temperature will promote sleep Alcohol interferes with &)M sleep, and should

be limited well before bedtime 'icotine is a stimulant, and could prevent the client from falling asleep )!ercise

close to bedtime acts as a stimulant, and can cause the client to be unable to sleep Tea contains caffeine, which isa stimulant The nurse could suggest non:caffeinated tea before bedtime unless this causes the client to wake


Rationa$e # A comfortable room temperature will promote sleep Alcohol interferes with &)M sleep, and should

be limited well before bedtime 'icotine is a stimulant, and could prevent the client from falling asleep )!erciseclose to bedtime acts as a stimulant, and can cause the client to be unable to sleep Tea contains caffeine, which is

a stimulant The nurse could suggest non:caffeinated tea before bedtime unless this causes the client to wake


%$o&a$ Rationa$e:



C$ient Need )u&:Nursing*+ntegrated Con!epts: 'ursing %rocess# -mplementation

(earning ut!ome: -dentify factors that affect sleep, and variables related to age or stage of development

Question 10

Type: MCSA





The nurse is teaching a class for staff members on the importance of assessing clients for sleep apnea in the long:

term care facility The nurse e!plains that the possible consequences of sleep apnea include which of the

following?

1. %ulmonary hypertension

2. Teeth grinding

3. Sleepwalking

. 6ypothyroidism

Corre!t "ns#er: "

Rationa$e 1# Sleep apnea causes the client0s blood pressure to rise and, over time, can cause cardiac arrest,

arrhythmias, and pulmonary hypertension Sleepwalking and :talking are parasomnias, or behaviors that occur

during sleepnot related to sleep apnea 6ypothyroidism does not result from sleep apnea

Rationa$e 2# Sleep apnea causes the client0s blood pressure to rise and, over time, can cause cardiac arrest,arrhythmias, and pulmonary hypertension Sleepwalking and :talking are parasomnias, or behaviors that occur


Rationa$e 3# Sleep apnea causes the client0s blood pressure to rise and, over time, can cause cardiac arrest,arrhythmias, and pulmonary hypertension Sleepwalking and :talking are parasomnias, or behaviors that occur


Rationa$e # Sleep apnea causes the client0s blood pressure to rise and, over time, can cause cardiac arrest,

arrhythmias, and pulmonary hypertension Sleepwalking and :talking are parasomnias, or behaviors that occur


%$o&a$ Rationa$e:


C$ient Need: %sychosocial -ntegrity

C$ient Need )u&:


(earning ut!ome: 'ame common sleep disorders and interventions to promote normal sleep

Question 1

Type: MCSA

The nurse admits a client scheduled for an )/9 and e!plains the purpose of the test as which of the following?

1. To measure the level of o!ygen in the blood during sleep

2. To study the brain activity during sleep





3. To measure eye movement during sleep

. To detect the cessation of breathing during sleep

Corre!t "ns#er: 1

Rationa$e 1# The )/9 measures eye movements during sleep An electrode is placed at the outer canthus of the

eye to record eye movement %ulse o!imetry measures o!ygen levels in the blood +rain activity is detected by th))9, and sleep apnea is detected by using an )C9 monitor

Rationa$e 2# The )/9 measures eye movements during sleep An electrode is placed at the outer canthus of theeye to record eye movement %ulse o!imetry measures o!ygen levels in the blood +rain activity is detected by th

))9, and sleep apnea is detected by using an )C9 monitor

Rationa$e 3# The )/9 measures eye movements during sleep An electrode is placed at the outer canthus of the

eye to record eye movement %ulse o!imetry measures o!ygen levels in the blood +rain activity is detected by th))9, and sleep apnea is detected by using an )C9 monitor

Rationa$e # The )/9 measures eye movements during sleep An electrode is placed at the outer canthus of theeye to record eye movement %ulse o!imetry measures o!ygen levels in the blood +rain activity is detected by th

))9, and sleep apnea is detected by using an )C9 monitor

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: -dentify tests used to diagnose sleep disorders

Question 1

Type: MCSA

The nurse is e!plaining to the client that there are many causes for sleep apnea, and that testing is designed to

identify the cause of the apnea so that appropriate treatment can be started The client asks the nurse to describe

the types of equipment used for the sleep apnea study The nurse tells the client that which of the following might

be used during the sleep apnea study?

1. An i%od to help the client to fall asleep to music

2. A videorecorder to pick up unusual respirations and movement

3. An intravenous pump to administer the dyes used

. A rectal probe for recording temperature during sleep

Corre!t "ns#er: (





Rationa$e 1# The client likely will be observed by videocamera to note movement and to pick up unusual breathing noises Clients are not given -4 dyes for a sleep study, and their temperatures are not monitored during

sleep -f the i%od is allowed, it would be brought to the study by the client to help fall asleep

Rationa$e 2# The client likely will be observed by videocamera to note movement and to pick up unusual

breathing noises Clients are not given -4 dyes for a sleep study, and their temperatures are not monitored duringsleep -f the i%od is allowed, it would be brought to the study by the client to help fall asleep

Rationa$e 3# The client likely will be observed by videocamera to note movement and to pick up unusual

breathing noises Clients are not given -4 dyes for a sleep study, and their temperatures are not monitored duringsleep -f the i%od is allowed, it would be brought to the study by the client to help fall asleep

Rationa$e # The client likely will be observed by videocamera to note movement and to pick up unusual

breathing noises Clients are not given -4 dyes for a sleep study, and their temperatures are not monitored during

sleep -f the i%od is allowed, it would be brought to the study by the client to help fall asleep

%$o&a$ Rationa$e:

Cogniti'e (e'e$: ApplyingC$ient Need: %hysiological -ntegrity

C$ient Need )u&:


(earning ut!ome: -dentify tests used to diagnose sleep disorders

Question 2

Type: MCMA

The nurse is aware that body movement is dependent on interdependent activity of several body systems,

including#BSelect all that apply


1. Musculoskeletal system

2. 'ervous system

3. 4estibular system

. &espiratory system

. Cardiovascular system


Rationa$e 1# The musculoskeletal system is involved in body movement, affecting alignment, and $oint mobility

Rationa$e 2# The nervous system is involved with balance and coordination





Rationa$e 3# The vestibular system is involved in body movement, affecting balance and coordination

Rationa$e # The respiratory system is affected by normal movement

Rationa$e # The cardiovascular system is affected by body movement

%$o&a$ Rationa$e:

Cogniti'e (e'e$: *nderstanding


C$ient Need )u&:


(earning ut!ome:

Question 21

Type: MCSA

The nurse is discussing alignment and posture with a group of teens Many of the female students have adopted acurved posture The nurse e!plains to the teens that

