Nokea
By what age is head control usually achieved in infants?
- A. 5 months
- B. 6 to 9 months
- C. 15 months
- D. 2 years
Correct Answer: A
Rationale: By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.
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A nurse is assisting a patient who is 2 days postoperative from a cesarean section dangle in preparation for sitting in a chair. After assisting the patient to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action?
- A. Supporting the patient as she stands, waiting a few moments, then continuing the move to the chair
- B. Calling for assistance and continuing the move with the assistance of another nurse
- C. Lowering the patient back to the side of the bed and pivoting her back into bed
- D. Having the patient sit down on the bed and dangle her feet before moving
Correct Answer: C
Rationale: If a patient becomes faint and their knees buckle when moving from bed to a chair or ambulating, the nurse should stop the activity, as the patient has demonstrated a clear risk for falling. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. When vital signs are stable, another attempt can be made with the assistance of another staff. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position and prevent hypotension related to a sudden change from the supine position.
In a nonerect patient, what is a potential consequence of immobility?
- A. Improved blood flow to the kidneys
- B. Urinary stasis favoring bacterial growth
- C. Bone mineralization
- D. Acidic urine
Correct Answer: B
Rationale: In a nonerect patient, the kidneys and ureters are level, limiting or delaying urinary drainage from the kidney pelvis to ureter and bladder. The resulting urinary stasis favors the growth of bacteria that can promote urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to bone demineralization, resulting in increased urinary calcium levels and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.
A nurse is teaching a patient with weak dorsiflexion how to prevent foot drop. Which instruction should the nurse include?
- A. Maintain the supine position with supination on the feet.
- B. Ask the family to bring in high-top sneakers to maintain foot dorsiflexion.
- C. Encourage hyperextension of the feet with adapdive devices or splints.
- D. Use pillows to keep the feet in the abducted position.
Correct Answer: B
Rationale: To prevent foot drop, the nurse should support the feet in dorsiflexion using a footboard and/or high-top sneakers for further support. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions do not prevent foot drop.
A nurse is instructing a patient recovering from a stroke on proper use of a cane. What information will the nurse include in the teaching plan?
- A. Support weight on the stronger leg and cane and advance weaker foot forward.
- B. Hold the cane in the same hand of the leg with the most severe deficit.
- C. Stand with as much weight distributed on the cane as possible.
- D. Avoid using the cane to rise from a sitting position, as this is unsafe.
Correct Answer: A
Rationale: The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.
Which of the following are appropriate instructions for quadricep-setting exercises?
- A. Breathe in and out smoothly during exercises
- B. Perform exercises two to three times per hour
- C. Perform exercises four to six times a day
- D. Hold breath during exercise drills
- E. Perform pushups three or four times a day
- F. Dangle for 30 to 60 minutes
- G. Use a footstool for dangling
Correct Answer: B,C,F
Rationale: Breathing in and out smoothly during quadricep-setting exercises maximizes lung inflation. The patient should perform quadricep-setting exercises two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for a few minutes is done to adjust to the upright position; dangling for 30 to 60 minutes is impractical for the nurse to supervise and may prove unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling.