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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank
Chapter 23
Question 1
Type: MCSA
The nurse is caring for a client who requires frequent repositioning, and determines that proper alignment is
obtained when which of the following is achieved?
1. There is little strain on the musculoskeletal system.
2. The client is in a supine position.
3. The client says she is properly aligned.
4. There are pillows under all extremities.
Correct Answer: 1
Rationale 1: Alignment is achieved when the client is positioned in a way that takes strain off of the muscles,
joints, tendons, and ligaments. Clients cannot be consistently maintained in a supine position because it will cause
skin breakdown and become uncomfortable. Clients might not be aware of when they are aligned, or they might
not be able to voice when they are comfortable. Pillows can help the nurse achieve alignment, but are not required
under every extremity, and should only be placed where they are needed.
Rationale 2: Alignment is achieved when the client is positioned in a way that takes strain off of the muscles,
joints, tendons, and ligaments. Clients cannot be consistently maintained in a supine position because it will cause
skin breakdown and become uncomfortable. Clients might not be aware of when they are aligned, or they might
not be able to voice when they are comfortable. Pillows can help the nurse achieve alignment, but are not required
under every extremity, and should only be placed where they are needed.
Rationale 3: Alignment is achieved when the client is positioned in a way that takes strain off of the muscles,
joints, tendons, and ligaments. Clients cannot be consistently maintained in a supine position because it will cause
skin breakdown and become uncomfortable. Clients might not be aware of when they are aligned, or they might
not be able to voice when they are comfortable. Pillows can help the nurse achieve alignment, but are not required
under every extremity, and should only be placed where they are needed.
Rationale 4: Alignment is achieved when the client is positioned in a way that takes strain off of the muscles,
joints, tendons, and ligaments. Clients cannot be consistently maintained in a supine position because it will cause
skin breakdown and become uncomfortable. Clients might not be aware of when they are aligned, or they might
not be able to voice when they are comfortable. Pillows can help the nurse achieve alignment, but are not required
under every extremity, and should only be placed where they are needed.
Global Rationale:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Cognitive Level: Applying


Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: Describe basic elements of normal movement.
Question 2
Type: MCSA
The nurse is teaching a group of clients at a mental health clinic about mobility and joint care. One client asks the
nurse what effect depression has on a person's mobility. The nurse responds with which of the following?
1. Many depressed clients are catatonic, and experience joint stiffness as a result.
2. The depressed client in a mental hospital does not get enough exercise.
3. Depression saps energy and the ability to exercise, affecting mobility and posture.
4. The depressed client does not drink enough fluids, which affects the joints.
Correct Answer: 3
Rationale 1: The depressed client has no energy for exercise, and may affect a slumped posture. Exercise not only
affects the quality of mobility, but also is directly related to mental health. Psychiatric facilities schedule
recreational and exercise times for their clients. The depressed client does not experience catatonia. There is no
information about the amount of fluids that the client is drinking.
Rationale 2: The depressed client has no energy for exercise, and may affect a slumped posture. Exercise not only
affects the quality of mobility, but also is directly related to mental health. Psychiatric facilities schedule
recreational and exercise times for their clients. The depressed client does not experience catatonia. There is no
information about the amount of fluids that the client is drinking.
Rationale 3: The depressed client has no energy for exercise, and may affect a slumped posture. Exercise not only
affects the quality of mobility, but also is directly related to mental health. Psychiatric facilities schedule
recreational and exercise times for their clients. The depressed client does not experience catatonia. There is no
information about the amount of fluids that the client is drinking.
Rationale 4: The depressed client has no energy for exercise, and may affect a slumped posture. Exercise not only
affects the quality of mobility, but also is directly related to mental health. Psychiatric facilities schedule
recreational and exercise times for their clients. The depressed client does not experience catatonia. There is no
information about the amount of fluids that the client is drinking.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Nursing/Integrated Concepts: Nursing Process: Implementation


Learning Outcome: Name factors affecting body alignment and mobility.
Question 3
Type: MCMA
The nurse is caring for a client who has been on bedrest for two days, and anticipates which of the following as a
result? Select all that apply.
Standard Text: Select all that apply.
1. Postural hypotension when the client stands for the first time
2. Muscle weakness
3. Increased risk for pneumonia
4. Boredom
5. Facial edema
Correct Answer: 1,2,3
Rationale 1: The immobile client is at increased risk for postural hypotension, muscle weakness, and pneumonia.
Boredom depends on the client's health status. Edema is more likely to occur in dependent areas.
Rationale 2: The immobile client is at increased risk for postural hypotension, muscle weakness, and pneumonia.
Boredom depends on the client's health status. Edema is more likely to occur in dependent areas.
Rationale 3: The immobile client is at increased risk for postural hypotension, muscle weakness, and pneumonia.
Boredom depends on the client's health status. Edema is more likely to occur in dependent areas.
Rationale 4: The immobile client is at increased risk for postural hypotension, muscle weakness, and pneumonia.
Boredom depends on the client's health status. Edema is more likely to occur in dependent areas.
Rationale 5: The immobile client is at increased risk for postural hypotension, muscle weakness, and pneumonia.
Boredom depends on the client's health status. Edema is more likely to occur in dependent areas.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Identify effects of immobility on body systems.
Question 4
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Type: MCSA
The nurse is caring for an alert client who has been in bed for three days. When performing a focused assessment,
the nurse checks the skin of the legs and feet for which of the following?
1. Dependent edema
2. Foot drop
3. Varicose veins
4. Cyanosis
Correct Answer: 1
Rationale 1: The feet and legs should be checked for dependent edema, which can increase the risk for skin
breakdown. Foot drop is more likely to occur in the client with reduced level of consciousness, who is not moving
the foot. Varicose veins and cyanosis would not be an anticipated risk of immobility unless other problems exist.
Rationale 2: The feet and legs should be checked for dependent edema, which can increase the risk for skin
breakdown. Foot drop is more likely to occur in the client with reduced level of consciousness, who is not moving
the foot. Varicose veins and cyanosis would not be an anticipated risk of immobility unless other problems exist.
Rationale 3: The feet and legs should be checked for dependent edema, which can increase the risk for skin
breakdown. Foot drop is more likely to occur in the client with reduced level of consciousness, who is not moving
the foot. Varicose veins and cyanosis would not be an anticipated risk of immobility unless other problems exist.
Rationale 4: The feet and legs should be checked for dependent edema, which can increase the risk for skin
breakdown. Foot drop is more likely to occur in the client with reduced level of consciousness, who is not moving
the foot. Varicose veins and cyanosis would not be an anticipated risk of immobility unless other problems exist.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Identify effects of immobility on body systems.
Question 5
Type: MCSA
When teaching the client how to use a straight cane, the nurse would include which of the following?
1. Hold the cane with the hand on the weak side.
2. Remove all scatter rugs from the home.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

3. Move the cane 12 inches ahead of the foot.


4. Keep the elbow straight when moving the cane forward.
Correct Answer: 2
Rationale 1: Scatter rugs can cause a client with a cane to fall, as the rug moves easily and does not provide a
stable surface for the client. Prevention of falls would be the priority teaching for this client. The cane is held in
the hand on the strongest side, moved forward 6 inches, and the elbow should be slightly bent.
Rationale 2: Scatter rugs can cause a client with a cane to fall, as the rug moves easily and does not provide a
stable surface for the client. Prevention of falls would be the priority teaching for this client. The cane is held in
the hand on the strongest side, moved forward 6 inches, and the elbow should be slightly bent.
Rationale 3: Scatter rugs can cause a client with a cane to fall, as the rug moves easily and does not provide a
stable surface for the client. Prevention of falls would be the priority teaching for this client. The cane is held in
the hand on the strongest side, moved forward 6 inches, and the elbow should be slightly bent.
Rationale 4: Scatter rugs can cause a client with a cane to fall, as the rug moves easily and does not provide a
stable surface for the client. Prevention of falls would be the priority teaching for this client. The cane is held in
the hand on the strongest side, moved forward 6 inches, and the elbow should be slightly bent.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe assistive devices used to support mobility.
Question 6
Type: MCSA
The nurse is reinforcing instructions about crutch walking received from physical therapy, and includes which of
the following?
1. Exercise both legs on a regular basis.
2. Going up and down stairs in the home is good exercise.
3. Perform arm-strengthening exercises daily.
4. Support weight with the axilla.
Correct Answer: 3

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 1: The client using crutches needs the strength in the arms to help support the body, so arm exercises
should be encouraged. The client should be taught stair-walking, but should be cautioned against using the stairs
unless it is unavoidable. Exercising the legs is often discouraged in a client with a leg injury requiring crutches.
Weight should be supported on the arms, not the axilla, as this can cause nerve damage.
Rationale 2: The client using crutches needs the strength in the arms to help support the body, so arm exercises
should be encouraged. The client should be taught stair-walking, but should be cautioned against using the stairs
unless it is unavoidable. Exercising the legs is often discouraged in a client with a leg injury requiring crutches.
Weight should be supported on the arms, not the axilla, as this can cause nerve damage.
Rationale 3: The client using crutches needs the strength in the arms to help support the body, so arm exercises
should be encouraged. The client should be taught stair-walking, but should be cautioned against using the stairs
unless it is unavoidable. Exercising the legs is often discouraged in a client with a leg injury requiring crutches.
Weight should be supported on the arms, not the axilla, as this can cause nerve damage.
Rationale 4: The client using crutches needs the strength in the arms to help support the body, so arm exercises
should be encouraged. The client should be taught stair-walking, but should be cautioned against using the stairs
unless it is unavoidable. Exercising the legs is often discouraged in a client with a leg injury requiring crutches.
Weight should be supported on the arms, not the axilla, as this can cause nerve damage.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe assistive devices used to support mobility.
Question 7
Type: MCSA
When planning care for the immobile client, the nurse includes which of the following?
1. Assess for complications resulting from immobility.
2. Plan for the client to obtain eight hours of uninterrupted sleep without repositioning.
3. Implement repositioning every hour.
4. Evaluate the client's ability to perform passive ROM.
Correct Answer: 1
Rationale 1: The nurse uses the nursing process to care for the immobile client and assesses for complications
resulting from lack of mobility. While sleep is important, the client who is unable to reposition themselves must
be repositioned every two hours, not hourly. The client performs active, not passive, ROM.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 2: The nurse uses the nursing process to care for the immobile client and assesses for complications
resulting from lack of mobility. While sleep is important, the client who is unable to reposition themselves must
be repositioned every two hours, not hourly. The client performs active, not passive, ROM.
Rationale 3: The nurse uses the nursing process to care for the immobile client and assesses for complications
resulting from lack of mobility. While sleep is important, the client who is unable to reposition themselves must
be repositioned every two hours, not hourly. The client performs active, not passive, ROM.
Rationale 4: The nurse uses the nursing process to care for the immobile client and assesses for complications
resulting from lack of mobility. While sleep is important, the client who is unable to reposition themselves must
be repositioned every two hours, not hourly. The client performs active, not passive, ROM.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Explain how the nursing process relates to clients with immobility.
Question 8
Type: MCSA
The nurse assists the client with emphysema admitted because of a respiratory infection to assume what position
to reduce the effort of breathing and improve gas exchange?
1. Left Sims' position
2. Fowler's position
3. High Fowler's position
4. Orthopneic position
Correct Answer: 4
Rationale 1: This client, also with increased work of breathing, should be placed in the orthopneic position
because it allows for the greatest chest expansion and makes breathing easier. The client is placed at a 90-degree
angle leaning on an over-bed table to achieve this position. The second best position would be the high Fowler's
or Fowler's position, but it is not as effective as the orthopneic position, because the pressure on the back reduces
chest expansion. Sims' position is side-lying, and would likely increase the client's respiratory distress, as chest
expansion would be reduced on the side she is lying on.
Rationale 2: This client, also with increased work of breathing, should be placed in the orthopneic position
because it allows for the greatest chest expansion and makes breathing easier. The client is placed at a 90-degree
angle leaning on an over-bed table to achieve this position. The second best position would be the high Fowler's
or Fowler's position, but it is not as effective as the orthopneic position, because the pressure on the back reduces
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