1. 3hen the body is properly aligned, the organs are properly supported

2. )quilibrium depends on the proper body alignment

3. Muscular strength decreases with physical activity

. /rthostatic hypotension is common with improper alignment

Corre!t "ns#er: "

Rationa$e 1# %roper alignment of the body allows organs to function at their best while also maintaining balance

Rationa$e 2# )quilibrium depends on the integration of stimuli from several organs, including the muscles and

tendons of the head and neck, the eyes and the inner ear

Rationa$e 3# Muscular strength decreases with immobility

Rationa$e # /rthostatic hypotension is common with prolonged bedrest

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:





Question 22

Type: MCMA

The nurse is caring for a client who has been on bedrest for a high risk pregnancy This client is at risk for#BSelect

all that apply


1. .isuse atrophy

2. /rthostatic hypotension

3. Thrombophlebitis

. .ependent edema

. 6ypostatic pneumonia

Corre!t "ns#er: ",(,1,<

Rationa$e 1# *nused muscles atrophy, losing most of their normal strength and function

Rationa$e 2# /rthostatic hypotension is common with prolonged bed rest

Rationa$e 3# 4enous vasodilation and stasis predispose clients to thrombus formation

Rationa$e # 3hen venous pressure is great, serum is forced from the blood vessels into the surrounding

interstitial space, causing edema

Rationa$e # 6ypostatic pneumonia is caused by static secretions in the alveoliD the pregnant client is unlikely to

e!perience this complication

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 23

Type: MCSA

The nurse adds range of motion e!ercises to a clientEs care plan when it is determined that the client is in a

persistent vegetative state This is done to prevent#

1. The muscles from becoming permanently shortened





2. The muscles from wasting away

3. The muscles from becoming flaccid

. The client from losing body mass

Corre!t "ns#er: "

Rationa$e 1# 2le!or muscles are stronger than e!tensors, so when a person is inactive, the $oints become pulled

into the fle!ed position Constant immobility causes muscles to shorten permanently and become fi!ed in the

fle!ed position

Rationa$e 2# &/M e!ercises will maintain $oint mobility, but will not prevent atrophy of muscles

Rationa$e 3# &/M e!ercises will maintain $oint mobilityD some muscles in this client may be flaccid, some may

become contracted

Rationa$e # &/M e!ercises will maintain $oint mobility, but will not prevent the client from losing body mass

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCMA

The nurse is e!plaining factors that affect an individualEs body alignment, mobility and daily activity level

)!amples of client factors that might decrease mobility and activity include#BSelect all that apply


1. 4estibular disorder

2. Spina bifida

3. Anemia

. /vernutrition

. )ar canal infection






Rationa$e 1# 4estibular Binner ear disorders affect a clientEs equilibrium, causing impaired balance



Rationa$e # 4estibular Binner ear disorders affect a clientEs equilibrium, causing impaired balance


%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCMA

The nurse is caring for a client who is a in traction due to a motor vehicle accident The nurse anticipates which o

the following effects of immobility?BSelect all that apply


1. /steoporosis

2. 4enous vasoconstriction

3. *rinary stasis

. .iarrhea

. .ecreased respiratory movement

Corre!t "ns#er: ",1,@

Rationa$e 1# 3ithout the stress of weight:bearing activity, bones deminerali5e



Rationa$e # 3ithout the stress of weight:bearing activity, bones deminerali5e






%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2/

Type: MCMA

The nurse is admitting a client to a rehabilitation facility after surgery for a hip replacement The nurse observes

the client as appearing depressed The client denies depression, but states that she is concerned about returning to

her regular activities, including walking for e!ercise, because she is so tired The nurse understands that #BSelect

all that apply


1. This client has unrealistic goals

2. Stress may be affecting this clientEs mobility

3. 3alking will tire the client

. The client is at increased risk of disease due to immobility

. This client is at risk for affective disorder

Corre!t "ns#er: (,<,@

Rationa$e 1# The clientEs goals are not unrealistic over time

Rationa$e 2# Stress and pain deplete the bodyEs energy reserves, producing fatigue

Rationa$e 3# Movement energi5es the client and facilitates coping

Rationa$e # A history of inactivity because of in$ury increases the risk of ma$or diseaseD early ambulation after

surgery is an essential preventive measure

Rationa$e # %eople who are unable to carry out usual activities related to their roles may become dependent onothersD lose of independence damages self:esteem and may in turn provoke an e!aggerated emotional response

%$o&a$ Rationa$e:



C$ient Need )u&:






(earning ut!ome:

Question 20

Type: MCSA

The client who has been hospitali5ed for a fractured femur e!presses surprise that she is so tired arter sitting up in

the chair for a short period of time The nurse e!plains that#

1. .ecreased mobility creates venous vasodilation and stasis

2. .ecreased mobility may interfere with the normal e!change of o!ygen and carbon dio!ide

3. .ecreased mobility may cause a negative calcium balance as a result of calcium loss from bone

. .ecreased mobility causes decreases in muscular strength

Corre!t "ns#er: <

Rationa$e 1# -mmobility causes venous vasodilation and stasis, but this would not account for the clientEs fatigue

Rationa$e 2# %rolonged immobility may inhibit the force of the cough, resulting in pooling of respiratory

secretionsD the client is not complaining of a cough or shortness of breath

Rationa$e 3# %rolonged immobility may cause disuse osteoporosis resulting from the loss of calcium from the bonesD this clientEs condition does not indicate long term immobility

Rationa$e # .isuse atrophy is cause by muscles not being usedD clientEs may be fatigued more quickly after only

a short illness or in$ury

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCMA

-n addition the musculoskeletal effects of immobility, the nurse e!plains that the cardiovascular system undergoe

changes during prolonged bedrest, such as#BSelect all that apply


1. 4enous stasis&amont, 'iedringhous, Comprehensive Nursing Care (nd )dition *pdate Test +ank




2. Tachycardia

3. )mboli

. Atelectasis

. Anore!ia


Rationa$e 1# 4enous stasis and vasodilation occur due to the inability of atrophied muscles to assist in pumping

blood back to the heart

Rationa$e 2# .ecreased mobility creates an imbalance in the autonomic nervous system, resulting in an increasedheart rate

Rationa$e 3# 4enous stasis and vasodilation predispose clients to thrombus formationD thrombophlebitis may

result in an emboli, which may lodge in vessels supplying vital organs

Rationa$e # Atelectasis is a potential respiratory system change

Rationa$e # Anore!ia is a potential result of decreased metabolic rate and increased catabolismD it is an effect ofimmobility on the metabolic system

