Nokea
A client experiencing low back pain asks the nurse which type of exercise will strengthen the lower back muscles. Which exercise should the nurse encourage the client to participate in to best strengthen the lower back muscles?
- A. Tennis
- B. Diving
- C. Canoeing
- D. Swimming
Correct Answer: D
Rationale: Walking and swimming are very beneficial in strengthening back muscles for the client with low back pain. The other options involve twisting and pulling of the back muscles, which is not helpful to the client experiencing back pain.
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A client with a history of depression is prescribed sertraline (Zoloft). The nurse should instruct the client to report which of the following side effects?
- A. Insomnia.
- B. Bradycardia.
- C. Hypotension.
- D. Weight loss.
Correct Answer: A
Rationale: Sertraline commonly causes insomnia, which should be reported to manage treatment.
The nurse is caring for a client with a diagnosis of deep vein thrombosis (DVT). Which of the following interventions is most appropriate?
- A. Applying cold packs to the affected leg.
- B. Encouraging ambulation every hour.
- C. Administering heparin as ordered.
- D. Elevating the leg above heart level.
Correct Answer: C,D
Rationale: Heparin prevents clot extension in DVT, and elevating the leg reduces swelling and promotes venous return.
Which federal law is most closely associated with the highly restrictive 'need to know'?
- A. The Patient Self Determination Act
- B. The Mental Health Parity Act
- C. The Health Insurance Portability and Accountability Act
- D. The Americans with Disabilities Act of 1990
Correct Answer: C
Rationale: The Health Insurance Portability and Accountability Act (HIPAA) enforces the 'need to know' principle, restricting access to protected health information to only those who require it for their job functions.
The nurse is caring for a client who has just undergone a colectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor for signs of bowel perforation.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Keep the client on bed rest for 48 hours.
Correct Answer: B
Rationale: Encouraging early ambulation post-colectomy prevents complications like ileus and deep vein thrombosis.
During you musculoskeletal assessment of the client, you determine that the client has muscular strength against gravity but not against resistance. You would document this assessment as:
- A. 1 on the scale of 1 to 3
- B. 2 on the scale of 1 to 5
- C. 3 on the scale of 0 to 5
- D. 4 on the scale of 0 to 5
Correct Answer: C
Rationale: Muscular strength against gravity but not resistance is graded as 3 on the 0-5 scale, indicating fair strength.