chest expansion. Sims' position is side-lying, and would likely increase the client's respiratory distress, as chest
expansion would be reduced on the side she is lying on.
Rationale 3: This client, also with increased work of breathing, should be placed in the orthopneic position
because it allows for the greatest chest expansion and makes breathing easier. The client is placed at a 90-degree
angle leaning on an over-bed table to achieve this position. The second best position would be the high Fowler's
or Fowler's position, but it is not as effective as the orthopneic position, because the pressure on the back reduces
chest expansion. Sims' position is side-lying, and would likely increase the client's respiratory distress, as chest
expansion would be reduced on the side she is lying on.
Rationale 4: This client, also with increased work of breathing, should be placed in the orthopneic position
because it allows for the greatest chest expansion and makes breathing easier. The client is placed at a 90-degree
angle leaning on an over-bed table to achieve this position. The second best position would be the high Fowler's
or Fowler's position, but it is not as effective as the orthopneic position, because the pressure on the back reduces
chest expansion. Sims' position is side-lying, and would likely increase the client's respiratory distress, as chest
expansion would be reduced on the side she is lying on.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: List and compare different body positions.
Question 9
Type: MCSA
The nurse is caring for a client who has had a below-the-knee amputation and is positioned in bed with the
affected knee on a pillow. To prevent hip and knee contractures, the nurse plans to do which of the following at
least once a shift?
1. Place the client in the lateral position with a pillow between the legs once a shift for 30 minutes.
2. Place the client in the semi-Fowler's position without pillows under the knees to promote extension.
3. Place the client in the prone position once a shift for 30 minutes.
4. Place the client in the high Fowler's position to fully flex the hip.
Correct Answer: 3
Rationale 1: The client who is positioned most of the time with the hips and knees flexed should be placed in the
prone position to extend the hips and knees and prevent contractures of these joints. The lateral position continues
to flex the hip and knees, as do both of the Fowler's positions.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 2: The client who is positioned most of the time with the hips and knees flexed should be placed in the
prone position to extend the hips and knees and prevent contractures of these joints. The lateral position continues
to flex the hip and knees, as do both of the Fowler's positions.
Rationale 3: The client who is positioned most of the time with the hips and knees flexed should be placed in the
prone position to extend the hips and knees and prevent contractures of these joints. The lateral position continues
to flex the hip and knees, as do both of the Fowler's positions.
Rationale 4: The client who is positioned most of the time with the hips and knees flexed should be placed in the
prone position to extend the hips and knees and prevent contractures of these joints. The lateral position continues
to flex the hip and knees, as do both of the Fowler's positions.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: List and compare different body positions.
Question 10
Type: MCSA
The nurse is planning care for an unconscious client who is breathing on his own. Which of the following does the
nurse plan to promote joint mobility for this client?
1. Back massage to promote joint circulation
2. Head flexion and extension
3. Transferring the client using a Hoyer lift
4. Placing a bed cradle under the sheet
Correct Answer: 2
Rationale 1: The nurse plans to perform passive ROM of the neck to promote joint mobility. Back massage,
transfer using a Hoyer lift, and use of a bed cradle might be indicated, but do not promote joint mobility.
Rationale 2: The nurse plans to perform passive ROM of the neck to promote joint mobility. Back massage,
transfer using a Hoyer lift, and use of a bed cradle might be indicated, but do not promote joint mobility.
Rationale 3: The nurse plans to perform passive ROM of the neck to promote joint mobility. Back massage,
transfer using a Hoyer lift, and use of a bed cradle might be indicated, but do not promote joint mobility.
Rationale 4: The nurse plans to perform passive ROM of the neck to promote joint mobility. Back massage,
transfer using a Hoyer lift, and use of a bed cradle might be indicated, but do not promote joint mobility.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Name and describe actions the nurse performs to support client mobility.
Question 11
Type: MCSA
The nurse is reviewing crutch-walking with the client prior to discharge. The nurse concludes that the client needs
further instruction if the client states which of the following?
1. "Each step I take with crutches should feel comfortable to me."
2. "I need to inspect the crutch tips and replace them if they are worn."
3. "I should pad the crutches well to protect my armpits."
4. "I should wear running shoes to support my feet."
Correct Answer: 3
Rationale 1: The crutches do not need to be padded on the top, as the hands and upper arms are used for support.
Allowing the armpits to bear the body weight will cause nerve damage and alignment problems. The other
statements by the client are correct.
Rationale 2: The crutches do not need to be padded on the top, as the hands and upper arms are used for support.
Allowing the armpits to bear the body weight will cause nerve damage and alignment problems. The other
statements by the client are correct.
Rationale 3: The crutches do not need to be padded on the top, as the hands and upper arms are used for support.
Allowing the armpits to bear the body weight will cause nerve damage and alignment problems. The other
statements by the client are correct.
Rationale 4: The crutches do not need to be padded on the top, as the hands and upper arms are used for support.
Allowing the armpits to bear the body weight will cause nerve damage and alignment problems. The other
statements by the client are correct.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe assistive devices used to support mobility.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Question 12
Type: MCSA
The physician has ordered ambulation for the 63-year-old client who has had surgery and has been in bed for three
days. The nurse plans to do which of the following for this client?
1. Begin ambulation immediately after breakfast.
2. Pre-ambulation exercises
3. Obtain assistance with transfer of the client.
4. Perform passive ROM before ambulating.
Correct Answer: 2
Rationale 1: Anticipating that the client's muscles will be weak, the nurse will plan to help the client perform preambulation exercises to help regain strength in the muscles before attempting to walk the client. It would be best
to wait an hour or two after meals to ambulate. Passive ROM will not help to strengthen muscles, although active
ROM will be helpful. The nurse is not preparing to transfer the client, and will need to determine if assistance is
required by the client's pre-bedrest activity level.
Rationale 2: Anticipating that the client's muscles will be weak, the nurse will plan to help the client perform preambulation exercises to help regain strength in the muscles before attempting to walk the client. It would be best
to wait an hour or two after meals to ambulate. Passive ROM will not help to strengthen muscles, although active
ROM will be helpful. The nurse is not preparing to transfer the client, and will need to determine if assistance is
required by the client's pre-bedrest activity level.
Rationale 3: Anticipating that the client's muscles will be weak, the nurse will plan to help the client perform preambulation exercises to help regain strength in the muscles before attempting to walk the client. It would be best
to wait an hour or two after meals to ambulate. Passive ROM will not help to strengthen muscles, although active
ROM will be helpful. The nurse is not preparing to transfer the client, and will need to determine if assistance is
required by the client's pre-bedrest activity level.
Rationale 4: Anticipating that the client's muscles will be weak, the nurse will plan to help the client perform preambulation exercises to help regain strength in the muscles before attempting to walk the client. It would be best
to wait an hour or two after meals to ambulate. Passive ROM will not help to strengthen muscles, although active
ROM will be helpful. The nurse is not preparing to transfer the client, and will need to determine if assistance is
required by the client's pre-bedrest activity level.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Learning Outcome: Describe proper procedures for assisting a client with mobility issues.
Question 13
Type: MCSA
The nurse is caring for a newly admitted client with a diagnosis of pneumonia. The client is in need of a bed bath
and a linen change. The nurse's priority action is which of the following?
1. Assess the client's ability to assist with the bath and with movement in bed.
2. Gather all supplies needed for the procedure.
3. Obtain a Hoyer lift to move the client up in bed.
4. Explain all procedures to the client.
Correct Answer: 1
Rationale 1: The nurse would assess the client's level of need and ability to perform the bath and move in bed.
There is no need to obtain a lift if the client is capable of moving independently. The nurse gathers supplies and
explains procedures after assessing the client's needs.
Rationale 2: The nurse would assess the client's level of need and ability to perform the bath and move in bed.
There is no need to obtain a lift if the client is capable of moving independently. The nurse gathers supplies and
explains procedures after assessing the client's needs.
Rationale 3: The nurse would assess the client's level of need and ability to perform the bath and move in bed.
There is no need to obtain a lift if the client is capable of moving independently. The nurse gathers supplies and
explains procedures after assessing the client's needs.
Rationale 4: The nurse would assess the client's level of need and ability to perform the bath and move in bed.
There is no need to obtain a lift if the client is capable of moving independently. The nurse gathers supplies and
explains procedures after assessing the client's needs.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Describe proper procedures for assisting a client with mobility issues.
Question 14
Type: MCSA
The nurse is caring for a client diagnosed with pneumonia who was placed on a cardiorespiratory monitor. Vital
signs are recorded from the monitor in order to allow the client to remain undisturbed during the night. The nurse
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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observes that the blood pressure, heart rate, and respirations are 20% below baseline. The nurse concludes which
of the following?
1. The client is about to have a cardiac arrest.
2. The client is in stage 2 of NREM sleep.
3. The client's metabolic rate has increased.
4. The client is in stage 4 of NREM sleep.
Correct Answer: 4
Rationale 1: During stage 4 sleep, the client is relaxed, and vital signs decrease from baseline by 20-30 percent.
Stage 2 sleep is characterized by light sleep with vital signs decreasing slightly. The client's metabolic rate is
decreased in stage 4. A decrease in vital signs is normal during stage 4 sleep, and the client is not at risk for
cardiac arrest.
Rationale 2: During stage 4 sleep, the client is relaxed, and vital signs decrease from baseline by 20-30 percent.
Stage 2 sleep is characterized by light sleep with vital signs decreasing slightly. The client's metabolic rate is
decreased in stage 4. A decrease in vital signs is normal during stage 4 sleep, and the client is not at risk for
cardiac arrest.
Rationale 3: During stage 4 sleep, the client is relaxed, and vital signs decrease from baseline by 20-30 percent.
Stage 2 sleep is characterized by light sleep with vital signs decreasing slightly. The client's metabolic rate is
decreased in stage 4. A decrease in vital signs is normal during stage 4 sleep, and the client is not at risk for
cardiac arrest.
Rationale 4: During stage 4 sleep, the client is relaxed, and vital signs decrease from baseline by 20-30 percent.
Stage 2 sleep is characterized by light sleep with vital signs decreasing slightly. The client's metabolic rate is
decreased in stage 4. A decrease in vital signs is normal during stage 4 sleep, and the client is not at risk for
cardiac arrest.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Describe the stages and functions of sleep.
Question 15
Type: MCSA
The elderly client reports difficulty sleeping at night, fatigue, and lack of energy. The nurse suggests which of the
following as a possible cause of the client's sleep problems?
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. Napping during the day