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCMA

The nurse is turning a client from her back to her side To promote the clientEs proper body alignment, and safety

the nurse#BSelect all that apply


1. )nsures the bed is clean and dry

2. %laces support devices in specified areas

3. %laces body parts on top of each other to ensure alignment

. %lans a (< hour schedule for position changes





. )nsures the mattress is soft

Corre!t "ns#er: ",(,<

Rationa$e 1# 3rinkled or damp sheets increase the risk of pressure ulcer formation

Rationa$e 2# Support devices, such as pillows and foot boards, should be used to maintain alignment and prevent

stress on muscles and $oints

Rationa$e 3# Avoid placing one body part directly on top of another body partD e!cessive pressure can damage

veins and predispose the client to thrombus formation

Rationa$e # %lan a continuous, (<:hour schedule for position changes

Rationa$e # The mattress should be firm, and level, and yields enough to fill in and support natural body

curvatures

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 3

Type: MCSA

A client has a nursing diagnosis of Activity -ntolerance An appropriate goal for this client would be#

1. Avoid complications associated with immobility

2. Avoid in$ury from improper use of body mechanics

3. -ncrease tolerance for physical activity

. Ambulate client with walker twice a day

Corre!t "ns#er: 1

Rationa$e 1# This goal may or may not be appropriate for this clientD the information does not support a nursing

diagnosis of -mpaired %hysical Mobility

Rationa$e 2# This goal is not immediately supported by the nursing diagnosis given

Rationa$e 3# This is an appropriate goal for this clientD appropriate interventions will vary





Rationa$e # This is an appropriate intervention for this clientD it is not a goal

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 31

Type: MCMA

The nurse is preparing to position a client in semi:2owlerEs position The appropriate support deviceBs to utili5e

include#BSelect all that apply


1. +edboards

2. 2oot boots

3. Chair beds

. %illows

. 2ootboard

Corre!t "ns#er: <,@

Rationa$e 1# Semi:2owlerEs



Rationa$e # Semi:2owlerEs

Rationa$e # Semi:2owlerEs

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:





Question 32

Type: S)F

As the nurse makes night rounds on sleeping clients, several clients are noted to be breathing very slowly Stages

of '&)M sleep account for some decreased physiological functions -dentify the stage that correlates to the

choice given

)tandard Te-t: Click and drag the options below to move them up or down

Choi!e 1. ;asts only a few minutes

Choi!e 2. ;ight sleep, body continues to slow down

Choi!e 3. Sleeper difficult to arouse

Choi!e . 6eart and respiratory rates (:1 below waking rates


Rationa$e 1# Stage - '&)M sleep is very light sleep, that lasts only a few minutesD person feels drowsy and

rela!ed


rela!ed


rela!ed

Rationa$e # Stage - '&)M sleep is very light sleep, that lasts only a few minutesD person feels drowsy andrela!ed

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 33

Type: MCMA

The client is postoperative day three from abdominal surgery 6e states that he hasnEt slept more than an hour or

so at a time due to the pain, but does not want to take medication to assist with sleeping The nurse describes the

functionBs of sleep as#BSelect all that apply






1. 'ecessary for protein synthesis

2. &estores normal levels of activity

3. &estores balance within the nervous system

. 'ecessary for fat metabolism

. Sympathetic nervous system activity


Rationa$e 1# Sleep is necessary for protein synthesis and cellular repair

Rationa$e 2# Sleep e!erts physiological effects on body systems and restores normal levels of activity

Rationa$e 3# Sleep restores balance within the nervous system

Rationa$e # Sleep is not necessary for fat metabolism

Rationa$e # Sympathetic nervous system is more active while the person is awake

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 3

Type: MCSA

The nurse is describing the difference between the quality and quantity of sleep Sleep quality refers to

1. The total time an individual sleeps

2. An individualEs ability to stay asleep

3. The sleep:wake cycle that changes through the lifespan

. 6ow long it takes a person to get to sleep

Corre!t "ns#er: (





Rationa$e 1# The total time the individual sleeps is the quantity of sleep

Rationa$e 2# Sleep quality refers to an individualEs ability to stay asleep and to get appropriate amounts of &)M

and '&)M sleep

Rationa$e 3# Sleep wake cycles are part of the biologic rhythm that involves physiological and psychological

activity and rest

Rationa$e # 6ow long it takes a person to get to sleep is described as Stage " '&)M sleep

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 3

Type: MCMA

The parents of a = year old are concerned about their child sleeping "" hours at night The nurse e!plains that age

related sleep habits include#BSelect all that apply


1. School age children need =:"( hours of sleep at night

2. -nfants and seniors often wake at night

3. -nfants and adults often wake at night

. Adolescents tend to get enough sleep

. -nfants will sleep through the night at < months of age

Corre!t "ns#er: ",(

Rationa$e 1# School:age children need =:"( hours of sleep at nightD children often become sleep deprived at this

age

Rationa$e 2# -nfants sill wake up at least once a night until = months of ageD seniors may have nighttime sleepinginterfered with by napping ;ack of e!ercise, or medication side effects

Rationa$e 3# Most infants still wake up at least once a night until = months of ageD adults should have a minimum

of G hours nightlyD unless adults are having troubled sleep, the norm is to sleep through the night





Rationa$e # Adolescents should have =@ hours of sleep from ages "1:"@ yearsD most teens get too little sleep,usually G@ hours or less

Rationa$e # -nfants will sleep 8:H hours at night by < months of age, but most still wake up at least once a night

until = months of age

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 3/

Type: MCMA

The nurse is taking a sleep history on a client who states that he has difficulty getting to sleep 3hich of thefollowing factors might be causing delayed onset of sleep#BSelect all that apply


1. 6yperthyroidism

2. 6ypothyroidism

3. )arly morning e!ercise

. Smoking

. .emerol

Corre!t "ns#er: ",<

Rationa$e 1# &ational#



Rationa$e # &ational#

Rationa$e # &ational#

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question 30

Type: MCMA

As the nurse obtains a general sleep history from a newly admitted clients, the client reports several parasomnias,

including#BSelect all that apply


1. Somnambulism

2. +ru!ism

3. 'arcolepsy

. Sleep apnea

. Sleep deprivation

Corre!t "ns#er: ",(

Rationa$e 1# Somnambulism is sleepwalking, which is a behavior that interferes with sleep



Rationa$e # Somnambulism is sleepwalking, which is a behavior that interferes with sleep


%$o&a$ Rationa$e:



C$ient Need )u&:Nursing*+ntegrated Con!epts: 'ursing %rocess# Assessment

(earning ut!ome:

