CHAPTER 44

1. MC The nurse is organizing a wellness project to educate teenagers about keeping their bodies healthy. Which information about diet and exercise should be included? A. Diet is the most important predictor of health. B. * The most important factors for maintaining health are diet and activity. C. Increase in exercise is sufficient to manage most people's weight gain. D. Obese women who remain active have a low mortality rate. 2. MC During a prenatal visit, the nurse is instructing a newly pregnant woman in regard to exercise. What advice is best for the nurse to give this client? A. Pregnant women can exercise if exercise was a part of their life prior to pregnancy. B. Due to the stress of a growing fetus, exercise should be limited to no more than 10 minutes per day. C. * Healthy pregnant women should exercise at least 30 minutes on most if not all days. D. The pregnant woman's exercise should actually increase above normal recommended levels to prevent water weight gain. 3. MC The nurse is caring for a client medically diagnosed with early osteoporosis. Which intervention is most applicable for this client? A. * Institute an exercise plan that includes weight-bearing activities. B. Increase the amount of calcium in the client's diet. C. Protect the client's bones with strict bed rest. D. Provide the client with assisted range of motion exercising twice daily. 4. MC The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care? A. Frequent position changes to reverse the contractures B. Exercises to strengthen flexor muscles C. * Range of motion exercises to prevent worsening of contractures D. Weight-bearing activities to stimulate joint relaxation 5. MC The nurse has documented that the client has orthostatic hypotension. Which of the following assessment findings would support this assessment? (Select all that apply.) A. * Decrease in blood pressure when moving from supine to standing B. Decrease in heart rate when moving from supine to sitting C. Pale color in the legs when lying in bed D. * Complaints of dizziness when first sitting up E. Increased respiratory rate on exertion 6. MC The client's chief complaint is, "I just can't get around like I used to. I have to stop halfway up the stairs to the bedroom, and just walking to the bathroom makes me so tired." Which nursing diagnosis is most likely appropriate for this client? Activity Intolerance: A. Level 1 B. Level 2 C. * Level 3 D. Level 4

7. MC The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should: A. * Include what mobility is impaired. B. Use Level 1, 2, 3, or 4 to describe immobility. C. Describe what happens when the client attempts mobility. D. Add strength assessment data. 8. MC The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? A. Nurses must wear back belts when lifting clients. B. All nursing personnel must attend annual body mechanics education. C. In order to prevent injury, nurses must strive to become physically fit. D. * No solo lifting of clients is permitted in the facility. 9. MC The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. The nurse should employ which techniques to best protect the back? (Select all that apply.) A. Place the feet together to provide a strong base of support. B. * Flex the knees to lower the center of gravity. C. Face the box, pick it up, and rotate the upper body toward the table. D. * Hold the box as close to the body as possible. E. Bend over and use a jerking motion to pull the box to waist level. 10. MC A. B. * C. D. How should the nurse position a client who is complaining of dyspnea? High Fowler's position with two pillows behind the head Orthopneic position across the overbed table Prone position with knees flexed and arms extended Sims position with both legs flexed

11. MC While assisting the client with a bath, the nurse encourages full range of motion in all the client's joints. Which activity would best support range of motion in the hand and arm? A. Give the client a washcloth to wash her face. B. Move the wash basin farther toward the foot of the bed so the client must reach. C. * Have the client brush her own hair and teeth. D. Move each of the client's hand and arm joints through passive range of motion. 12. MC The bed-bound client complains of pain and burning in the right calf area. What action should be taken by the nurse? A. Deeply palpate the area for rebound tenderness. B. Percuss over the area for change in tone. C. * Measure the calf and compare to the opposite calf. D. Medicate the client for pain and reassess in 30 minutes. 13. MC The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse? A. Percuss for flatness over the liver.

B. * C. D. 14. MC indicated? A. * B. C. D.

Palpate for bladder fullness. Use the prn order to medicate the client with an antacid. Inspect the sacral area for edema. The client who is unconscious is developing foot drop. What nursing action is Place high-topped shoes on the client while in bed. Keep the linens on the end of the bed turned back to expose the feet. Use only the prone and Sims positions for client positioning. Use a device to elevate the linens off the feet.

15. MC The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? (Select all that apply.) A. * Place a turn sheet on the bed. B. * Always use two personnel to move the client. C. Stand at the head of the bed to pull the client up. D. Slide the client toward the head of the bed. E. * Encourage the client to assist as possible. 16. MC Which nursing action is first when assisting the client to a lateral position for placement of a bedpan? A. * Perform hand hygiene. B. Move the client to the side of the bed. C. Place the client's arm over the chest. D. Raise the opposite side rail. 17. MC A. B. C. * D. Which client would require logrolling for position changes? A client with documented pneumonia The client who has had abdominal surgery The client who fell from a house, sustaining a fractured tibia A client who has a severe headache from hypertensive crisis

18. MC The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? A. Toward the nearest corner of the head of the bed B. Toward the side of the bed C. * Toward the far corner of the foot of the bed D. Directly toward the client 19. MC wheelchair? A. B. C. * D. 20. MC position for A. * B. C. D. 21. MC What is the priority action of the nurse prior to transferring a client from bed to Place the bed in its lowest position. Place the wheelchair parallel to the bed. Lock the brakes on the bed. Place a transfer belt on the client. The nurse is preparing to transfer a client from the bed to a gurney. The correct the bed to be placed is parallel to the gurney and which of the following? Slightly higher Slightly lower At the same height At least 2 inches lower The postoperative client is ambulating for the first time since surgery. The client has

been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? A. The UAP B. A licensed practical (vocational) nurse C. * A registered nurse D. It makes no difference 22. MC The nurse is assisting a newly delivered mother in ambulating to the nursery to see her baby. The client complains of light-headedness and begins to faint. What is the nurse's most important action? A. Ensure the client's modesty as she falls. B. * Be certain the client does not hit her head on anything. C. Call for immediate assistance. D. Check the vital signs and for excessive vaginal bleeding. 23. MC The nurse is providing range of motion exercising to the client's elbow when the client complains of pain. What action should the nurse take? A. Stop immediately and report the pain to the client's physician. B. Discontinue the treatment and document the results in the medical record. C. * Reduce the movement of the joint just until the point of slight resistance. D. Continue to exercise the joint as before to loosen the stiffness. 24. MC The client has a history of postural hypotension. Which activities would the nurse advise this client would be likely to cause postural hypotension? (Select all that apply.) A. * Hot baths B. * Heavy meals C. Use of a rocking chair D. * Valsalva maneuvers E. * Bending down to the floor 25. FI The nurse is teaching a client how to use a cane while rehabilitating from a left leg injury. The nurse should advise this client to place the cane on which side of the body? __________ A. Right 26. FI The nurse is evaluating the proper fit of crutches for a client who is to be discharged home. What portion of this client's body should support the weight? __________ A. Arms