2. Evening walks with her spouse
3. Moderate food intake at the evening meal
4. Warm bath before bedtime
Correct Answer: 1
Rationale 1: Seniors can have a tendency to nap in the daytime when they get tired, and this can cause them to
have trouble falling asleep or staying asleep at night. Taking an evening walk, eating moderate nighttime meals,
and taking a warm bath before bedtime are all ways to promote sleep.
Rationale 2: Seniors can have a tendency to nap in the daytime when they get tired, and this can cause them to
have trouble falling asleep or staying asleep at night. Taking an evening walk, eating moderate nighttime meals,
and taking a warm bath before bedtime are all ways to promote sleep.
Rationale 3: Seniors can have a tendency to nap in the daytime when they get tired, and this can cause them to
have trouble falling asleep or staying asleep at night. Taking an evening walk, eating moderate nighttime meals,
and taking a warm bath before bedtime are all ways to promote sleep.
Rationale 4: Seniors can have a tendency to nap in the daytime when they get tired, and this can cause them to
have trouble falling asleep or staying asleep at night. Taking an evening walk, eating moderate nighttime meals,
and taking a warm bath before bedtime are all ways to promote sleep.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Identify factors that affect sleep, and variables related to age or stage of development.
Question 16
Type: MCMA
The client who is about to be discharged asks the nurse for suggestions on how to improve the quality of sleep to
wake feeling refreshed in the morning. The nurse makes which of the following suggestions? Select all that apply.
Standard Text: Select all that apply.
1. Adjust the temperature in the room to a comfortable level.
2. Change the time of aerobic exercise to one hour prior to sleep.
3. A cup of tea before bed is relaxing.
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4. Limit the use of alcohol to early in the evening.


5. Do not smoke before bedtime.
Correct Answer: 1,4,5
Rationale 1: A comfortable room temperature will promote sleep. Alcohol interferes with REM sleep, and should
be limited well before bedtime. Nicotine is a stimulant, and could prevent the client from falling asleep. Exercise
close to bedtime acts as a stimulant, and can cause the client to be unable to sleep. Tea contains caffeine, which is
a stimulant. The nurse could suggest non-caffeinated tea before bedtime unless this causes the client to wake
during the night to urinate.
Rationale 2: A comfortable room temperature will promote sleep. Alcohol interferes with REM sleep, and should
be limited well before bedtime. Nicotine is a stimulant, and could prevent the client from falling asleep. Exercise
close to bedtime acts as a stimulant, and can cause the client to be unable to sleep. Tea contains caffeine, which is
a stimulant. The nurse could suggest non-caffeinated tea before bedtime unless this causes the client to wake
during the night to urinate.
Rationale 3: A comfortable room temperature will promote sleep. Alcohol interferes with REM sleep, and should
be limited well before bedtime. Nicotine is a stimulant, and could prevent the client from falling asleep. Exercise
close to bedtime acts as a stimulant, and can cause the client to be unable to sleep. Tea contains caffeine, which is
a stimulant. The nurse could suggest non-caffeinated tea before bedtime unless this causes the client to wake
during the night to urinate.
Rationale 4: A comfortable room temperature will promote sleep. Alcohol interferes with REM sleep, and should
be limited well before bedtime. Nicotine is a stimulant, and could prevent the client from falling asleep. Exercise
close to bedtime acts as a stimulant, and can cause the client to be unable to sleep. Tea contains caffeine, which is
a stimulant. The nurse could suggest non-caffeinated tea before bedtime unless this causes the client to wake
during the night to urinate.
Rationale 5: A comfortable room temperature will promote sleep. Alcohol interferes with REM sleep, and should
be limited well before bedtime. Nicotine is a stimulant, and could prevent the client from falling asleep. Exercise
close to bedtime acts as a stimulant, and can cause the client to be unable to sleep. Tea contains caffeine, which is
a stimulant. The nurse could suggest non-caffeinated tea before bedtime unless this causes the client to wake
during the night to urinate.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Identify factors that affect sleep, and variables related to age or stage of development.
Question 17
Type: MCSA

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The nurse is teaching a class for staff members on the importance of assessing clients for sleep apnea in the longterm care facility. The nurse explains that the possible consequences of sleep apnea include which of the
following?
1. Pulmonary hypertension
2. Teeth grinding
3. Sleepwalking
4. Hypothyroidism
Correct Answer: 1
Rationale 1: Sleep apnea causes the client's blood pressure to rise and, over time, can cause cardiac arrest,
arrhythmias, and pulmonary hypertension. Sleepwalking and -talking are parasomnias, or behaviors that occur
during sleepnot related to sleep apnea. Hypothyroidism does not result from sleep apnea.
Rationale 2: Sleep apnea causes the client's blood pressure to rise and, over time, can cause cardiac arrest,
arrhythmias, and pulmonary hypertension. Sleepwalking and -talking are parasomnias, or behaviors that occur
during sleepnot related to sleep apnea. Hypothyroidism does not result from sleep apnea.
Rationale 3: Sleep apnea causes the client's blood pressure to rise and, over time, can cause cardiac arrest,
arrhythmias, and pulmonary hypertension. Sleepwalking and -talking are parasomnias, or behaviors that occur
during sleepnot related to sleep apnea. Hypothyroidism does not result from sleep apnea.
Rationale 4: Sleep apnea causes the client's blood pressure to rise and, over time, can cause cardiac arrest,
arrhythmias, and pulmonary hypertension. Sleepwalking and -talking are parasomnias, or behaviors that occur
during sleepnot related to sleep apnea. Hypothyroidism does not result from sleep apnea.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Name common sleep disorders and interventions to promote normal sleep.
Question 18
Type: MCSA
The nurse admits a client scheduled for an EOG and explains the purpose of the test as which of the following?
1. To measure the level of oxygen in the blood during sleep
2. To study the brain activity during sleep
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3. To measure eye movement during sleep