Question 3

Type: MCSA





The nurse is e!plaining sleep deprivation to a client whose sleep history is suggestive of the deprivation Clinical

signs of '&)M deprivation include

1. )motional lability

2. .ifficulty getting dressed

3. -mpaired $udgement

. 3ithdrawal

Corre!t "ns#er: <

Rationa$e 1# )motional lability is a common clinical sign of &)M deprivation



Rationa$e # )motional lability is a common clinical sign of &)M deprivation

%$o&a$ Rationa$e:


C$ient Need: 6ealth %romotion and Maintenance

C$ient Need )u&:


(earning ut!ome:

Question 3

Type: MCMA

The nurse is preparing the care plan for a client with difficulty falling to sleep Appropriate interventions to reduc

environmental distractions in hospitals include#BSelect all that apply


1. Taking vital signs early in the evening

2. Closing the door of the clientEs room

3. %osition dependent clients appropriately

. Make nursing rounds in hallway

. Assist client with voiding before bedtime





Corre!t "ns#er: ",(

Rationa$e 1# %erforming only essential nursing tasks during sleeping hours will decrease environmentaldistractions

Rationa$e 2# %erforming only essential nursing tasks during sleeping hours will decrease environmental

distractions

Rationa$e 3# %erforming only essential nursing tasks during sleeping hours will decrease environmentaldistractions

Rationa$e # %erforming only essential nursing tasks during sleeping hours will decrease environmental

distractions


distractions

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question

Type: MCMA

A client is admitted to the emergency unit as a result of a minor motor vehicle accident that was due to his fallingasleep at the wheel -nformation that is appropriate for the nurse to include in the teaching plan for this client

includes#BSelect all that apply


1. )!ercise every day when ever it fits in the schedule

2. 'aps are acceptable, if short

3. +lock out e!tra noise if possible with a television on in the background

. 6eavy snacks before bedtime may disturb sleep

. )stablish a regular bedtime ritual


Rationa$e 1# .aily e!ercise is important, but avoid e!cessive physical e!ertion less than ( hours before bedtime







Rationa$e # .aily e!ercise is important, but avoid e!cessive physical e!ertion less than ( hours before bedtime


%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 1

Type: MCMA

The nursing care plan for the client with insomnia includes several non:pharmacologic interventions such as#

BSelect all that apply


1. A brisk walk around the facility

2. A small drink of brandy

3. A small glass of milk

. Taking a warm bath

. *sing the computer in bed until sleepy

Corre!t "ns#er: 1,<

Rationa$e 1# 3hen unable to sleep, a rela!ing,



Rationa$e # 3hen unable to sleep, a rela!ing,


%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCMA

The nurse is caring for a client in the intensive care unit This client is at risk for sensory overload, which may be

manifested in the following manner#BSelect all that apply


1. .ecreased attention span

2. -rritability

3. Scattered attention

. 6allucinations

. )motional lability

Corre!t "ns#er: (,1

Rationa$e 1# .ecreased attention span is a common manifestation of sensory deprivation

Rationa$e 2# -rritability, an!iety and restlessness are common manifestations of sensory overload

Rationa$e 3# Scattered attention and racing thoughts are common manifestations of sensory overload

Rationa$e # 6allucinations or delusions are common manifestations of sensory deprivation

Rationa$e # )motional lability is a common manifestation of sensory deprivation

%$o&a$ Rationa$e:

Cogniti'e (e'e$: ApplyingC$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question 3

Type: MCSA





The nurse is assessing a clientEs sensory reception and perception The client has a history of a motor vehicle

accident several years ago that resulted in a spinal cord in$ury This client is at risk for altered sensory reception o

which type of stimuli?

1. 4isual

2. Auditory

3. 9ustatory

. 4isceral

Corre!t "ns#er: <

Rationa$e 1# +ased on the information given, this client is not at risk for altered reception or perception of visual

stimuli

Rationa$e 2# +ased on the information given, this client is not at additional risk for altered reception or perceptioof auditory stimuli

Rationa$e 3# +ased on the information given, the client is not at additional risk for altered reception or perception

of gustatory Btaste stimuli

Rationa$e # This client may have a decreased awareness of visceral stimuli, such as a full stomach or need to

empty the bladder based on the altered impulse conduction due to the spinal cord in$ury

%$o&a$ Rationa$e:

Cogniti'e (e'e$: ApplyingC$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question

Type: MCMA

The nurse is caring for a group of clients in a long term care facility 3hich of the following clients are at risk for

sensory deprivation?BSelect all that apply


1. The alert and oriented client who has no family in the area

2. The confused client who has no family in the area





3. The alert and oriented client who has several children, grandchildren, and great:grand children who are allinvolved in the clientEs care

. The alert and oriented client who is unable to move independently

. The confused client whose hearing aids work intermittently

Corre!t "ns#er: ",(,<,@

Rationa$e 1# The alert and oriented client in a long term care facility with no family are at risk due to the potentia

lack of people to visit and talk with the client regularly

Rationa$e 2# The confused client is at risk due to an altered perception of stimulationD without regular visitors tha

the client recogni5es could increase confusion

Rationa$e 3# The alert and oriented client with many potential visitors is at risk for sensory overload due to too

many visitors

Rationa$e # The alert and oriented client who is unable to move independently is at risk for sensory deprivationdue to the inability to move to reach glasses, reading material, etc independently

Rationa$e # The confused client without functioning hearing aids is at risk for continued altered sensory

reception

%$o&a$ Rationa$e:


C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question

Type: MCMA

The nurse identifies the client at risk for sensory overload based on several factors, including#BSelect all that

apply


1. -n:patient hospitali5ation

2. )!treme shortness of breath

3. Signs of depression

. -ncreased an!iety over a new diagnosis





. ;ost hearing aids


Rationa$e 1# This client is at risk for sensory overload due to being admitted to a noisy healthcare setting

Rationa$e 2# The client with shortness of breath has increased stimulation, both physically and emotionally

Ban!iety

Rationa$e 3# The client with signs of depression is likely to withdraw or block out e!ternal stimuli

Rationa$e # A client with increased internal stimuli, such as an!iety or pain is at risk for sensory overload

Rationa$e # The client who has lost his or her hearing aids is at risk for sensory deprivation

%$o&a$ Rationa$e:


C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question /

Type: MCMA

The client with impaired vision is at risk of sensory overload and sensory deprivation The nurse identifies aids fo

this client to help the client deal with the deficit#BSelect all that apply


1. 3indow shades

2. 2lashing alarm clocks

3. Sign language instruction

. Color coding on stoves

. ;arge writing on name tags


Rationa$e 1# 3indow shades are important to reduce glare

Rationa$e 2# 2lashing alarm clocks are helpful for people with hearing deficits





Rationa$e 3# Sign language instruction is helpful for people with hearing deficits

Rationa$e # Color coding on stove controls is helpful for people with visual deficits

Rationa$e # ;arge writing on name tags of health care providers will be helpful for all clients, including people

with visual deficits

%$o&a$ Rationa$e:


C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question 0

Type: MCSA

The nurse identifies several factors that may contribute to sensory overload in a hospitali5ed school:age child,

including

1. 'arcotic medications

2. +eing one of several children in a family

3. .iagnosis of chicken po!

