Fundamentals Of Nursing NCLEX Quiz 39

2.

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

Have the client identify coping methods
Get the description of the location and intensity of the pain
Accept the client’s report of pain
Determine the client’s status of pain

Correct Answer

A. Accept the client’s report of pain

Explanation

Although all of the options above are correct. the first and most important piece of information in this client’s pain assessment is what the client is telling you about the pain –“the client’s report.”

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3.

Which statement best describes the effects of immobility in children?

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

Correct Answer

A. Immobility in children has similar physical effects to those found in adults

Explanation

Care of the immobile child includes efforts to prevent complications of muscle atrophy. contractures. skin breakdown. decreased metabolism and bone demineralization. Secondary alterations also occur in the cardiovascular. respiratory and renal systems. Similar effects and alterations occur in adults.

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4.

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

3 oz. broiled fish. 1 baked potato. ½ cup canned beets. 1 orange. and milk
3 oz. canned salmon. fresh broccoli. 1 biscuit. tea. and 1 apple
A bologna sandwich. fresh eggplant. 2 oz fresh fruit. tea. and apple juice
3 oz. turkey. 1 fresh sweet potato. 1/2 cup fresh green beans. milk. and 1 orange

Correct Answer

A. 3 oz. turkey. 1 fresh sweet potato. 1/2 cup fresh green beans. milk. and 1 orange

Explanation

Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats

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5.

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

A 79 year-old malnourished client on bed rest
An obese client who uses a wheelchair
An incontinent client who has had 3 diarrhea stools
An 80 year-old ambulatory diabetic client

Correct Answer

A. A 79 year-old malnourished client on bed rest

Explanation

Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus. malnutrition is a major risk factor for decubitus. due in part to poor hydration and inadequate protein intake.

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6.

Mrs. Kennedy had a CVA (cerebrovascular accident) and has severe right-sided weakness. She has been 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?

Holding the cane in her left hand. Mrs. Kennedy moves the cane forward first. then her right leg. and finally her left leg
Holding the cane in her right hand. Mrs. Kennedy moves the cane forward first. then her left leg. and finally her right leg
Holding the cane in her right hand. Mrs. Kennedy moves the cane and her right leg forward. then moves her left leg forward.
Holding the cane in her left hand. Mrs. Kennedy moves the cane and her left leg forward. then moves her right leg forward

Correct Answer

A. Holding the cane in her left hand. Mrs. Kennedy moves the cane forward first. then her right leg. and finally her left leg

Explanation

When a person with weakness on one side uses a cane. there should always be two points of contact with the floor. When Mrs. Kennedy. moves the cane forward. she has both feet on the floor. providing stability. As she moves the weak leg. the cane and the strong leg provide support. 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 arm strength to ensure that the cane provides adequate stability when standing on the weak leg. The cane should be held in the left hand. the hand opposite the affected leg. If Mrs. Kennedy. moved the cane and her strong foot at the same time. she would be left standing on her weak leg at one point. This would be unstable at best; at worst. impossible

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7.

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?

Tuna salad sandwich on whole wheat bread.
Vegetable soup made with vegetable stock. carrots. celery. and legumes served with toasted oat bread
Chef’s salad with hard boiled eggs and fat-free dressing
Broiled chicken stuffed with chopped apples and walnuts

Correct Answer

A. Vegetable soup made with vegetable stock. carrots. celery. and legumes served with toasted oat bread

Explanation

Mayonnaise in tuna salad is high in fat. The whole wheat bread has some fiber. This choice shows a low-fat soup (which would have been higher in fat if made with chicken or beef stock) and high-fiber bread and soup contents (both the vegetables and the legumes). Salad is high 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.

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3

8.

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

Stiffness of the right ankle joint
Soreness of the gums
Short-term memory loss.
Decreased appetite.

Correct Answer

A. Stiffness of the right ankle joint

Explanation

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

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9.

An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has iron deficiency anemia. Because iron deficiency anemia is suspected. which of the following is the most important information to obtain from the infant’s parents?

Normal dietary intake.
Relevant socio cultural. economic. and educational background of the family.
Any evidence of blood in the stools
A history of maternal anemia during pregnancy

Correct Answer

A. Normal dietary intake.

Explanation

Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For the first 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 the infant’s rapid growth needs. Iron deficiency may occur in the infant who drinks mostly milk. which contains no iron. and does not receive adequate dietary iron or supplemental iron. Daily dietary intake 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 very unlikely to be related to gastrointestinal bleeding. Anemia during pregnancy is unlikely to be the cause of the infant’s iron deficiency anemia. Fetal iron stores are drawn from the mother even if she is anemic.

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10.

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?

The client’s dietary habits include foods high in bulk.
The client’s fluid intake is between 2500-3000 ml per day
The client engages in moderate exercise each day
The client’s bowel habits were not discussed.

Correct Answer

A. The client’s bowel habits were not discussed.

Explanation

Foods high in bulk are appropriate. Exercise should be a part of a bowel training regimen. To assess the client for a bowel training program the factors causing the bowel alteration should be assessed. A routine for bowel elimination should be based on the client’s previous bowel habits and alterations in bowel habits that have occurred because of illness or trauma. The client and the family should assist in the planning of the program which should include foods high in bulk. adequate exercise. and fluid intake of 2500-3000 ml.

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Fundamentals Of Nursing NCLEX Quiz 39

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

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

Which statement best describes the effects of immobility in children?

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

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

Mrs. Kennedy had a CVA (cerebrovascular accident) and has severe right-sided weakness. She has been 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?

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?

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

An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has iron deficiency anemia. Because iron deficiency anemia is suspected. which of the following is the most important information to obtain from the infant’s parents?

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?