4. To detect the cessation of breathing during sleep
Correct Answer: 3
Rationale 1: The EOG measures eye movements during sleep. An electrode is placed at the outer canthus of the
eye to record eye movement. Pulse oximetry measures oxygen levels in the blood. Brain activity is detected by the
EEG, and sleep apnea is detected by using an ECG monitor.
Rationale 2: The EOG measures eye movements during sleep. An electrode is placed at the outer canthus of the
eye to record eye movement. Pulse oximetry measures oxygen levels in the blood. Brain activity is detected by the
EEG, and sleep apnea is detected by using an ECG monitor.
Rationale 3: The EOG measures eye movements during sleep. An electrode is placed at the outer canthus of the
eye to record eye movement. Pulse oximetry measures oxygen levels in the blood. Brain activity is detected by the
EEG, and sleep apnea is detected by using an ECG monitor.
Rationale 4: The EOG measures eye movements during sleep. An electrode is placed at the outer canthus of the
eye to record eye movement. Pulse oximetry measures oxygen levels in the blood. Brain activity is detected by the
EEG, and sleep apnea is detected by using an ECG monitor.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Identify tests used to diagnose sleep disorders.
Question 19
Type: MCSA
The nurse is explaining to the client that there are many causes for sleep apnea, and that testing is designed to
identify the cause of the apnea so that appropriate treatment can be started. The client asks the nurse to describe
the types of equipment used for the sleep apnea study. The nurse tells the client that which of the following might
be used during the sleep apnea study?
1. An iPod to help the client to fall asleep to music
2. A videorecorder to pick up unusual respirations and movement
3. An intravenous pump to administer the dyes used
4. A rectal probe for recording temperature during sleep
Correct Answer: 2
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Rationale 1: The client likely will be observed by videocamera to note movement and to pick up unusual
breathing noises. Clients are not given IV dyes for a sleep study, and their temperatures are not monitored during
sleep. If the iPod is allowed, it would be brought to the study by the client to help fall asleep.
Rationale 2: The client likely will be observed by videocamera to note movement and to pick up unusual
breathing noises. Clients are not given IV dyes for a sleep study, and their temperatures are not monitored during
sleep. If the iPod is allowed, it would be brought to the study by the client to help fall asleep.
Rationale 3: The client likely will be observed by videocamera to note movement and to pick up unusual
breathing noises. Clients are not given IV dyes for a sleep study, and their temperatures are not monitored during
sleep. If the iPod is allowed, it would be brought to the study by the client to help fall asleep.
Rationale 4: The client likely will be observed by videocamera to note movement and to pick up unusual
breathing noises. Clients are not given IV dyes for a sleep study, and their temperatures are not monitored during
sleep. If the iPod is allowed, it would be brought to the study by the client to help fall asleep.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Identify tests used to diagnose sleep disorders.
Question 20
Type: MCMA
The nurse is aware that body movement is dependent on interdependent activity of several body systems,
including:(Select all that apply)
Standard Text: Select all that apply.
1. Musculoskeletal system
2. Nervous system
3. Vestibular system
4. Respiratory system
5. Cardiovascular system
Correct Answer: 1,2,3
Rationale 1: The musculoskeletal system is involved in body movement, affecting alignment, and joint mobility
Rationale 2: The nervous system is involved with balance and coordination
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Rationale 3: The vestibular system is involved in body movement, affecting balance and coordination
Rationale 4: The respiratory system is affected by normal movement
Rationale 5: The cardiovascular system is affected by body movement
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 21
Type: MCSA
The nurse is discussing alignment and posture with a group of teens. Many of the female students have adopted a
curved posture. The nurse explains to the teens that
1. When the body is properly aligned, the organs are properly supported
2. Equilibrium depends on the proper body alignment
3. Muscular strength decreases with physical activity
4. Orthostatic hypotension is common with improper alignment
Correct Answer: 1
Rationale 1: Proper alignment of the body allows organs to function at their best while also maintaining balance
Rationale 2: Equilibrium depends on the integration of stimuli from several organs, including the muscles and
tendons of the head and neck, the eyes and the inner ear
Rationale 3: Muscular strength decreases with immobility
Rationale 4: Orthostatic hypotension is common with prolonged bedrest
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
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Question 22
Type: MCMA
The nurse is caring for a client who has been on bedrest for a high risk pregnancy. This client is at risk for:(Select
all that apply)
Standard Text: Select all that apply.
1. Disuse atrophy
2. Orthostatic hypotension
3. Thrombophlebitis
4. Dependent edema
5. Hypostatic pneumonia
Correct Answer: 1,2,3,4
Rationale 1: Unused muscles atrophy, losing most of their normal strength and function
Rationale 2: Orthostatic hypotension is common with prolonged bed rest
Rationale 3: Venous vasodilation and stasis predispose clients to thrombus formation
Rationale 4: When venous pressure is great, serum is forced from the blood vessels into the surrounding
interstitial space, causing edema
Rationale 5: Hypostatic pneumonia is caused by static secretions in the alveoli; the pregnant client is unlikely to
experience this complication
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 23
Type: MCSA
The nurse adds range of motion exercises to a clients care plan when it is determined that the client is in a
persistent vegetative state. This is done to prevent:
1. The muscles from becoming permanently shortened
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2. The muscles from wasting away


3. The muscles from becoming flaccid
4. The client from losing body mass
Correct Answer: 1
Rationale 1: Flexor muscles are stronger than extensors, so when a person is inactive, the joints become pulled
into the flexed position. Constant immobility causes muscles to shorten permanently and become fixed in the
flexed position
Rationale 2: ROM exercises will maintain joint mobility, but will not prevent atrophy of muscles
Rationale 3: ROM exercises will maintain joint mobility; some muscles in this client may be flaccid, some may
become contracted
Rationale 4: ROM exercises will maintain joint mobility, but will not prevent the client from losing body mass
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 24
Type: MCMA
The nurse is explaining factors that affect an individuals body alignment, mobility and daily activity level.
Examples of client factors that might decrease mobility and activity include:(Select all that apply)
Standard Text: Select all that apply.
1. Vestibular disorder
2. Spina bifida
3. Anemia
4. Overnutrition
5. Ear canal infection
Correct Answer: 1,2,3,4
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Rationale 1: Vestibular (inner ear disorders) affect a clients equilibrium, causing impaired balance
Rationale 2: Vestibular (inner ear disorders) affect a clients equilibrium, causing impaired balance
Rationale 3: Vestibular (inner ear disorders) affect a clients equilibrium, causing impaired balance
Rationale 4: Vestibular (inner ear disorders) affect a clients equilibrium, causing impaired balance
Rationale 5: Vestibular (inner ear disorders) affect a clients equilibrium, causing impaired balance
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 25
Type: MCMA
The nurse is caring for a client who is a in traction due to a motor vehicle accident. The nurse anticipates which of
the following effects of immobility?(Select all that apply)
Standard Text: Select all that apply.
1. Osteoporosis
2. Venous vasoconstriction
3. Urinary stasis
4. Diarrhea
5. Decreased respiratory movement
Correct Answer: 1,3,5
Rationale 1: Without the stress of weight-bearing activity, bones demineralize
Rationale 2: Without the stress of weight-bearing activity, bones demineralize
Rationale 3: Without the stress of weight-bearing activity, bones demineralize
Rationale 4: Without the stress of weight-bearing activity, bones demineralize
Rationale 5: Without the stress of weight-bearing activity, bones demineralize
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Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 26
Type: MCMA
The nurse is admitting a client to a rehabilitation facility after surgery for a hip replacement. The nurse observes
the client as appearing depressed. The client denies depression, but states that she is concerned about returning to
her regular activities, including walking for exercise, because she is so tired. The nurse understands that :(Select
all that apply)
Standard Text: Select all that apply.
1. This client has unrealistic goals
2. Stress may be affecting this clients mobility
3. Walking will tire the client
4. The client is at increased risk of disease due to immobility
5. This client is at risk for affective disorder
Correct Answer: 2,4,5
Rationale 1: The clients goals are not unrealistic over time
Rationale 2: Stress and pain deplete the bodys energy reserves, producing fatigue
Rationale 3: Movement energizes the client and facilitates coping
Rationale 4: A history of inactivity because of injury increases the risk of major disease; early ambulation after
surgery is an essential preventive measure
Rationale 5: People who are unable to carry out usual activities related to their roles may become dependent on
others; lose of independence damages self-esteem and may in turn provoke an exaggerated emotional response
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment


Learning Outcome:
Question 27
Type: MCSA
The client who has been hospitalized for a fractured femur expresses surprise that she is so tired arter sitting up in
the chair for a short period of time. The nurse explains that:
1. Decreased mobility creates venous vasodilation and stasis
2. Decreased mobility may interfere with the normal exchange of oxygen and carbon dioxide
3. Decreased mobility may cause a negative calcium balance as a result of calcium loss from bone
4. Decreased mobility causes decreases in muscular strength
Correct Answer: 4
Rationale 1: Immobility causes venous vasodilation and stasis, but this would not account for the clients fatigue
Rationale 2: Prolonged immobility may inhibit the force of the cough, resulting in pooling of respiratory
secretions; the client is not complaining of a cough or shortness of breath
Rationale 3: Prolonged immobility may cause disuse osteoporosis resulting from the loss of calcium from the
bones; this clients condition does not indicate long term immobility
Rationale 4: Disuse atrophy is cause by muscles not being used; clients may be fatigued more quickly after only
a short illness or injury
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 28
Type: MCMA
In addition the musculoskeletal effects of immobility, the nurse explains that the cardiovascular system undergoes
changes during prolonged bedrest, such as:(Select all that apply)
Standard Text: Select all that apply.
1. Venous stasis
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2. Tachycardia
3. Emboli
4. Atelectasis
5. Anorexia
Correct Answer: 1,2,3
Rationale 1: Venous stasis and vasodilation occur due to the inability of atrophied muscles to assist in pumping
blood back to the heart
Rationale 2: Decreased mobility creates an imbalance in the autonomic nervous system, resulting in an increased
heart rate
Rationale 3: Venous stasis and vasodilation predispose clients to thrombus formation; thrombophlebitis may
result in an emboli, which may lodge in vessels supplying vital organs
Rationale 4: Atelectasis is a potential respiratory system change
Rationale 5: Anorexia is a potential result of decreased metabolic rate and increased catabolism; it is an effect of
immobility on the metabolic system
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 29
Type: MCMA
The nurse is turning a client from her back to her side. To promote the clients proper body alignment, and safety
the nurse:(Select all that apply)
Standard Text: Select all that apply.
1. Ensures the bed is clean and dry
2. Places support devices in specified areas
3. Places body parts on top of each other to ensure alignment
4. Plans a 24 hour schedule for position changes
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5. Ensures the mattress is soft


Correct Answer: 1,2,4
Rationale 1: Wrinkled or damp sheets increase the risk of pressure ulcer formation
Rationale 2: Support devices, such as pillows and foot boards, should be used to maintain alignment and prevent
stress on muscles and joints
Rationale 3: Avoid placing one body part directly on top of another body part; excessive pressure can damage
veins and predispose the client to thrombus formation
Rationale 4: Plan a continuous, 24-hour schedule for position changes
Rationale 5: The mattress should be firm, and level, and yields enough to fill in and support natural body
curvatures
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 30
Type: MCSA
A client has a nursing diagnosis of Activity Intolerance. An appropriate goal for this client would be:
1. Avoid complications associated with immobility
2. Avoid injury from improper use of body mechanics
3. Increase tolerance for physical activity
4. Ambulate client with walker twice a day
Correct Answer: 3
Rationale 1: This goal may or may not be appropriate for this client; the information does not support a nursing
diagnosis of Impaired Physical Mobility
Rationale 2: This goal is not immediately supported by the nursing diagnosis given
Rationale 3: This is an appropriate goal for this client; appropriate interventions will vary
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Rationale 4: This is an appropriate intervention for this client; it is not a goal


Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome:
Question 31
Type: MCMA
The nurse is preparing to position a client in semi-Fowlers position. The appropriate support device(s) to utilize
include:(Select all that apply)
Standard Text: Select all that apply.
1. Bedboards
2. Foot boots
3. Chair beds
4. Pillows
5. Footboard
Correct Answer: 4,5
Rationale 1: Semi-Fowlers
Rationale 2: Semi-Fowlers
Rationale 3: Semi-Fowlers
Rationale 4: Semi-Fowlers
Rationale 5: Semi-Fowlers
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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Question 32
Type: SEQ
As the nurse makes night rounds on sleeping clients, several clients are noted to be breathing very slowly. Stages
of NREM sleep account for some decreased physiological functions. Identify the stage that correlates to the
choice given
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Lasts only a few minutes
Choice 2. Light sleep, body continues to slow down
Choice 3. Sleeper difficult to arouse
Choice 4. Heart and respiratory rates 20-30% below waking rates
Correct Answer: 1,2,3,4
Rationale 1: Stage I NREM sleep is very light sleep, that lasts only a few minutes; person feels drowsy and
relaxed
Rationale 2: Stage I NREM sleep is very light sleep, that lasts only a few minutes; person feels drowsy and
relaxed
Rationale 3: Stage I NREM sleep is very light sleep, that lasts only a few minutes; person feels drowsy and
relaxed
Rationale 4: Stage I NREM sleep is very light sleep, that lasts only a few minutes; person feels drowsy and
relaxed
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 33
Type: MCMA
The client is postoperative day three from abdominal surgery. He states that he hasnt slept more than an hour or
so at a time due to the pain, but does not want to take medication to assist with sleeping. The nurse describes the
function(s) of sleep as:(Select all that apply)
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Standard Text: Select all that apply.


