1. The nurse is caring for an elderly woman who has had a fractured hip repaired.

In the first few days following the surgical repair, which of the following nursing
measures will best facilitate the resumption of activities for this client?

A. arranging for the wheelchair

B. asking her family to visit
C. assisting her to sit out of bed in a chair qid
D. encouraging the use of an overhead trapeze

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

A. measure intake and output.

B. check albumin level.
C. monitor glucose levels.
D. increase enteral feeding.

3. The pathological process causing esophageal varices is:

A. ascites and edema.

B. systemic hypertension.
C. portal hypertension.
D. dilated veins and varicosities.

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

A. Elevate the head of the bed on 4-6 inch blocks.

B. Lie down after eating.
C. Increase fluid intake just before bedtime.
D. Wear a girdle.
5. What is the main benefit of therapeutic massages is:

A. to help a person with swollen legs to decrease the fluid retention.

B. to help a person with duodenal ulcers feel better.
C. to help damaged tissue in a diabetic to heal.
D. to improve circulation and muscles tone.

6. Which of the following foods should be avoided by clients who are proneto
develop heartburn as a result of gastroesophageal reflux disease (GERD)?

A. Lettuce
B. Eggs
C. Chocolate
D. Butterscotch

7. Which of the following should be included in a plan of care for a client

receiving total parenteral nutrition (TPN)?

A. Withhold medications while the TPN is infusing.

B. Change TPN solution every 24 hours.
C. Flush the TPN line with water prior to initiating nutritional support.
D. Keep client on complete bed rest during TPN therapy.

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

A. Remove all dairy products from the diet.

B. Frozen yogurt can be included in the diet.
C. Drink small amounts of milk on an empty stomach.
D. Spread out selection of dairy products throughout the day.

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

A. stay the same.
B. be lowered.
C. be increased.
D. no effect on pain tolerance.

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

A. costs less.
B. restricts movement and decreases.
C. gives client control over pain syndrome.
D. allows the family to care for the patient at home.

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

A. exercise doing weight bearing activities

B. exercise to reduce weight
C. avoid exercise activities that increase the risk of fracture
D. exercise to strengthen muscles and thereby protect bones

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

A. have the client identify coping methods

B. get the description of the location and intensity of the pain
C. accept the client’s report of pain
D. determine the client’s status of pain

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

A. Immobility prevents the progression of language and fine motor development

B. Immobility in children has similar physical effects to those found in adults
C. Children are more susceptible to the effects of immobility than are adults
D. Children are likely to have prolonged immobility with subsequent complications

14. After a myocardial infarction, a client is placed on a sodium restricted diet.

When the nurse is teaching the client about the diet, which meal planwould be the
most appropriate to suggest?

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

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

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

B. An obese client who uses a wheelchair
C. An incontinent client who has had 3 diarrhea stools
D. An 80 year-old ambulatory diabetic client

16. Mrs. Kennedy had a CVA (cerebrovascular accident) and has severe right-sided
weakness. She has been taught to walk with a cane. The nurse is evaluating her use
of the cane prior to discharge. Which of the following reflects correct use of the
cane?

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

17. The nurse is instructing a woman in a low-fat, high-fiber diet. Which of the
following food choices, if selected by the client, indicate an understanding of a low-
fat, high-fiber diet?

A. Tuna salad sandwich on whole wheat bread.

B. Vegetable soup made with vegetable stock, carrots, celery, and legumes served with
toasted oat bread
C. Chef’s salad with hard boiled eggs and fat-free dressing
D. Broiled chicken stuffed with chopped apples and walnuts

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

A. Stiffness of the right ankle joint

B. Soreness of the gums
C. Short-term memory loss.
D. Decreased appetite.

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

A. Normal dietary intake.

B. Relevant socio cultural, economic, and educational background of the family.
C. Any evidence of blood in the stools
D. A history of maternal anemia during pregnancy
20. A 46-year-old female with chronic constipation is assessed by the nurse for a
bowel training regimen. Which factor indicates further information is needed by the
nurse?

A. The client’s dietary habits include foods high in bulk.

B. The client’s fluid intake is between 2500-3000 ml per day
C. The client engages in moderate exercise each day
D. The client’s bowel habits were not discussed.

Answers and Rationale

1. Answer: D. encouraging the use of an overhead trapeze

Exercise is important to keep the joints and muscles functioning and to prevent secondary
complications. Using the overhead trapeze prevents hazards of immobility by permitting
movement in bed and strengthening of the upper extremities in preparation for
ambulation. Sitting in a wheelchair would require too great hip flexion initially. Asking
her family to visit would not facilitate the resumption of activities. Sitting in a chair
would cause too much hip flexion. The client initially needs to be in a low Fowler’s
position or taking a few steps (as ordered) with the aid of a walker.