. 6aving intravenous lines inserted

Corre!t "ns#er: <

Rationa$e 1# 'arcotics and sedatives can decrease the awareness of stimuli

Rationa$e 2# +eing an only child would put the child at risk for sensory overload

Rationa$e 3# 6aving a diagnosis of chicken po! Ba communicable disease puts the child at risk of sensory

deprivation due to infection control procedures

Rationa$e # -ntravenous lines and other intrusive tubes can contribute to sensory overload

%$o&a$ Rationa$e:


C$ient Need:

C$ient Need )u&:


(earning ut!ome:





Question

Type: MCMA

As the nurse is collects data for a newly admitted client, it becomes clear that the client is confused The nurse

notes interventions appropriate for promoting orientation as#BSelect all that apply


1. Address the client by name

2. Assign a variety of caregivers

3. Speak quickly so the client does not have time to argue

. Tell the client when you are leaving and when you will return

. )ncouraging the client to wear familiar clothing


Rationa$e 1# Addressing the client by name assists in keeping the client oriented to person



Rationa$e # Addressing the client by name assists in keeping the client oriented to person


%$o&a$ Rationa$e:


C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question Type: MCMA

'ursing interventions that are appropriate for the client who has lost his or her vision include#BSelect all that

apply






1. *se of a radio or audiotapes

2. /rdering a bland diet

3. /ffering a massage

. %lacing silk flowers in the clientEs room

. *sing therapeutic pet therapy


Rationa$e 1# Auditory stimulation can supplement sensory input for the client with a visual impairment

Rationa$e 2# .iets that include a variety of flavors and te!tures can stimulate the taste buds

Rationa$e 3# Massages can be used to stimulate touch receptors

Rationa$e # 2resh flowers can stimulate the sense of smell

Rationa$e # %et therapy can be used to stimulate touch receptors

%$o&a$ Rationa$e:


C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question

Type: MCMA

The nurse is discussing strategies for preventing sensory impairments with the parents of a newborn Topics to

include to protect hearing include#BSelect all that apply


1. /btain regular immuni5ations

2. Seek medical attention for reduced eye contact

3. 7eep auditory stimulation to a minimum

. 6ave children wear ear protection in noisy environments

. 6ave regular health e!aminations






Rationa$e 1# -mmuni5ations against diseases that can cause hearing loss are important preventive measures

Rationa$e 2# .ecreased eye contact from an infant is more indicative of a visual problem

Rationa$e 3# Auditory stimulation is important for normal growth and development

Rationa$e # Children should wear ear protection in loud environments

Rationa$e # &egular health e!aminations allow for screening by health care providers

%$o&a$ Rationa$e:


C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question 1

Type: MCSA

The nurse is caring for a client with an impaired visual field Appropriate communication strategies with this

client include#

1. Convey your presence by moving to a position where you can be seen

2. .ecreasing background noises before speaking

3. *se longer phrases

. %ronounce every name with care

Corre!t "ns#er: "

Rationa$e 1# Convey your presence by moving to a position within the clientEs visual field

Rationa$e 2# .ecreasing background noises is more appropriate for the client with a hearing deficit

Rationa$e 3# *sing longer phrases are more easily understood for the client with a hearing deficit

Rationa$e # %ronouncing every name carefully with references to the name is a strategy that is useful for the

client who has a hearing deficit

%$o&a$ Rationa$e:






C$ient Need:

C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCMA

The nurse is aware that body movement is dependent on interdependent activity of several body systems,including the#


1. Musculoskeletal system

2. 'ervous system

3. 4estibular system

. &espiratory system

. Cardiovascular system


Rationa$e 1# The musculoskeletal system is involved in body movement, affecting alignment, and $oint mobility

Rationa$e 2# The nervous system is involved with balance and coordination

Rationa$e 3# The vestibular system is involved in body movement, affecting balance and coordination

Rationa$e # The respiratory system is affected by normal movement

Rationa$e # The cardiovascular system is affected by body movement

%$o&a$ Rationa$e:



C$ient Need )u&:Nursing*+ntegrated Con!epts: 'ursing %rocess# Assessment

(earning ut!ome:

Question 3

Type: MCSA

The nurse is discussing alignment and posture with a group of teens Many of the female students have adopted a

curved posture The nurse e!plains to the teens that#





1. 3hen the body is properly aligned, the organs are properly supported

2. )quilibrium depends on the proper body alignment

3. Muscular strength decreases with physical activity

. /rthostatic hypotension is common with improper alignment

Corre!t "ns#er: "

Rationa$e 1# %roper alignment of the body allows organs to function at their best while also maintaining balance

Rationa$e 2# )quilibrium depends on the integration of stimuli from several organs, including the muscles and

tendons of the head and neck, the eyes, and the inner ear

Rationa$e 3# Muscular strength decreases with immobility

Rationa$e # /rthostatic hypotension is common with prolonged bedrest

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question

Type: MCMAThe nurse is caring for a client who has been on bedrest for a high:risk pregnancy This client is at risk for#


1. .isuse atrophy

2. /rthostatic hypotension

3. Thrombophlebitis

. .ependent edema

. 6ypostatic pneumonia


Rationa$e 1# *nused muscles atrophy, losing most of their normal strength and function





Rationa$e 2# /rthostatic hypotension is common with prolonged bedrest

Rationa$e 3# 4enous vasodilation and stasis predispose clients to thrombus formation

Rationa$e # 3hen venous pressure is great, serum is forced from the blood vessels into the surrounding

interstitial space, causing edema

Rationa$e # 6ypostatic pneumonia is caused by static secretions in the alveoliD the pregnant client is unlikely toe!perience this complication

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question

Type: MCSA

The nurse adds range of motion e!ercises to a clientEs care plan when it is determined that the client is in a persistent vegetative state This is done to prevent#

1. The muscles from becoming permanently shortened

2. The muscles from wasting away

3. The muscles from becoming flaccid

. The client from losing body mass

Corre!t "ns#er: "