1. Necessary for protein synthesis
2. Restores normal levels of activity
3. Restores balance within the nervous system
4. Necessary for fat metabolism
5. Sympathetic nervous system activity
Correct Answer: 1,2,3
Rationale 1: Sleep is necessary for protein synthesis and cellular repair
Rationale 2: Sleep exerts physiological effects on body systems and restores normal levels of activity
Rationale 3: Sleep restores balance within the nervous system
Rationale 4: Sleep is not necessary for fat metabolism
Rationale 5: Sympathetic nervous system is more active while the person is awake
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 34
Type: MCSA
The nurse is describing the difference between the quality and quantity of sleep. Sleep quality refers to
1. The total time an individual sleeps
2. An individuals ability to stay asleep
3. The sleep-wake cycle that changes through the lifespan
4. How long it takes a person to get to sleep
Correct Answer: 2
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Rationale 1: The total time the individual sleeps is the quantity of sleep
Rationale 2: Sleep quality refers to an individuals ability to stay asleep and to get appropriate amounts of REM
and NREM sleep
Rationale 3: Sleep wake cycles are part of the biologic rhythm that involves physiological and psychological
activity and rest
Rationale 4: How long it takes a person to get to sleep is described as Stage 1 NREM sleep
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 35
Type: MCMA
The parents of a 9 year old are concerned about their child sleeping 11 hours at night. The nurse explains that agerelated sleep habits include:(Select all that apply)
Standard Text: Select all that apply.
1. School age children need 9-12 hours of sleep at night
2. Infants and seniors often wake at night
3. Infants and adults often wake at night
4. Adolescents tend to get enough sleep
5. Infants will sleep through the night at 4 months of age
Correct Answer: 1,2
Rationale 1: School-age children need 9-12 hours of sleep at night; children often become sleep deprived at this
age
Rationale 2: Infants sill wake up at least once a night until 9 months of age; seniors may have nighttime sleeping
interfered with by napping. Lack of exercise, or medication side effects
Rationale 3: Most infants still wake up at least once a night until 9 months of age; adults should have a minimum
of 7 hours nightly; unless adults are having troubled sleep, the norm is to sleep through the night
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Rationale 4: Adolescents should have 9.5 hours of sleep from ages 13-15 years; most teens get too little sleep,
usually 7.5 hours or less
Rationale 5: Infants will sleep 6-8 hours at night by 4 months of age, but most still wake up at least once a night
until 9 months of age
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 36
Type: MCMA
The nurse is taking a sleep history on a client who states that he has difficulty getting to sleep. Which of the
following factors might be causing delayed onset of sleep:(Select all that apply)
Standard Text: Select all that apply.
1. Hyperthyroidism
2. Hypothyroidism
3. Early morning exercise
4. Smoking
5. Demerol
Correct Answer: 1,4
Rationale 1: Rational:
Rationale 2: Rational:
Rationale 3: Rational:
Rationale 4: Rational:
Rationale 5: Rational:
Global Rationale:
Cognitive Level: Understanding
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Client Need: Physiological Integrity


Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 37
Type: MCMA
As the nurse obtains a general sleep history from a newly admitted clients, the client reports several parasomnias,
including:(Select all that apply)
Standard Text: Select all that apply.
1. Somnambulism
2. Bruxism
3. Narcolepsy
4. Sleep apnea
5. Sleep deprivation
Correct Answer: 1,2
Rationale 1: Somnambulism is sleepwalking, which is a behavior that interferes with sleep
Rationale 2: Somnambulism is sleepwalking, which is a behavior that interferes with sleep
Rationale 3: Somnambulism is sleepwalking, which is a behavior that interferes with sleep
Rationale 4: Somnambulism is sleepwalking, which is a behavior that interferes with sleep
Rationale 5: Somnambulism is sleepwalking, which is a behavior that interferes with sleep
Global Rationale:
Cognitive Level: Understanding
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 38
Type: MCSA

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The nurse is explaining sleep deprivation to a client whose sleep history is suggestive of the deprivation. Clinical
signs of NREM deprivation include
1. Emotional lability
2. Difficulty getting dressed
3. Impaired judgement
4. Withdrawal
Correct Answer: 4
Rationale 1: Emotional lability is a common clinical sign of REM deprivation
Rationale 2: Emotional lability is a common clinical sign of REM deprivation
Rationale 3: Emotional lability is a common clinical sign of REM deprivation
Rationale 4: Emotional lability is a common clinical sign of REM deprivation
Global Rationale:
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 39
Type: MCMA
The nurse is preparing the care plan for a client with difficulty falling to sleep. Appropriate interventions to reduce
environmental distractions in hospitals include:(Select all that apply)
Standard Text: Select all that apply.
1. Taking vital signs early in the evening
2. Closing the door of the clients room
3. Position dependent clients appropriately
4. Make nursing rounds in hallway
5. Assist client with voiding before bedtime
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Correct Answer: 1,2


Rationale 1: Performing only essential nursing tasks during sleeping hours will decrease environmental
distractions
Rationale 2: Performing only essential nursing tasks during sleeping hours will decrease environmental
distractions
Rationale 3: Performing only essential nursing tasks during sleeping hours will decrease environmental
distractions
Rationale 4: Performing only essential nursing tasks during sleeping hours will decrease environmental
distractions
Rationale 5: Performing only essential nursing tasks during sleeping hours will decrease environmental
distractions
Global Rationale:
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 40
Type: MCMA
A client is admitted to the emergency unit as a result of a minor motor vehicle accident that was due to his falling
asleep at the wheel. Information that is appropriate for the nurse to include in the teaching plan for this client
includes:(Select all that apply)
Standard Text: Select all that apply.
1. Exercise every day when ever it fits in the schedule
2. Naps are acceptable, if short
3. Block out extra noise if possible with a television on in the background
4. Heavy snacks before bedtime may disturb sleep
5. Establish a regular bedtime ritual
Correct Answer: 2,4,5
Rationale 1: Daily exercise is important, but avoid excessive physical exertion less than 2 hours before bedtime
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Rationale 2: Daily exercise is important, but avoid excessive physical exertion less than 2 hours before bedtime
Rationale 3: Daily exercise is important, but avoid excessive physical exertion less than 2 hours before bedtime
Rationale 4: Daily exercise is important, but avoid excessive physical exertion less than 2 hours before bedtime
Rationale 5: Daily exercise is important, but avoid excessive physical exertion less than 2 hours before bedtime
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 41
Type: MCMA
The nursing care plan for the client with insomnia includes several non-pharmacologic interventions such as:
(Select all that apply)
Standard Text: Select all that apply.
1. A brisk walk around the facility
2. A small drink of brandy
3. A small glass of milk
4. Taking a warm bath
5. Using the computer in bed until sleepy
Correct Answer: 3,4
Rationale 1: When unable to sleep, a relaxing,
Rationale 2: When unable to sleep, a relaxing,
Rationale 3: When unable to sleep, a relaxing,
Rationale 4: When unable to sleep, a relaxing,
Rationale 5: When unable to sleep, a relaxing,
Global Rationale:
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Cognitive Level: Applying


Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 42
Type: MCMA
The nurse is caring for a client in the intensive care unit. This client is at risk for sensory overload, which may be
manifested in the following manner:(Select all that apply)
Standard Text: Select all that apply.
1. Decreased attention span
2. Irritability
3. Scattered attention
4. Hallucinations
5. Emotional lability
Correct Answer: 2,3
Rationale 1: Decreased attention span is a common manifestation of sensory deprivation
Rationale 2: Irritability, anxiety and restlessness are common manifestations of sensory overload
Rationale 3: Scattered attention and racing thoughts are common manifestations of sensory overload
Rationale 4: Hallucinations or delusions are common manifestations of sensory deprivation
Rationale 5: Emotional lability is a common manifestation of sensory deprivation
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 43
Type: MCSA
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The nurse is assessing a clients sensory reception and perception. The client has a history of a motor vehicle
accident several years ago that resulted in a spinal cord injury. This client is at risk for altered sensory reception of
which type of stimuli?
1. Visual
2. Auditory
3. Gustatory
4. Visceral
Correct Answer: 4
Rationale 1: Based on the information given, this client is not at risk for altered reception or perception of visual
stimuli
Rationale 2: Based on the information given, this client is not at additional risk for altered reception or perception
of auditory stimuli
Rationale 3: Based on the information given, the client is not at additional risk for altered reception or perception
of gustatory (taste) stimuli
Rationale 4: This client may have a decreased awareness of visceral stimuli, such as a full stomach or need to
empty the bladder based on the altered impulse conduction due to the spinal cord injury
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 44
Type: MCMA
The nurse is caring for a group of clients in a long term care facility. Which of the following clients are at risk for
sensory deprivation?(Select all that apply)
Standard Text: Select all that apply.
1. The alert and oriented client who has no family in the area
2. The confused client who has no family in the area

