CH.

43
Which one of the following nursing interventions for a client in pain is based
on the gate-control theory?
1. Giving the client a back massage
2. Changing the client's position in bed
3. Giving the client a pain medication
4. Limiting the number of visitors

ANS: 1


The nurse on a postoperative care unit is assessing the quality of the client's
pain. In order to obtain this specific information about the pain experience
from the client, the nurse should ask:
1. "What does your discomfort feel like?"
2. "What activities make the pain worse?"
3. "How much does it hurt on a scale of 0 to 10?"
4. "How much discomfort are you able to tolerate?"
ANS: 1

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:
Promote venous return to the heart.

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?
"I'll check the label of my multivitamin. If it has calcium, I can save money by
not taking another pill. "

The patient at greatest risk for developing multiple adverse effects of
immobility is a:
80-year-old woman who has suffered a hemorrhagic cerebrovascular accident
(CVA).

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?
Risk for activity intolerance

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?
Coffee ground-like aspirate from the feeding tube

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.)
The three-legged stool on wheels in The braided throw rugs in the entry hallway
and between the bedroom and bathroom

Immobilized patients are at risk for impaired skin integrity. Which of the
following interventions would reduce this risk? (Select all that apply
Using an objective, valid scale to assess patient's risk for pressure ulcer
development
Using a device to relieve pressure when patient is seated in chair
Teaching patient how to shift weight at regular intervals while sitting in a chair
A good rule is: the higher the risk for skin breakdown, the shorter the interval
between position changes

Which of the following indicates that additional assistance is needed to
transfer the patient from the bed to the stretcher?
The patient received an injection of morphine 30 minutes ago for pain.

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?
"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.

Which is an outcome for a patient diagnosed with osteoporosis?
Maintain independence with activities of daily living (ADLs).

1. Erin performs a neurological assessment on Mr. Silliman. When assessing
his legs, she notices that he is not able to dorsiflex and invert his right foot.
Which condition may Mr. Silliman have?
A. Pigeon toes
B. Scoliosis
C. Footdrop
D. Bowlegs
Answer: C

3. Erin assesses Mr. Silliman's legs and notices that the calf and thigh of the
right leg are a little smaller than those of the left leg. Mr. Silliman's
immobility since the accident has caused ___________ _____________
in his right leg.
Answer: Muscle atrophy

Erin assesses Mr. Silliman for a possible thrombus. Which factors together
form Virchow's triad? (Select all that apply.)
A. Damage to the vessel wall
B. Alterations in blood flow
C. Damage to the nerve root
D. Alterations in blood constituents
E. Damage to muscle fibers
Answer: A, B, D


Before transferring a patient from the bed to a stretcher, which assessment
data does the nurse need to gather? (Select all that apply.)
Patient's weight
Patient's level of cooperation
Patient's ability to assist
Presence of medical equipment

A patient of any age can develop a contracture of a joint when:
The muscle fibers become shortened because of disuse.

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?
Cream of broccoli soup with whole wheat crackers and tapioca for dessert

Review questions
The use of client distraction in pain control is based on the principle that:
1. Small C fibers transmit impulses via the spinothalamic tract
2. The reticular formation can send inhibitory signals to gating mechanisms
3. large A fibers compete with pain impulses to close gates to painful stimuli
4. Transmission of pain impulses from the spinal cord to the cerebral cortex
can inhibited
Answer is: 2.