basic care and comfort

7/28/2019 Basic Care and Comfort

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1. Nurse Jessie is caring for an elderly woman who has had a fractured hip repaired. In the first few daysfollowing the surgical repair, which of the following nursing measures will best facilitate the resumption ofactivities for this client?

a. arranging for the wheelchairb. asking her family to visit

c. assisting her to sit out of bed in a chair qidd. encouraging the use of an overhead trapeze

2. What do you think is the most important nursing order in a client with major head trauma who is aboutto receive bolus enteral feeding?

a. measure intake and output.b. check albumin level.c. monitor glucose levels.d. increase enteral feeding.

3. What is the pathological process causing esophageal varices is

a. ascites and edema.b. systemic hypertension.c. portal hypertension.d. dilated veins and varicesitis.

4. Which of the following interventions will help lessen the effect of GERD (acid reflux)?

a. Elevate the head of the bed on 4-6 inch blocks.b. Lie down after eating.c. Increase fluid intake just before bedtime.d. Wear a girdle.

5. What is the main benefit of therapeutic massages is:

a. to help a person with swollen legs to decrease the fluid retention.b. to help a person with duodenal ulcers feel better.c. to help damaged tissue in a diabetic to heal.d. to improve circulation and muscles tone.

6. Which of the following foods should be avoided by clients who are prone to develop heartburn as aresult of gastroesophgeal reflux disease (GERD)?

a. Lettuceb. Eggsc. Chocolated. Butterscotch

7. Which of the following should be included in a plan of care for a client receiving total parenteralnutrition (TPN)?


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a. Withhold medications while the TPN is infusing.b. Change TPN solution every 24 hours.c. Flush the TPN line with water prior to initiating nutritional support.d. Keep client on complete bed rest during TPN therapy.

8. Which of the following should be included in a plan of care for a client who is lactose intolerant?

a. Remove all dairy products from the diet.b. Frozen yogurt can be included in the diet.c. Drink small amounts of milk on an empty stomach.d. Spread out selection of dairy products throughout the day.

9. Pain tolerance in an elderly patient with cancer would:

a. stay the same.b. be lowered.c. be increased.d. no effect on pain tolerance.

10. What is the main advantage of cutaneous stimulation in managing paint:

a. costs less.b. restricts movement and decreases.c. gives client control over pain syndrome.d. allows the family to care for the patient at home.

11. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most importantinstruction regarding exercise would be to

a. exercise doing weight bearing activitiesb. exercise to reduce weightc. avoid exercise activities that increase the risk of fractured. exercise to strengthen muscles and thereby protect bones

12. A client in a long term care facility complains of pain. The nurse collects data about the clients pain.The first step in pain assessment is for the nurse to

a. have the client identify coping methodsb. get the description of the location and intensity of the painc. accept the clients report of paind. determine the clients status of pain

13. Which statement best describes the effects of immobility in children?

a. Immobility prevents the progression of language and fine motor developmentb. Immobility in children has similar physical effects to those found in adultsc. Children are more susceptible to the effects of immobility than are adultsd. Children are likely to have prolonged immobility with subsequent complications


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14. After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teachingthe client about the diet, which meal plan would be the most appropriate to suggest?

a. 3 oz. broiled fish, 1 baked potato, cup canned beets, 1 orange, and milkb. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 applec. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juiced. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

15. A nurse is assessing several clients in a long term health care facility. Which client is at highest riskfor development of decubitus ulcers?

a. A 79 year-old malnourished client on bed restb. An obese client who uses a wheelchairc. An incontinent client who has had 3 diarrhea stoolsd. An 80 year-old ambulatory diabetic client

16. Ms. Kelly. has had a CVA (cerebrovascular accident) and has severe right-sided weakness. She hasbeen taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of

the following reflects correct use of the cane?