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3. The alert and oriented client who has several children, grandchildren, and great-grand children who are all
involved in the clients care
4. The alert and oriented client who is unable to move independently
5. The confused client whose hearing aids work intermittently
Correct Answer: 1,2,4,5
Rationale 1: The alert and oriented client in a long term care facility with no family are at risk due to the potential
lack of people to visit and talk with the client regularly
Rationale 2: The confused client is at risk due to an altered perception of stimulation; without regular visitors that
the client recognizes could increase confusion
Rationale 3: The alert and oriented client with many potential visitors is at risk for sensory overload due to too
many visitors
Rationale 4: The alert and oriented client who is unable to move independently is at risk for sensory deprivation
due to the inability to move to reach glasses, reading material, etc. independently
Rationale 5: The confused client without functioning hearing aids is at risk for continued altered sensory
reception
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 45
Type: MCMA
The nurse identifies the client at risk for sensory overload based on several factors, including:(Select all that
apply)
Standard Text: Select all that apply.
1. In-patient hospitalization
2. Extreme shortness of breath
3. Signs of depression
4. Increased anxiety over a new diagnosis
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5. Lost hearing aids


Correct Answer: 1,2,4
Rationale 1: This client is at risk for sensory overload due to being admitted to a noisy healthcare setting
Rationale 2: The client with shortness of breath has increased stimulation, both physically and emotionally
(anxiety)
Rationale 3: The client with signs of depression is likely to withdraw or block out external stimuli
Rationale 4: A client with increased internal stimuli, such as anxiety or pain is at risk for sensory overload
Rationale 5: The client who has lost his or her hearing aids is at risk for sensory deprivation
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 46
Type: MCMA
The client with impaired vision is at risk of sensory overload and sensory deprivation. The nurse identifies aids for
this client to help the client deal with the deficit:(Select all that apply)
Standard Text: Select all that apply.
1. Window shades
2. Flashing alarm clocks
3. Sign language instruction
4. Color coding on stoves
5. Large writing on name tags
Correct Answer: 1,4,5
Rationale 1: Window shades are important to reduce glare
Rationale 2: Flashing alarm clocks are helpful for people with hearing deficits
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Rationale 3: Sign language instruction is helpful for people with hearing deficits
Rationale 4: Color coding on stove controls is helpful for people with visual deficits
Rationale 5: Large writing on name tags of health care providers will be helpful for all clients, including people
with visual deficits
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 47
Type: MCSA
The nurse identifies several factors that may contribute to sensory overload in a hospitalized school-age child,
including
1. Narcotic medications
2. Being one of several children in a family
3. Diagnosis of chicken pox
4. Having intravenous lines inserted
Correct Answer: 4
Rationale 1: Narcotics and sedatives can decrease the awareness of stimuli
Rationale 2: Being an only child would put the child at risk for sensory overload
Rationale 3: Having a diagnosis of chicken pox (a communicable disease) puts the child at risk of sensory
deprivation due to infection control procedures
Rationale 4: Intravenous lines and other intrusive tubes can contribute to sensory overload
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
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Question 48
Type: MCMA
As the nurse is collects data for a newly admitted client, it becomes clear that the client is confused. The nurse
notes interventions appropriate for promoting orientation as:(Select all that apply)
Standard Text: Select all that apply.
1. Address the client by name
2. Assign a variety of caregivers
3. Speak quickly so the client does not have time to argue
4. Tell the client when you are leaving and when you will return
5. Encouraging the client to wear familiar clothing
Correct Answer: 1,4,5
Rationale 1: Addressing the client by name assists in keeping the client oriented to person
Rationale 2: Addressing the client by name assists in keeping the client oriented to person
Rationale 3: Addressing the client by name assists in keeping the client oriented to person
Rationale 4: Addressing the client by name assists in keeping the client oriented to person
Rationale 5: Addressing the client by name assists in keeping the client oriented to person
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 49
Type: MCMA
Nursing interventions that are appropriate for the client who has lost his or her vision include:(Select all that
apply)
Standard Text: Select all that apply.
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1. Use of a radio or audiotapes


2. Ordering a bland diet
3. Offering a massage
4. Placing silk flowers in the clients room
5. Using therapeutic pet therapy
Correct Answer: 1,3,5
Rationale 1: Auditory stimulation can supplement sensory input for the client with a visual impairment
Rationale 2: Diets that include a variety of flavors and textures can stimulate the taste buds
Rationale 3: Massages can be used to stimulate touch receptors
Rationale 4: Fresh flowers can stimulate the sense of smell
Rationale 5: Pet therapy can be used to stimulate touch receptors
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 50
Type: MCMA
The nurse is discussing strategies for preventing sensory impairments with the parents of a newborn. Topics to
include to protect hearing include:(Select all that apply)
Standard Text: Select all that apply.
1. Obtain regular immunizations
2. Seek medical attention for reduced eye contact
3. Keep auditory stimulation to a minimum
4. Have children wear ear protection in noisy environments
5. Have regular health examinations
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Correct Answer: 1,4,5


Rationale 1: Immunizations against diseases that can cause hearing loss are important preventive measures
Rationale 2: Decreased eye contact from an infant is more indicative of a visual problem
Rationale 3: Auditory stimulation is important for normal growth and development
Rationale 4: Children should wear ear protection in loud environments
Rationale 5: Regular health examinations allow for screening by health care providers
Global Rationale:
Cognitive Level: Applying
Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 51
Type: MCSA
The nurse is caring for a client with an impaired visual field. Appropriate communication strategies with this
client include:
1. Convey your presence by moving to a position where you can be seen
2. Decreasing background noises before speaking
3. Use longer phrases
4. Pronounce every name with care
Correct Answer: 1
Rationale 1: Convey your presence by moving to a position within the clients visual field
Rationale 2: Decreasing background noises is more appropriate for the client with a hearing deficit
Rationale 3: Using longer phrases are more easily understood for the client with a hearing deficit
Rationale 4: Pronouncing every name carefully with references to the name is a strategy that is useful for the
client who has a hearing deficit
Global Rationale:
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Cognitive Level: Applying


Client Need:
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 52
Type: MCMA
The nurse is aware that body movement is dependent on interdependent activity of several body systems,
including the:
Standard Text: Select all that apply.
1. Musculoskeletal system.
2. Nervous system.
3. Vestibular system.
4. Respiratory system.
5. Cardiovascular system.
Correct Answer: 1,2,3
Rationale 1: The musculoskeletal system is involved in body movement, affecting alignment, and joint mobility.
Rationale 2: The nervous system is involved with balance and coordination.
Rationale 3: The vestibular system is involved in body movement, affecting balance and coordination.
Rationale 4: The respiratory system is affected by normal movement.
Rationale 5: The cardiovascular system is affected by body movement.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 53
Type: MCSA
The nurse is discussing alignment and posture with a group of teens. Many of the female students have adopted a
curved posture. The nurse explains to the teens that:
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1. When the body is properly aligned, the organs are properly supported.
2. Equilibrium depends on the proper body alignment.
3. Muscular strength decreases with physical activity.
4. Orthostatic hypotension is common with improper alignment.
Correct Answer: 1
Rationale 1: Proper alignment of the body allows organs to function at their best while also maintaining balance.
Rationale 2: Equilibrium depends on the integration of stimuli from several organs, including the muscles and
tendons of the head and neck, the eyes, and the inner ear.
Rationale 3: Muscular strength decreases with immobility.
Rationale 4: Orthostatic hypotension is common with prolonged bedrest.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 54
Type: MCMA
The nurse is caring for a client who has been on bedrest for a high-risk pregnancy. This client is at risk for:
Standard Text: Select all that apply.
1. Disuse atrophy.
2. Orthostatic hypotension.
3. Thrombophlebitis.
4. Dependent edema.
5. Hypostatic pneumonia.
Correct Answer: 1,2,3,4
Rationale 1: Unused muscles atrophy, losing most of their normal strength and function.
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Rationale 2: Orthostatic hypotension is common with prolonged bedrest.


Rationale 3: Venous vasodilation and stasis predispose clients to thrombus formation.
Rationale 4: When venous pressure is great, serum is forced from the blood vessels into the surrounding
interstitial space, causing edema.
Rationale 5: Hypostatic pneumonia is caused by static secretions in the alveoli; the pregnant client is unlikely to
experience this complication.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 55
Type: MCSA
The nurse adds range of motion exercises to a clients care plan when it is determined that the client is in a
persistent vegetative state. This is done to prevent:
1. The muscles from becoming permanently shortened.
2. The muscles from wasting away.
3. The muscles from becoming flaccid.
4. The client from losing body mass.
Correct Answer: 1
Rationale 1: Flexor muscles are stronger than extensors, so when a person is inactive, the joints become pulled
into the flexed position. Constant immobility causes muscles to shorten permanently and become fixed in the
flexed position.
Rationale 2: ROM exercises will maintain joint mobility, but will not prevent atrophy of muscles.
Rationale 3: ROM exercises will maintain joint mobility; some muscles in this client might be flaccid, some can
become contracted.
Rationale 4: ROM exercises will maintain joint mobility, but will not prevent the client from losing body mass.
Global Rationale:
Cognitive Level: Understanding
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Client Need: Physiological Integrity


Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 56
Type: MCMA
The nurse is explaining factors that affect an individuals body alignment, mobility, and daily activity level.
Examples of client factors that might decrease mobility and activity include:
Standard Text: Select all that apply.
1. Vestibular disorder.
2. Spina bifida.
3. Anemia.
4. Overnutrition.
5. Ear canal infection.
Correct Answer: 1,2,3,4
Rationale 1: Vestibular (inner ear disorders) affect a clients equilibrium, causing impaired balance.
Rationale 2: Vestibular (inner ear disorders) affect a clients equilibrium, causing impaired balance.
Rationale 3: Vestibular (inner ear disorders) affect a clients equilibrium, causing impaired balance.
Rationale 4: Vestibular (inner ear disorders) affect a clients equilibrium, causing impaired balance.
Rationale 5: Vestibular (inner ear disorders) affect a clients equilibrium, causing impaired balance.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 57
Type: MCMA
The nurse is caring for a client who is in traction due to a motor vehicle accident. The nurse anticipates which of
the following effects of immobility?
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Standard Text: Select all that apply.


1. Osteoporosis
2. Venous vasoconstriction
3. Urinary stasis
4. Diarrhea
5. Decreased respiratory movement
Correct Answer: 1,3,5
Rationale 1: Without the stress of weight-bearing activity, bones demineralize.
Rationale 2: Without the stress of weight-bearing activity, bones demineralize.
Rationale 3: Without the stress of weight-bearing activity, bones demineralize.
Rationale 4: Without the stress of weight-bearing activity, bones demineralize.
Rationale 5: Without the stress of weight-bearing activity, bones demineralize.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 58
Type: MCMA
The nurse is admitting a client to a rehabilitation facility after surgery for a hip replacement. The nurse observes
the client appearing depressed. The client denies depression, but states that she is concerned about returning to her
regular activities, including walking for exercise, because she is so tired. The nurse understands that:
Standard Text: Select all that apply.
1. This client has unrealistic goals.
2. Stress might be affecting this clients mobility.
3. Walking will tire the client.
4. The client is at increased risk of disease due to immobility.
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5. This client is at risk for affective disorder.


