Solutions - Chapter 44 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action?
1.  Heart rate 86 beats/min
2.  Reddened area on sacrum
3.  Nonproductive cough
4.  Urine output of 50 ml/h
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1ACT. What assessment findings alert you that Mr. Chan is developing problems associated with his current state of decreased mobility?
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1TYK. To increase stability during client transfer, the nurse increases the base of support by performing which action?
1.  Leaning slightly backward
2.  Spacing the feet farther apart
3.  Tensing the abdominal muscles
4.  Bending the knees
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2ACT. Mr. Chan may benefit from using a walker to assist with ambulation at home. What teaching should be done in regard to use of a walker?
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2TYK. Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply.
1.  Increase muscle tone and improve circulation.
2.  Increase blood pressure.
3.  Increase muscle mass and strength.
4.  Decrease heart rate and cardiac output.
5.  Maintain joint range of motion.
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3ACT. The care plan does not address one of Mr. Chan’s risk factors—obesity. Would you add this to the plan?
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3TYK. Five minutes after the client’s first postoperative exercise, the client’s vital signs have not yet returned to baseline. Which is an appropriate nursing diagnosis?
1.  Activity Intolerance
2.  Risk for Activity Intolerance
3.  Impaired Physical Mobility
4.  Risk for Disuse Syndrome
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4ACT. What assumptions has the nurse made in assigning the desired outcome of “Immobility Consequences: Psycho-Cognitive”?
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4TYK. Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching?
1.  “Going up, the strong leg goes first, then the weaker leg with both crutches.”
2.  “Going down, the weaker leg goes first with both crutches, then the strong leg.”
3.  “The weaker leg always goes first with both crutches.”
4.  “A cane or single crutch may be used instead of both crutches if held on the weaker side.”
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5ACT. How are the choices of outcomes influenced by the cause of his nursing diagnosis (a chronic illness)?
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5TYK. A nurse is teaching a client about active range-of-motion (ROM) exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following?
1.  Exercises past the point of resistance.
2.  Performs each exercise one time.
3.  Performs each series of exercises once a day.
4.  Uses the same sequence during each exercise session.
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6TYK. When assessing a client’s gait, which does the nurse look for and encourage?
1.  The spine rotates, initiating locomotion.
2.  Gaze is slightly downward.
3.  Toes strike the ground before the heel.
4.  Arm on the same side as the swing-through foot moves forward at the same time.
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7TYK. Performance of activities of daily living (ADLs) and active range-of-motion (ROM) exercises can be accomplished simultaneously as illustrated by which of the following? Select all that apply.
1.  Elbow flexion with eating and bathing
2.  Elbow extension with shaving and eating
3.  Wrist hyperextension with writing
4.  Thumb ROM with eating and writing
5.  Hip flexion with walking
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8TYK. A client weighs 250 pounds and needs to be transferred from the bed to a chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate?
1.  “Using proper body mechanics will prevent you from injuring yourself.”
2.  “You are physically fit and at lesser risk for injury when transferring the client.”
3.  “Use the mechanical lift and another person to transfer the client from the bed to the chair.”
4.  “Use the back belt to avoid hurting your back.”
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9TYK. The client is ambulating for the first time after surgery. The client tells the nurse, “I feel faint.” Which is the best action by the nurse?
1.  Find another nurse for help.
2.  Return the client to her room as quickly as possible.
3.  Tell the client to take rapid, shallow breaths.
4.  Assist the client to a nearby chair.
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