Rationa$e 1# 2le!or muscles are stronger than e!tensors, so when a person is inactive, the $oints become pulled

into the fle!ed position Constant immobility causes muscles to shorten permanently and become fi!ed in thefle!ed position

Rationa$e 2# &/M e!ercises will maintain $oint mobility, but will not prevent atrophy of muscles

Rationa$e 3# &/M e!ercises will maintain $oint mobilityD some muscles in this client might be flaccid, some can become contracted

Rationa$e # &/M e!ercises will maintain $oint mobility, but will not prevent the client from losing body mass

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question /

Type: MCMA

The nurse is e!plaining factors that affect an individualEs body alignment, mobility, and daily activity level)!amples of client factors that might decrease mobility and activity include#


1. 4estibular disorder

2. Spina bifida

3. Anemia

. /vernutrition

. )ar canal infection







%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: 'ursing %rocess# Assessment(earning ut!ome:

Question 0

Type: MCMA

The nurse is caring for a client who is in traction due to a motor vehicle accident The nurse anticipates which of

the following effects of immobility?






1. /steoporosis

2. 4enous vasoconstriction

3. *rinary stasis

. .iarrhea

. .ecreased respiratory movement







%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question

Type: MCMA

The nurse is admitting a client to a rehabilitation facility after surgery for a hip replacement The nurse observes

the client appearing depressed The client denies depression, but states that she is concerned about returning to he

regular activities, including walking for e!ercise, because she is so tired The nurse understands that#


1. This client has unrealistic goals

2. Stress might be affecting this clientEs mobility

3. 3alking will tire the client

. The client is at increased risk of disease due to immobility





. This client is at risk for affective disorder


Rationa$e 1# The clientEs goals are not unrealistic over time

Rationa$e 2# Stress and pain deplete the bodyEs energy reserves, producing fatigue

Rationa$e 3# Movement energi5es the client and facilitates coping

Rationa$e # A history of inactivity because of in$ury increases the risk of ma$or diseaseD early ambulation after

surgery is an essential preventive measure

Rationa$e # %eople who are unable to carry out usual activities related to their roles can become dependent onothersD loss of independence damages self:esteem, and in turn can provoke an e!aggerated emotional response

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question

Type: MCSA

The client who has been hospitali5ed for a fractured femur e!presses surprise that she is so tired after sitting up inthe chair for a short period of time The nurse e!plains that#

1. .ecreased mobility creates venous vasodilation and stasis

2. .ecreased mobility can interfere with the normal e!change of o!ygen and carbon dio!ide

3. .ecreased mobility can cause a negative calcium balance as a result of calcium loss from bone

. .ecreased mobility causes decreases in muscular strength

Corre!t "ns#er: <

Rationa$e 1# -mmobility causes venous vasodilation and stasis, but this would not account for the clientEs fatigue

Rationa$e 2# %rolonged immobility can inhibit the force of the cough, resulting in pooling of respiratory

secretionsD the client is not complaining of a cough or shortness of breath

Rationa$e 3# %rolonged immobility can cause disuse osteoporosis resulting from the loss of calcium from the

bonesD this clientEs condition does not indicate long:term immobility





Rationa$e # .isuse atrophy is caused by muscles not being usedD clients can be fatigued more quickly after onlya short illness or in$ury

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question /

Type: MCMA

-n addition to the musculoskeletal effects of immobility, the nurse e!plains that the cardiovascular system

undergoes other changes during prolonged bedrest, such as#


1. 4enous stasis

2. Tachycardia

3. )mboli

. Atelectasis

. Anore!ia


Rationa$e 1# 4enous stasis and vasodilation occur due to the inability of atrophied muscles to assist in pumping

blood back to the heart

Rationa$e 2# .ecreased mobility creates an imbalance in the autonomic nervous system, resulting in an increased

heart rate

Rationa$e 3# 4enous stasis and vasodilation predispose clients to thrombus formationD thrombophlebitis can resul

in an embolus, which can lodge in vessels supplying vital organs

Rationa$e # Atelectasis is a potential respiratory system change

Rationa$e # Anore!ia is a potential result of decreased metabolic rate and increased catabolismD it is an effect of

immobility on the metabolic system

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question /1

Type: MCMA

The nurse is turning a client from her back to her side To promote safety and the clientEs proper body alignment,the nurse#


1. )nsures the bed is clean and dry

2. %laces support devices in specified areas

3. %laces body parts on top of each other to ensure alignment

. %lans a (< hour schedule for position changes

. )nsures the mattress is soft


Rationa$e 1# 3rinkled or damp sheets increase the risk of pressure ulcer formation

Rationa$e 2# Support devices, such as pillows and foot boards, should be used to maintain alignment and prevent

stress on muscles and $oints

Rationa$e 3# Avoid placing one body part directly on top of another body partD e!cessive pressure can damage

veins and predispose the client to thrombus formation

Rationa$e # %lan a continuous, (<:hour schedule for position changes

Rationa$e # The mattress should be firm and level, and yield enough to fill in and support natural body

curvatures

%$o&a$ Rationa$e:

Cogniti'e (e'e$: *nderstandingC$ient Need: %hysiological -ntegrity

C$ient Need )u&:


(earning ut!ome:

Question /2

Type: MCSA





A client has a nursing diagnosis of Activity -ntolerance An appropriate goal for this client would be#

1. Avoid complications associated with immobility

2. Avoid in$ury from improper use of body mechanics

3. -ncrease tolerance for physical activity

. Ambulate the client with a walker twice a day

Corre!t "ns#er: 1

Rationa$e 1# This goal might not be appropriate for this clientD the information does not support a nursing

diagnosis of -mpaired %hysical Mobility

Rationa$e 2# This goal is not immediately supported by the nursing diagnosis given

Rationa$e 3# This is an appropriate goal for this clientD appropriate interventions will vary

Rationa$e # This is an appropriate intervention for this clientD it is not a goal

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question /3

Type: S)F

As the nurse makes night rounds on sleeping clients, several clients are noted to be breathing very slowly Stages

of '&)M sleep account for some decreased physiological functions -dentify the stage that correlates to the

choice given#

)tandard Te-t: Click and drag the options below to move them up or down

Choi!e 1. ;asts only a few minutes

Choi!e 2. ;ight sleepD body continues to slow down

Choi!e 3. Sleeper difficult to arouse

Choi!e . 6eart and respiratory rates (I1 below waking rates






Rationa$e 1# Stage - '&)M sleep is very light sleep that lasts only a few minutesD the person feels drowsy andrela!ed