Correct Answer: 2,4,5
Rationale 1: The clients goals are not unrealistic over time.
Rationale 2: Stress and pain deplete the bodys energy reserves, producing fatigue.
Rationale 3: Movement energizes the client and facilitates coping.
Rationale 4: A history of inactivity because of injury increases the risk of major disease; early ambulation after
surgery is an essential preventive measure.
Rationale 5: People who are unable to carry out usual activities related to their roles can become dependent on
others; loss of independence damages self-esteem, and in turn can provoke an exaggerated emotional response.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 59
Type: MCSA
The client who has been hospitalized for a fractured femur expresses surprise that she is so tired after sitting up in
the chair for a short period of time. The nurse explains that:
1. Decreased mobility creates venous vasodilation and stasis.
2. Decreased mobility can interfere with the normal exchange of oxygen and carbon dioxide.
3. Decreased mobility can cause a negative calcium balance as a result of calcium loss from bone.
4. Decreased mobility causes decreases in muscular strength.
Correct Answer: 4
Rationale 1: Immobility causes venous vasodilation and stasis, but this would not account for the clients fatigue.
Rationale 2: Prolonged immobility can inhibit the force of the cough, resulting in pooling of respiratory
secretions; the client is not complaining of a cough or shortness of breath.
Rationale 3: Prolonged immobility can cause disuse osteoporosis resulting from the loss of calcium from the
bones; this clients condition does not indicate long-term immobility.
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Rationale 4: Disuse atrophy is caused by muscles not being used; clients can be fatigued more quickly after only
a short illness or injury.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 60
Type: MCMA
In addition to the musculoskeletal effects of immobility, the nurse explains that the cardiovascular system
undergoes other changes during prolonged bedrest, such as:
Standard Text: Select all that apply.
1. Venous stasis.
2. Tachycardia.
3. Emboli.
4. Atelectasis.
5. Anorexia.
Correct Answer: 1,2,3
Rationale 1: Venous stasis and vasodilation occur due to the inability of atrophied muscles to assist in pumping
blood back to the heart.
Rationale 2: Decreased mobility creates an imbalance in the autonomic nervous system, resulting in an increased
heart rate.
Rationale 3: Venous stasis and vasodilation predispose clients to thrombus formation; thrombophlebitis can result
in an embolus, which can lodge in vessels supplying vital organs.
Rationale 4: Atelectasis is a potential respiratory system change.
Rationale 5: Anorexia is a potential result of decreased metabolic rate and increased catabolism; it is an effect of
immobility on the metabolic system.
Global Rationale:
Cognitive Level: Understanding
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Client Need: Physiological Integrity


Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 61
Type: MCMA
The nurse is turning a client from her back to her side. To promote safety and the clients proper body alignment,
the nurse:
Standard Text: Select all that apply.
1. Ensures the bed is clean and dry.
2. Places support devices in specified areas.
3. Places body parts on top of each other to ensure alignment.
4. Plans a 24 hour schedule for position changes.
5. Ensures the mattress is soft.
Correct Answer: 1,2,4
Rationale 1: Wrinkled or damp sheets increase the risk of pressure ulcer formation.
Rationale 2: Support devices, such as pillows and foot boards, should be used to maintain alignment and prevent
stress on muscles and joints.
Rationale 3: Avoid placing one body part directly on top of another body part; excessive pressure can damage
veins and predispose the client to thrombus formation.
Rationale 4: Plan a continuous, 24-hour schedule for position changes.
Rationale 5: The mattress should be firm and level, and yield enough to fill in and support natural body
curvatures.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 62
Type: MCSA
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A client has a nursing diagnosis of Activity Intolerance. An appropriate goal for this client would be:
1. Avoid complications associated with immobility.
2. Avoid injury from improper use of body mechanics.
3. Increase tolerance for physical activity.
4. Ambulate the client with a walker twice a day.
Correct Answer: 3
Rationale 1: This goal might not be appropriate for this client; the information does not support a nursing
diagnosis of Impaired Physical Mobility.
Rationale 2: This goal is not immediately supported by the nursing diagnosis given.
Rationale 3: This is an appropriate goal for this client; appropriate interventions will vary.
Rationale 4: This is an appropriate intervention for this client; it is not a goal.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome:
Question 63
Type: SEQ
As the nurse makes night rounds on sleeping clients, several clients are noted to be breathing very slowly. Stages
of NREM sleep account for some decreased physiological functions. Identify the stage that correlates to the
choice given:
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Lasts only a few minutes.
Choice 2. Light sleep; body continues to slow down.
Choice 3. Sleeper difficult to arouse
Choice 4. Heart and respiratory rates 2030% below waking rates
Correct Answer: 1,2,3,4
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Rationale 1: Stage I NREM sleep is very light sleep that lasts only a few minutes; the person feels drowsy and
relaxed.
Rationale 2: Stage I NREM sleep is very light sleep that lasts only a few minutes; the person feels drowsy and
relaxed.
Rationale 3: Stage I NREM sleep is very light sleep that lasts only a few minutes; the person feels drowsy and
relaxed.
Rationale 4: Stage I NREM sleep is very light sleep that lasts only a few minutes; the person feels drowsy and
relaxed.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 64
Type: MCMA
The client is postoperative day three from abdominal surgery. He states that he hasnt slept more than an hour or
so at a time due to the pain, but does not want to take medication to assist with sleeping. The nurse describes the
functions of sleep as:
Standard Text: Select all that apply.
1. Necessary for protein synthesis.
2. Restores normal levels of activity.
3. Restores balance within the nervous system.
4. Necessary for fat metabolism.
5. Sympathetic nervous system activity.
Correct Answer: 1,2,3
Rationale 1: Sleep is necessary for protein synthesis and cellular repair.
Rationale 2: Sleep exerts physiological effects on body systems and restores normal levels of activity.
Rationale 3: Sleep restores balance within the nervous system.
Rationale 4: Sleep is not necessary for fat metabolism.
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Rationale 5: The sympathetic nervous system is more active while the person is awake.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 65
Type: MCSA
The nurse is describing the difference between the quality and quantity of sleep. Sleep quality refers to:
1. The total time an individual sleeps.
2. An individuals ability to stay asleep.
3. The sleepwake cycle that changes through the life span.
4. How long it takes a person to get to sleep.
Correct Answer: 2
Rationale 1: The total time the individual sleeps is the quantity of sleep.
Rationale 2: Sleep quality refers to an individuals ability to stay asleep and to get appropriate amounts of REM
and NREM sleep.
Rationale 3: Sleepwake cycles are part of the biologic rhythm that involves physiological and psychological
activity and rest.
Rationale 4: How long it takes a person to get to sleep is described as stage 1 NREM sleep.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 66
Type: MCMA
The parents of a 9-year-old are concerned about their child sleeping 11 hours at night. The nurse explains that agerelated sleep habits include:
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Standard Text: Select all that apply.


1. School-age children need 912 hours of sleep at night.
2. Infants and seniors often wake at night.
3. Infants and adults often wake at night.
4. Adolescents tend to get enough sleep.
5. Infants will sleep through the night at 4 months of age.
Correct Answer: 1,2
Rationale 1: School-age children need 912 hours of sleep at night; children often become sleep-deprived at this
age.
Rationale 2: Infants wake up at least once a night until 9 months of age; seniors can have nighttime sleeping
interfered with by napping, lack of exercise, or medication side effects.
Rationale 3: Most infants wake up at least once a night until 9 months of age. Adults should have a minimum of 7
hours nightly; unless adults are having troubled sleep, the norm is to sleep through the night.
Rationale 4: Adolescents should have 9.5 hours of sleep from ages 13 to 15 years; most teens get too little sleep,
usually 7.5 hours or less.
Rationale 5: Infants will sleep 68 hours at night by 4 months of age, but most still wake up at least once a night
until 9 months of age.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 67
Type: MCMA
The nurse is taking a sleep history on a client who states that he has difficulty getting to sleep. Which of the
following factors might be causing delayed onset of sleep?
Standard Text: Select all that apply.
1. Hyperthyroidism
2. Hypothyroidism
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3. Early morning exercise


4. Smoking
5. Demerol
Correct Answer: 1,4
Rationale 1:
Rationale 2:
Rationale 3:
Rationale 4:
Rationale 5:
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 68
Type: MCMA
As the nurse obtains a general sleep history from a newly admitted client, the client reports several parasomnias,
including:
Standard Text: Select all that apply.
1. Somnambulism.
2. Bruxism.
3. Narcolepsy.
4. Sleep apnea.
5. Sleep deprivation.
Correct Answer: 1,2
Rationale 1: Somnambulism is sleepwalking, which is a behavior that interferes with sleep.
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Rationale 2: Somnambulism is sleepwalking, which is a behavior that interferes with sleep.


Rationale 3: Somnambulism is sleepwalking, which is a behavior that interferes with sleep.
Rationale 4: Somnambulism is sleepwalking, which is a behavior that interferes with sleep.
Rationale 5: Somnambulism is sleepwalking, which is a behavior that interferes with sleep.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 69
Type: MCSA
The nurse is explaining sleep deprivation to a client whose sleep history is suggestive of deprivation. Clinical
signs of NREM deprivation include:
1. Emotional lability.
2. Difficulty getting dressed.
3. Impaired judgment.
4. Withdrawal.
Correct Answer: 4
Rationale 1: Emotional lability is a common clinical sign of REM deprivation.
Rationale 2: Emotional lability is a common clinical sign of REM deprivation.
Rationale 3: Emotional lability is a common clinical sign of REM deprivation.
Rationale 4: Emotional lability is a common clinical sign of REM deprivation.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
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Question 70
Type: MCMA
The nurse is preparing the care plan for a client with difficulty falling asleep. Appropriate interventions to reduce
environmental distractions in hospitals include:
Standard Text: Select all that apply.
1. Taking vital signs early in the evening.
2. Closing the door of the clients room.
3. Positioning dependent clients appropriately.
4. Making nursing rounds in the hallway.
5. Assisting client with voiding before bedtime.
Correct Answer: 1,2
Rationale 1: Performing only essential nursing tasks during sleeping hours will decrease environmental
distractions.
Rationale 2: Performing only essential nursing tasks during sleeping hours will decrease environmental
distractions.
Rationale 3: Performing only essential nursing tasks during sleeping hours will decrease environmental
distractions.
Rationale 4: Performing only essential nursing tasks during sleeping hours will decrease environmental
distractions.
Rationale 5: Performing only essential nursing tasks during sleeping hours will decrease environmental
distractions.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 71
Type: MCMA
A client is admitted to the Emergency Department as a result of a minor motor vehicle accident caused by his
falling asleep at the wheel. Information that is appropriate for the nurse to include in the teaching plan for this
client includes:
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Standard Text: Select all that apply.


