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20 Cards in this Set

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The nurse suspects the client is at risk for falling. Which of the following statements made by the client would most alert the nurse to this risk?
A. “I recently began taking medication for high blood pressure.”
B. “I no longer have pain in my knee after physical therapy treatment.”
C. “I have lost 20 pounds during the past 6 months.”
D. “My cancer has been in remission for 5 years.”
A
Fibrous tissues that bind joints together, connecting bone and cartilage are known as:
A. Ligaments
B. Tendons
C. Cartilaginous tissues
D. Skeletal muscles
A
The hip joint is classified as what type of joint?
A. Synostotic
B. Cartilaginous
C. Fibrous
D. Synovial
D
When a client is immobilized, which of the following positions is preferred to prevent skin breakdown?
A. Side-lying with knees flexed
B. Semi-Fowler’s position
C. Supine with lower extremities extended
D. Prone with upper extremities flexed
B
An immobilized client is at risk for:
A. Hypercalcemia
B. Hypocalcemia
C. Hypernatremia
D. Hyponatremia
A
The most significant hazard of restricted mobility is:
A. Orthostatic hypotension
B. Tachycardia
C. Foot drop
D. Deep vein thrombosis
D
Which of the following nursing interventions is most important in preventing deep vein thrombosis in an immobilized client?
A. Measure calf circumference daily.
B. Provide passive range of motion (ROM) every shift.
C. Ensure that compression devices are fitted correctly and pumping.
D. Dorsiflex foot of suspected extremity.
C
Which of the following is the highest priority nursing diagnosis in an immobilized client? Risk for:
A. Ineffective peripheral tissue perfusion
B. Disuse syndrome
C. Deficient fluid volume
D. Ineffective airway clearance
D
What type of diet is most important for an immobilized client?
A. High protein, high calorie
B. Low sodium
C. Heart healthy
D. Restricted carbohydrates
A
The immobilized client should be instructed to:
A. Take in a minimum of 2000 ml/day
B. Deep breathe and cough every 2 to 4 hours
C. Eat a restricted-calorie diet
D. Quickly resume walking exercises when able
A
A physiological risk associated with prolonged immobility.
1. Decreased bone resorption
2. Decreased cardiac workload
3. Decreased serum calcium levels
4. Increased hemoglobin formation.
2. Decreased cardiac workload
A client has been on bed rest for several days. The clients stands and the nurse notes that the clients systolic pressure drops 20 mm HG This is reffered to as
1. Orthostatic hypotension
2. rebound hypotension
3. positional hypotension
4. central venous hypotension
1. orthostatic hypotension
The purpose of elastic stockings after a surgical procedure is to:
1. Prevent varicose veins
2. prevent muscular atrophy
3. Ensure joint mobility and prevent contractures
4. Facilitate the return of venous blood to the heart
4. Facilitate the return of Venous blood to the heart
The most important objective of bed rest for a client with bilaterial pneumonia would be to:
1. allow the client uninterrupted sleep
2. Reduce the oxygen needs of the body
3. Decrese the need for pain medications
4. Prevent the client from falling due to an unsteady gait
2. Reduced the oxygen needs of the body
The client at greatest risk for developing adverse effects of immobility is a:
1. 3-year-old child with a fractured femur
2. 48-year-old woman following a thyroidectomy
3. 78-year-old man in traction for a broken hip
4. 38-year-old woman undergoing a hysterectomy
3. 78-year-old man in traction for a broken hip
A client has been immobilized for 5 days becasue of extensive abdominal surgery. When getting this client out of bed for the first time a nursing diagnosis related to the safety of this client would be:
1. pain
2. impaired skin integrity
3. altered tissue perfusion
4. risk for activity intolerance
4. risk for activity intolerance
Heparin and low-molecular-weight heparin LMWH are the most widely used drugs in the prophylaxis of deep vein thrombosis (DVT). Common dosage for heparin therapy is
1. 5000 units given subcutaneously 2 hours before surgery and repeated every 8 to 12 hours
2. 500 units given subcutaneously 2 hours before surgery and repeated every 8-12 hours
3. 500 units given subcutaneously 2 hours before surgery and repeated every 8 to 12 hours
4. 5000 units given subcutaneously 8 hours before surgery and repeated every 2 to 4 hours
1. 5000 units given subcutaneously 2 hours before surgery and repeated every 8 to 12 hours
This allows the client to pull with the upper extremities to raise the trunk off the bed, to assist in transfer form bed to wheel chair or to perform upper arm excercises
1. trapeze bar
2. tronchanter roll
3. hand rolls
4. footboard
1. trapeze board
The client in this positionis lying face or chest down:
1. supine
2. prone
3. fowler's
4. lateral
2. prone
these activities are necessary to be independent in society and include such skills as shopping preparing meals, banking, and talking medications:
1. Activities of daily living ADLS
2. work activities
3. Instrumental Activities of daily living IADLS
4. Homemaker activities
3. instrumental activities of daily living IADLS