Rationa$e 2# Stage - '&)M sleep is very light sleep that lasts only a few minutesD the person feels drowsy and

rela!ed

Rationa$e 3# Stage - '&)M sleep is very light sleep that lasts only a few minutesD the person feels drowsy and

rela!ed

Rationa$e # Stage - '&)M sleep is very light sleep that lasts only a few minutesD the person feels drowsy and

rela!ed

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question /

Type: MCMA

The client is postoperative day three from abdominal surgery 6e states that he hasnEt slept more than an hour or

so at a time due to the pain, but does not want to take medication to assist with sleeping The nurse describes thefunctions of sleep as#


1. 'ecessary for protein synthesis

2. &estores normal levels of activity

3. &estores balance within the nervous system

. 'ecessary for fat metabolism

. Sympathetic nervous system activity


Rationa$e 1# Sleep is necessary for protein synthesis and cellular repair

Rationa$e 2# Sleep e!erts physiological effects on body systems and restores normal levels of activity

Rationa$e 3# Sleep restores balance within the nervous system

Rationa$e # Sleep is not necessary for fat metabolism





Rationa$e # The sympathetic nervous system is more active while the person is awake

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question /

Type: MCSA

The nurse is describing the difference between the quality and quantity of sleep Sleep quality refers to#

1. The total time an individual sleeps

2. An individualEs ability to stay asleep

3. The sleepIwake cycle that changes through the life span

. 6ow long it takes a person to get to sleep

Corre!t "ns#er: (

Rationa$e 1# The total time the individual sleeps is the quantity of sleep

Rationa$e 2# Sleep quality refers to an individualEs ability to stay asleep and to get appropriate amounts of &)M

and '&)M sleep

Rationa$e 3# SleepIwake cycles are part of the biologic rhythm that involves physiological and psychologicalactivity and rest

Rationa$e # 6ow long it takes a person to get to sleep is described as stage " '&)M sleep

%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: 'ursing %rocess# -mplementation(earning ut!ome:

Question //

Type: MCMA

The parents of a =:year:old are concerned about their child sleeping "" hours at night The nurse e!plains that age

related sleep habits include#






1. School:age children need =I"( hours of sleep at night

2. -nfants and seniors often wake at night

3. -nfants and adults often wake at night

. Adolescents tend to get enough sleep

. -nfants will sleep through the night at < months of age

Corre!t "ns#er: ",(

Rationa$e 1# School:age children need =I"( hours of sleep at nightD children often become sleep:deprived at thisage

Rationa$e 2# -nfants wake up at least once a night until = months of ageD seniors can have nighttime sleeping

interfered with by napping, lack of e!ercise, or medication side effects

Rationa$e 3# Most infants wake up at least once a night until = months of age Adults should have a minimum of

hours nightlyD unless adults are having troubled sleep, the norm is to sleep through the night

Rationa$e # Adolescents should have =@ hours of sleep from ages "1 to "@ yearsD most teens get too little sleep,

usually G@ hours or less

Rationa$e # -nfants will sleep 8IH hours at night by < months of age, but most still wake up at least once a night

until = months of age

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question /0

Type: MCMA

The nurse is taking a sleep history on a client who states that he has difficulty getting to sleep 3hich of thefollowing factors might be causing delayed onset of sleep?


1. 6yperthyroidism

2. 6ypothyroidism





3. )arly morning e!ercise

. Smoking

. .emerol

Corre!t "ns#er: ",<

Rationa$e 1#

Rationa$e 2#

Rationa$e 3#

Rationa$e #

Rationa$e #

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question /

Type: MCMA

As the nurse obtains a general sleep history from a newly admitted client, the client reports several parasomnias,including#


1. Somnambulism

2. +ru!ism

3. 'arcolepsy

. Sleep apnea

. Sleep deprivation

Corre!t "ns#er: ",(










%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question /

Type: MCSAThe nurse is e!plaining sleep deprivation to a client whose sleep history is suggestive of deprivation Clinical

signs of '&)M deprivation include#

1. )motional lability

2. .ifficulty getting dressed

3. -mpaired $udgment

. 3ithdrawal

Corre!t "ns#er: <




Rationa$e # )motional lability is a common clinical sign of &)M deprivation

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:





Question 0

Type: MCMA

The nurse is preparing the care plan for a client with difficulty falling asleep Appropriate interventions to reduce

environmental distractions in hospitals include#


1. Taking vital signs early in the evening

2. Closing the door of the clientEs room

3. %ositioning dependent clients appropriately

. Making nursing rounds in the hallway

. Assisting client with voiding before bedtime

Corre!t "ns#er: ",(


distractions


distractions


distractions


distractions


distractions

%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: 'ursing %rocess# -mplementation(earning ut!ome:

Question 01

Type: MCMA

A client is admitted to the )mergency .epartment as a result of a minor motor vehicle accident caused by hisfalling asleep at the wheel -nformation that is appropriate for the nurse to include in the teaching plan for this

client includes#






1. )!ercise every day whenever it fits in the schedule

2. 'aps are acceptable, if short

3. +lock out e!tra noise if possible with a television on in the background

. 6eavy snacks before bedtime can disturb sleep

. )stablish a regular bedtime ritual







%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 02

Type: MCMA

The nursing care plan for the client with insomnia includes several nonpharmacologic interventions, such as#


1. A brisk walk around the facility

2. A small drink of brandy

3. A small glass of milk

. Taking a warm bath

. *sing the computer in bed until sleepy





Corre!t "ns#er: 1,<






%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 03

Type: MCMA

The nurse is caring for a client in the intensive care unit This client is at risk for sensory overload, which can

manifest in the following manner#


1. .ecreased attention span

2. -rritability

3. Scattered attention

. 6allucinations

. )motional lability

Corre!t "ns#er: (,1

Rationa$e 1# .ecreased attention span is a common manifestation of sensory deprivation

Rationa$e 2# -rritability, an!iety, and restlessness are common manifestations of sensory overload

Rationa$e 3# Scattered attention and racing thoughts are common manifestations of sensory overload

Rationa$e # 6allucinations or delusions are common manifestations of sensory deprivation





Rationa$e # )motional lability is a common manifestation of sensory deprivation

%$o&a$ Rationa$e:


C$ient Need: %sychosocial

C$ient Need )u&:


(earning ut!ome:

Question 0

Type: MCSA

The nurse is assessing a clientEs sensory reception and perception The client has a history of a motor vehicleaccident several years ago that resulted in a spinal cord in$ury This client is at risk for altered sensory reception o

which type of stimuli?