a. Holding the cane in her left hand, Ms. Kelly. moves the cane forward first, then her right leg, and finallyher left legb. Holding the cane in her right hand, Ms. Kelly. moves the cane forward first, then her left leg, and finallyher right legc. Holding the cane in her right hand, Ms. Kelly. moves the cane and her right leg forward, then movesher left leg forward.d. Holding the cane in her left hand, Ms. Kelly. moves the cane and her left leg forward, then moves herright leg forward

17. The nurse is instructing a woman in a low-fat, high-fiber diet. Which of the following food choices, if

selected by the client, indicate an understanding of a low-fat, high-fiber diet?

a. Tuna salad sandwich on whole wheat bread.b. Vegetable soup made with vegetable stock, carrots, celery, and legumes served with toasted oat breadc. Chefs salad with hard boiled eggs and fat-free dressingd. Broiled chicken stuffed with chopped apples and walnuts

18. An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints bythe patient indicates to the nurse that he is developing a complication of immobility?

a. Stiffness of the right ankle jointb. Soreness of the gums

c. Short-term memory loss.d. Decreased appetite.

19. An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has irondeficiency anemia. Because iron deficiency anemia is suspected, which of the following is the mostimportant information to obtain from the infants parents?

a. Normal dietary intake.b. Relevant sociocultural, economic, and educational background of the family.


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c. Any evidence of blood in the stoolsd. A history of maternal anemia during pregnancy

20. A 46-year-old female with chronic constipation is assessed by the nurse for a bowel training regimen.Which factor indicates further information is needed by the nurse?

a. The clients dietary habits include foods high in bulk. b. The clients fluid intake is between 2500-3000 ml per dayc. The client engages in moderate exercise each dayd. The clients bowel habits were not discussed.

1. Answer D. Exercise is important to keep the joints and muscles functioning and to preventsecondary complications. Using the overhead trapeze prevents hazards of immobility bypermitting movement in bed and strengthening of the upper extremities in preparation forambulation. Sitting in a wheelchair would require too great hip flexion initially. Asking her family tovisit would not facilitate the resumption of activities. Sitting in a chair would cause too much hipflexion. The client initially needs to be in a low Fowlers position or taking a few steps (as ordered)

with the aid of a walker.2. Answer A. It is important to measure intake and output, which should equal. Enteral feeding are

hyperosmotic agents pulling fluid from cells into vascular bed. Water given before feeding willpresent a hyperosmotic diuresis. I and O measures assess fluid balance.

3. Answer C. Esophageal varices results from increased portal hypertension. In portalhypertension, the liver cannot accept all of the fluid from the portal vein. The excess fluid will backflow to the vessels with lesser pressure, such as esophageal veins or rectal veins causingesophageal varices or hemorrhoids.

4. Answer A. Elevation of the head of the bed allows gravity to assist in decreasing the backflow ofacid into the esophagus. Fluid does not flow uphill. The other three options all increase fluidbackflow into the esophagus through position or increasing abdominal pressure.

5. Answer D. Particularly in the elderly adults, therapeutic massage will help improve circulationand muscle tone as well as the personal attention and social interaction that a good massageprovides. A massage is contraindicated in any condition where massage to damaged tissue candislodge a blood clot.

6. Answer C. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leadingto reflux and clinical symptoms of GERD. All of the other foods do not affect LES pressure.

7. Answer B. TPN solutions should be changed every 24 hours in order to prevent bacterialovergrowth due to hypertonicity of the solution. Option 1 is incorrect; medication therapy cancontinue during TPN therapy. Option 3 is incorrect; flushing is not required because the initiationof TPN does not require a client to remain on bed rest during therapy. However, other clinicalconditions of the client may affect mobility issues and warrant the clients being on bed rest.

8. Answer B. Clients who are lactose intolerant can digest frozen yogurt. Yogurt products areformed by bacterial action, and this action assists in the digestion of lactose. The freezingprocess further stops bacterial action so that limited lactase activity remains. Option 1 is incorrect;elimination of all dairy products can lead to significant clinical deficiencies of other nutrients.Option 3 is incorrect because drinking milk on an empty stomach can exacerbate clinical

symptoms. Drinking milk with a meal may benefit the client because other foods, (especially fat)may decrease transit time and allow for increased lactase activity. Option 4 is incorrect becausealthough individual tolerance should be acknowledged, spreading out the use of known dairyproducts will usually exacerbate clinical symptoms.