1. Exercise every day whenever it fits in the schedule.
2. Naps are acceptable, if short.
3. Block out extra noise if possible with a television on in the background.
4. Heavy snacks before bedtime can disturb sleep.
5. Establish a regular bedtime ritual.
Correct Answer: 2,4,5
Rationale 1: Daily exercise is important, but avoid excessive physical exertion less than 2 hours before bedtime.
Rationale 2: Daily exercise is important, but avoid excessive physical exertion less than 2 hours before bedtime.
Rationale 3: Daily exercise is important, but avoid excessive physical exertion less than 2 hours before bedtime.
Rationale 4: Daily exercise is important, but avoid excessive physical exertion less than 2 hours before bedtime.
Rationale 5: Daily exercise is important, but avoid excessive physical exertion less than 2 hours before bedtime.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 72
Type: MCMA
The nursing care plan for the client with insomnia includes several nonpharmacologic interventions, such as:
Standard Text: Select all that apply.
1. A brisk walk around the facility.
2. A small drink of brandy.
3. A small glass of milk.
4. Taking a warm bath.
5. Using the computer in bed until sleepy.
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Correct Answer: 3,4


Rationale 1: When unable to sleep, a relaxing,
Rationale 2: When unable to sleep, a relaxing,
Rationale 3: When unable to sleep, a relaxing,
Rationale 4: When unable to sleep, a relaxing,
Rationale 5: When unable to sleep, a relaxing,
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 73
Type: MCMA
The nurse is caring for a client in the intensive care unit. This client is at risk for sensory overload, which can
manifest in the following manner:
Standard Text: Select all that apply.
1. Decreased attention span
2. Irritability
3. Scattered attention
4. Hallucinations
5. Emotional lability
Correct Answer: 2,3
Rationale 1: Decreased attention span is a common manifestation of sensory deprivation.
Rationale 2: Irritability, anxiety, and restlessness are common manifestations of sensory overload.
Rationale 3: Scattered attention and racing thoughts are common manifestations of sensory overload.
Rationale 4: Hallucinations or delusions are common manifestations of sensory deprivation.
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Rationale 5: Emotional lability is a common manifestation of sensory deprivation.


Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 74
Type: MCSA
The nurse is assessing a clients sensory reception and perception. The client has a history of a motor vehicle
accident several years ago that resulted in a spinal cord injury. This client is at risk for altered sensory reception of
which type of stimuli?
1. Visual
2. Auditory
3. Gustatory
4. Visceral
Correct Answer: 4
Rationale 1: Based on the information given, this client is not at risk for altered reception or perception of visual
stimuli.
Rationale 2: Based on the information given, this client is not at additional risk for altered reception or perception
of auditory stimuli.
Rationale 3: Based on the information given, the client is not at additional risk for altered reception or perception
of gustatory (taste) stimuli.
Rationale 4: This client could have a decreased awareness of visceral stimuli, such as a full stomach or need to
empty the bladder based on the altered impulse conduction due to the spinal cord injury.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 75
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Type: MCMA
The nurse is caring for a group of clients in a long-term care facility. Which of the following clients are at risk for
sensory deprivation?
Standard Text: Select all that apply.
1. The alert and oriented client who has no family in the area
2. The confused client who has no family in the area
3. The alert and oriented client who has several children, grandchildren, and great-grandchildren who are all
involved in the clients care
4. The alert and oriented client who is unable to move independently
5. The confused client whose hearing aids work intermittently
Correct Answer: 1,2,4,5
Rationale 1: The alert and oriented client in a long-term care facility with no family is at risk due to the potential
lack of people to visit and talk with the client regularly.
Rationale 2: The confused client is at risk due to an altered perception of stimulation; without regular visitors
who the client recognizes, this could increase confusion.
Rationale 3: The alert and oriented client with many potential visitors is at risk for sensory overload due to too
many visitors.
Rationale 4: The alert and oriented client who is unable to move independently is at risk for sensory deprivation
due to the inability to move to reach eyeglasses, reading material, etc., independently.
Rationale 5: The confused client without functioning hearing aids is at risk for continued altered sensory
reception.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 76
Type: MCMA
The nurse identifies the client at risk for sensory overload based on several factors, including:
Standard Text: Select all that apply.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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1. In-patient hospitalization.
2. Extreme shortness of breath.
3. Signs of depression.
4. Increased anxiety over a new diagnosis.
5. Lost hearing aids.
Correct Answer: 1,2,4
Rationale 1: This client is at risk for sensory overload due to being admitted to a noisy healthcare setting.
Rationale 2: The client with shortness of breath has increased stimulation, both physically and emotionally
(anxiety).
Rationale 3: The client with signs of depression is likely to withdraw or block out external stimuli.
Rationale 4: A client with increased internal stimuli, such as anxiety or pain, is at risk for sensory overload.
Rationale 5: The client who has lost his hearing aids is at risk for sensory deprivation.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 77
Type: MCMA
The client with impaired vision is at risk of sensory overload and sensory deprivation. The nurse identifies the
following aids for this client to help the client deal with the deficit:
Standard Text: Select all that apply.
1. Window shades
2. Flashing alarm clocks
3. Sign language instruction
4. Color-coding on stoves
5. Large writing on name tags
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Correct Answer: 1,4,5


Rationale 1: Window shades are important to reduce glare.
Rationale 2: Flashing alarm clocks are helpful for people with hearing deficits.
Rationale 3: Sign language instruction is helpful for people with hearing deficits.
Rationale 4: Color-coding on stove controls is helpful for people with visual deficits.
Rationale 5: Large writing on name tags of healthcare providers will be helpful for all clients, including people
with visual deficits.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 78
Type: MCSA
The nurse identifies several factors that might contribute to sensory overload in a hospitalized school-age child,
including:
1. Narcotic medications.
2. Being one of several children in a family.
3. Diagnosis of chickenpox.
4. Having intravenous lines inserted.
Correct Answer: 4
Rationale 1: Narcotics and sedatives can decrease the awareness of stimuli.
Rationale 2: Being an only child would put the child at risk for sensory overload.
Rationale 3: Having a diagnosis of chickenpox (a communicable disease) puts the child at risk of sensory
deprivation due to infection control procedures.
Rationale 4: Intravenous lines and other intrusive tubes can contribute to sensory overload.
Global Rationale:
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Cognitive Level: Applying


Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 79
Type: MCMA
As the nurse is collecting data for a newly admitted client, it becomes clear that the client is confused. The nurse
notes interventions appropriate for promoting orientation, such as:
Standard Text: Select all that apply.
1. Address the client by name.
2. Assign a variety of caregivers.
3. Speak quickly so the client does not have time to argue.
4. Tell the client when you are leaving and when you will return.
5. Encourage the client to wear familiar clothing.
Correct Answer: 1,4,5
Rationale 1: Addressing the client by name assists in keeping the client oriented to person.
Rationale 2: Addressing the client by name assists in keeping the client oriented to person.
Rationale 3: Addressing the client by name assists in keeping the client oriented to person.
Rationale 4: Addressing the client by name assists in keeping the client oriented to person.
Rationale 5: Addressing the client by name assists in keeping the client oriented to person.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 80
Type: MCMA
Nursing interventions that are appropriate for the client who has lost her vision include:
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Standard Text: Select all that apply.


1. Use of a radio or audiotapes.
2. Ordering a bland diet.
3. Offering a massage.
4. Placing silk flowers in the clients room.
5. Using therapeutic pet therapy.
Correct Answer: 1,3,5
Rationale 1: Auditory stimulation can supplement sensory input for the client with a visual impairment.
Rationale 2: Diets that include a variety of flavors and textures can stimulate the taste buds.
Rationale 3: Massages can be used to stimulate touch receptors.
Rationale 4: Fresh flowers can stimulate the sense of smell.
Rationale 5: Pet therapy can be used to stimulate touch receptors.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 81
Type: MCMA
The nurse is discussing strategies for preventing sensory impairments with the parents of a newborn. Strategies to
protect hearing include:
Standard Text: Select all that apply.
1. Obtain regular immunizations.
2. Seek medical attention for reduced eye contact.
3. Keep auditory stimulation to a minimum.
4. Have the child wear ear protection in noisy environments.
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5. Have regular health examinations.


Correct Answer: 1,4,5
Rationale 1: Immunizations against diseases that can cause hearing loss are important preventive measures.
Rationale 2: Decreased eye contact from an infant is more indicative of a visual problem.
Rationale 3: Auditory stimulation is important for normal growth and development.
Rationale 4: Children should wear ear protection in loud environments.
Rationale 5: Regular health examinations allow for screening by healthcare providers.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:
Question 82
Type: MCSA
The nurse is caring for a client with an impaired visual field. Appropriate communication strategies with this
client include:
1. Convey your presence by moving to a position where you can be seen.
2. Decrease background noises before speaking.
3. Use longer phrases.
4. Pronounce every name with care.
Correct Answer: 1
Rationale 1: Convey your presence by moving to a position within the clients visual field.
Rationale 2: Decreasing background noises is more appropriate for the client with a hearing deficit.
Rationale 3: Longer phrases are more easily understood by the client with a hearing deficit.
Rationale 4: Pronouncing every name carefully is a strategy that is useful for the client who has a hearing
deficitCognitive Level: Applying
Global Rationale:
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Cognitive Level: Pronouncing every name carefully is a strategy that is useful for the client who has a hearing
deficitCognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
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