1. 4isual

2. Auditory

3. 9ustatory

. 4isceral

Corre!t "ns#er: <

Rationa$e 1# +ased on the information given, this client is not at risk for altered reception or perception of visualstimuli

Rationa$e 2# +ased on the information given, this client is not at additional risk for altered reception or perceptio

of auditory stimuli

Rationa$e 3# +ased on the information given, the client is not at additional risk for altered reception or perceptionof gustatory Btaste stimuli

Rationa$e # This client could have a decreased awareness of visceral stimuli, such as a full stomach or need to

empty the bladder based on the altered impulse conduction due to the spinal cord in$ury

%$o&a$ Rationa$e:


C$ient Need: %sychosocial

C$ient Need )u&:


(earning ut!ome:

Question 0





Type: MCMA

The nurse is caring for a group of clients in a long:term care facility 3hich of the following clients are at risk for

sensory deprivation?


1. The alert and oriented client who has no family in the area

2. The confused client who has no family in the area

3. The alert and oriented client who has several children, grandchildren, and great:grandchildren who are allinvolved in the clientEs care

. The alert and oriented client who is unable to move independently

. The confused client whose hearing aids work intermittently

Corre!t "ns#er: ",(,<,@

Rationa$e 1# The alert and oriented client in a long:term care facility with no family is at risk due to the potential

lack of people to visit and talk with the client regularly

Rationa$e 2# The confused client is at risk due to an altered perception of stimulationD without regular visitorswho the client recogni5es, this could increase confusion

Rationa$e 3# The alert and oriented client with many potential visitors is at risk for sensory overload due to too

many visitors

Rationa$e # The alert and oriented client who is unable to move independently is at risk for sensory deprivation

due to the inability to move to reach eyeglasses, reading material, etc, independently

Rationa$e # The confused client without functioning hearing aids is at risk for continued altered sensory

reception

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 0/

Type: MCMA

The nurse identifies the client at risk for sensory overload based on several factors, including#






1. -n:patient hospitali5ation

2. )!treme shortness of breath

3. Signs of depression

. -ncreased an!iety over a new diagnosis

. ;ost hearing aids


Rationa$e 1# This client is at risk for sensory overload due to being admitted to a noisy healthcare setting

Rationa$e 2# The client with shortness of breath has increased stimulation, both physically and emotionallyBan!iety

Rationa$e 3# The client with signs of depression is likely to withdraw or block out e!ternal stimuli

Rationa$e # A client with increased internal stimuli, such as an!iety or pain, is at risk for sensory overload

Rationa$e # The client who has lost his hearing aids is at risk for sensory deprivation

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 00

Type: MCMA

The client with impaired vision is at risk of sensory overload and sensory deprivation The nurse identifies the

following aids for this client to help the client deal with the deficit#


1. 3indow shades

2. 2lashing alarm clocks

3. Sign language instruction

. Color:coding on stoves

. ;arge writing on name tags






Rationa$e 1# 3indow shades are important to reduce glare

Rationa$e 2# 2lashing alarm clocks are helpful for people with hearing deficits

Rationa$e 3# Sign language instruction is helpful for people with hearing deficits

Rationa$e # Color:coding on stove controls is helpful for people with visual deficits

Rationa$e # ;arge writing on name tags of healthcare providers will be helpful for all clients, including people

with visual deficits

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 0

Type: MCSA

The nurse identifies several factors that might contribute to sensory overload in a hospitali5ed school:age child,

including#

1. 'arcotic medications

2. +eing one of several children in a family

3. .iagnosis of chickenpo!

. 6aving intravenous lines inserted

Corre!t "ns#er: <

Rationa$e 1# 'arcotics and sedatives can decrease the awareness of stimuli

Rationa$e 2# +eing an only child would put the child at risk for sensory overload

Rationa$e 3# 6aving a diagnosis of chickenpo! Ba communicable disease puts the child at risk of sensorydeprivation due to infection control procedures

Rationa$e # -ntravenous lines and other intrusive tubes can contribute to sensory overload

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question 0

Type: MCMA

As the nurse is collecting data for a newly admitted client, it becomes clear that the client is confused The nursenotes interventions appropriate for promoting orientation, such as#


1. Address the client by name

2. Assign a variety of caregivers

3. Speak quickly so the client does not have time to argue

. Tell the client when you are leaving and when you will return

. )ncourage the client to wear familiar clothing







%$o&a$ Rationa$e:



C$ient Need )u&:Nursing*+ntegrated Con!epts: 'ursing %rocess# -mplementation

(earning ut!ome:

Question

Type: MCMA

'ursing interventions that are appropriate for the client who has lost her vision include#






1. *se of a radio or audiotapes

2. /rdering a bland diet

3. /ffering a massage

. %lacing silk flowers in the clientEs room

. *sing therapeutic pet therapy


Rationa$e 1# Auditory stimulation can supplement sensory input for the client with a visual impairment

Rationa$e 2# .iets that include a variety of flavors and te!tures can stimulate the taste buds

Rationa$e 3# Massages can be used to stimulate touch receptors

Rationa$e # 2resh flowers can stimulate the sense of smell

Rationa$e # %et therapy can be used to stimulate touch receptors

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 1

Type: MCMA

The nurse is discussing strategies for preventing sensory impairments with the parents of a newborn Strategies to

protect hearing include#


1. /btain regular immuni5ations

2. Seek medical attention for reduced eye contact

3. 7eep auditory stimulation to a minimum

. 6ave the child wear ear protection in noisy environments





. 6ave regular health e!aminations


Rationa$e 1# -mmuni5ations against diseases that can cause hearing loss are important preventive measures

Rationa$e 2# .ecreased eye contact from an infant is more indicative of a visual problem

Rationa$e 3# Auditory stimulation is important for normal growth and development

Rationa$e # Children should wear ear protection in loud environments

Rationa$e # &egular health e!aminations allow for screening by healthcare providers

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCSA

The nurse is caring for a client with an impaired visual field Appropriate communication strategies with this

client include#

1. Convey your presence by moving to a position where you can be seen

2. .ecrease background noises before speaking

3. *se longer phrases

. %ronounce every name with care

Corre!t "ns#er: "

Rationa$e 1# Convey your presence by moving to a position within the clientEs visual field

Rationa$e 2# .ecreasing background noises is more appropriate for the client with a hearing deficit

Rationa$e 3# ;onger phrases are more easily understood by the client with a hearing deficit

Rationa$e # %ronouncing every name carefully is a strategy that is useful for the client who has a hearingdeficitCognitive ;evel# Applying

%$o&a$ Rationa$e:





Cogniti'e (e'e$: %ronouncing every name carefully is a strategy that is useful for the client who has a hearingdeficitCognitive ;evel# Applying


C$ient Need )u&:


(earning ut!ome:

ramont2e rev tif ch23

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