9. Answer B. There is potential for a lowered pain tolerance to exist with diminished adaptativecapacity.

10. Answer C. Cutaneous stimulation allows the patient to have control over his pain and allows himto be in his own environment. Cutaneous stimulation increases movement and decreases pain.


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11. Answer A. Weight bearing exercises are beneficial in the treatment of osteoporosis. Althoughloss of bone cannot be substantially reversed, further loss can be greatly reduced if the clientincludes weight bearing exercises along with estrogen replacement and calcium supplements intheir treatment protocol.

12. Answer C.Although all of the options above are correct, the first and most important piece ofinformation in this clients pain assessment is what the client is telling you about the pain theclients report.

13. Answer B. Care of the immobile child includes efforts to prevent complications of muscleatrophy, contractures, skin breakdown, decreased metabolism and bone demineralization.Secondary alterations also occur in the cardiovascular, respiratory and renal systems. Similareffects and alterations occur in adults.

14. Answer D. Canned fish and vegetables and cured meats are high in sodium. This meal does notcontain any canned fish and/or vegetables or cured meats

15. Answer A. Weighing significantly less than ideal body weight increases the number and surfacearea of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a majorrisk factor for decubiti, due in part to poor hydration and inadequate protein intake.

16. Answer A. When a person with weakness on one side uses a cane, there should always be twopoints of contact with the floor. When Ms. Kelly. moves the cane forward, she has both feet onthe floor, providing stability. As she moves the weak leg, the cane and the strong leg providesupport. Finally, the cane, which is even with the weak leg, provides stability while she moves the

strong leg. She should not hold the cane with her weak arm. The use of the cane requires armstrength to ensure that the cane provides adequate stability when standing on the weak leg. Thecane should be held in the left hand, the hand opposite the affected leg. If Ms. Kelly. moved thecane and her strong foot at the same time, she would be left standing on her weak leg at onepoint. This would be unstable at best; at worse, impossible

17. Answer B. Mayonnaise in tuna salad is high in fat. The whole wheat bread has some fiber. Thischoice shows a low-fat soup (which would have been higher in fat if made with chicken or beefstock) and high-fiber bread and soup contents (both the vegetables and the legumes). Salad ishigh in fiber, but hard boiled eggs are high in fat. There is some fiber in the apples and walnuts.The walnuts are high in fat, as is the chicken.

18. Answer A. Stiffness of a joint may indicate the beginning of a contracture and/or early muscleatrophy. Soreness of the gums is not related to immobility. Short-term memory loss is not relatedto immobility. Decreased appetite is unlikely to be related to immobility.

19. Answer A. Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For thefirst 4 to 5 months of infancy iron stores laid down for the baby during pregnancy are adequate.When fetal iron stores are depleted, supplemental dietary iron needs to be supplied to meet theinfants rapid growth needs. Iron deficiency may occur in the infant who drinks mostly milk, whichcontains no iron, and does not receive adequate dietary iron or supplemental iron. Daily dietaryintake is much more related to the diagnosis of iron deficiency anemia than is sociocultural,economic, and educational background of the family. Iron deficiency anemia in an infant is veryunlikely to be related to gastrointestinal bleeding. Anemia during pregnancy is unlikely to be thecause of the infants iron deficiency anemia. Fetal iron stores are drawn from the mother even ifshe is anemic.

20. Answer D. Foods high in bulk are appropriate. Exercise should be a part of a bowel trainingregimen. To assess the client for a bowel training program the factors causing the bowelalteration should be assessed. A routine for bowel elimination should be based on the clients

previous bowel habits and alterations in bowel habits that have occurred because of illness ortrauma. The client and the family should assist in the planning of the program which shouldinclude foods high in bulk, adequate exercise, and fluid intake of 2500-3000 ml.

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