Nokea
Physical examination of a client regarding mobility status should:
- A. begin with gait.
- B. be oriented to time, place, and person.
- C. begin with the Romberg test.
- D. begin with the Tandem Walk test.
Correct Answer: A
Rationale: Gait is usually assessed as the client walks into the room. Normal gait is smooth, flowing, and rhythmic without assistive devices.
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The immobile client is in a hospital bed at home. Which information should the home health nurse include when teaching family caregivers how to safely move and reposition the client?
- A. Before moving the client, raise the bed to waist level. After completing the move, return the bed to the lowest level.
- B. The pillow should be removed from under the client's head when positioning in a dorsal recumbent position.
- C. Tighten your abdominal muscles and keep your feet together; use a lift sheet and pull the client up in bed.
- D. When the client is lying on the back, rest the client's heels on the bed and keep the feet perpendicular to the legs.
Correct Answer: A
Rationale: A: Raising the bed to waist level and lowering it after reduces injury risk. B: A pillow prevents neck hyperextension. C: A broad stance, not feet together, improves balance. D: Heels should be off the bed to prevent pressure ulcers.
Pressure ulcers usually occur:
- A. When clients are left in one position in bed for extended periods of time
- B. When clients are underweight
- C. When clients are overweight
- D. Only in underweight and overweight clients
Correct Answer: A
Rationale: Pressure ulcers occur over bony prominences due to decreased circulation from prolonged immobility, not specifically related to body weight.
The client is receiving 2 liters of oxygen by nasal cannula. Which rationale should the nurse use to explain the reason for oxygen being bubbled through a humidifier?
- A. Prevents the burning sensation of direct oxygen
- B. Prevents the drying of the nasal passages
- C. Prevents a chemical reaction between the tubing and oxygen
- D. Prevents contamination with environmental gases
Correct Answer: B
Rationale: B: Humidification prevents nasal passage drying. A: Oxygen doesn't burn. C: No chemical reaction occurs with tubing. D: Environmental gases don't contaminate oxygen.
The death of a beloved spouse places the surviving partner in which type of crisis?
- A. maturational
- B. reactive
- C. nonreactive
- D. situational
Correct Answer: D
Rationale: A situational crisis is an unexpected, unplanned event, such as the death of a spouse. Option 1 is a normal maturational crisis; Choices 2 and 3 are not recognized crisis states.
A nurse is assessing a patient in the ICU. The patient has the following signs: weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?
- A. Hypoglycemic patient
- B. Hyperglycemic patient
- C. Cardiac arrest
- D. End-stage renal failure
Correct Answer: B
Rationale: All of the clinical signs indicate a hyperglycemic condition.