2. Answer: A. measure intake and output

It is important to measure intake and output, which should equal. Enteral feeding are
hyperosmotic agents pulling fluid from cells into vascular bed. Water given before
feeding will present a hyperosmotic diuresis. I and O measures assess fluid balance.

3. Answer: C. portal hypertension

Esophageal varices results from increased portal hypertension. In portal hypertension, the
liver cannot accept all of the fluid from the portal vein. The excess fluid will back flow to
the vessels with lesser pressure, such as esophageal veins or rectal veins causing
esophageal varices or hemorrhoids.

4. Answer: A. Elevate the head of the bed on 4-6 inch blocks

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

5. Answer: D. to improve circulation and muscles tone

Particularly in the elderly adults, therapeutic massage will help improve circulation
and muscle tone as well as the personal attention and social interaction that a good
massage provides. A massage is contraindicated in any condition where massage to
damaged tissue can dislodge a blood clot.

6. Answer: C. Chocolate

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

7. Answer: B. Change TPN solution every 24 hours

TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth
due to hypertonicity of the solution. Option 1 is incorrect; medicationtherapy can
continue during TPN therapy. Option 3 is incorrect; flushing is not required because the
initiation of TPN does not require a client to remain on bed rest during therapy. However,
other clinical conditions of the client may affect mobility issues and warrant the client’s
being on bed rest.

8. Answer: B. Frozen yogurt can be included in the diet

Clients who are lactose intolerant can digest frozen yogurt. Yogurt products are formed
by bacterial action, and this action assists in the digestion of lactose. The freezing process
further stops bacterial action so that limited lactase activity remains. Option 1 is
incorrect; elimination of all dairy products can lead to significant clinical deficiencies of
other nutrients. Option 3 is incorrect because drinking milk on an empty stomach can
exacerbate clinical symptoms. Drinking milk with a meal may benefit the client because
other foods, (especially fat) may decrease transit time and allow for increased lactase
activity. Option 4 is incorrect because although individual tolerance should be
acknowledged, spreading out the use of known dairy products will usually exacerbate
clinical symptoms.

9. Answer: B. be lowered

There is potential for a lowered pain tolerance to exist with diminished adaptative
capacity.

10. Answer: C. gives client control over pain syndrome.

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

11. Answer: A. exercise doing weight bearing activities

Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of
bone cannot be substantially reversed, further loss can be greatly reduced if the client
includes weight bearing exercises along with estrogen replacement and calcium
supplements in their treatment protocol.

12. Answer: C. accept the client’s report of pain

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

13. Answer: B. Immobility in children has similar physical effects to those found in
adults

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

14. Answer: D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk,
and 1 orange

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

15. Answer: A. A 79 year-old malnourished client on bed rest

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

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

When a person with weakness on one side uses a cane, there should always be two points
of contact with the floor. When Mrs. Kennedy. moves the cane forward, she has both feet
on the floor, providing stability. As she moves the weak leg, the cane and the strong leg
provide support. Finally, the cane, which is even with the weak leg, provides stability
while she moves the strong leg. She should not hold the cane with her weak arm. The use
of the cane requires arm strength to ensure that the cane provides adequate stability when
standing on the weak leg. The cane should be held in the left hand, the hand opposite the
affected leg. If Mrs. Kennedy. moved the cane and her strong foot at the same time, she
would be left standing on her weak leg at one point. This would be unstable at best; at
worst, impossible

17. Answer: B. Vegetable soup made with vegetable stock, carrots, celery, and
legumes served with toasted oat bread

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

18. Answer: A. Stiffness of the right ankle joint

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

19. Answer: A. Normal dietary intake.

Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For the first
4 to 5 months of infancy iron stores laid down for the baby during pregnancy are
adequate. When fetal iron stores are depleted, supplemental dietary iron needs to be
supplied to meet the infant’s rapid growth needs. Iron deficiency may occur in the infant
who drinks mostly milk, which contains no iron, and does not receive adequate dietary
iron or supplemental iron. Daily dietary intake is much more related to the diagnosis of
iron deficiency anemia than is sociocultural, economic, and educational background of
the family. Iron deficiency anemia in an infant is very unlikely to be related to
gastrointestinal bleeding. Anemia during pregnancy is unlikely to be the cause of the
infant’s iron deficiency anemia. Fetal iron stores are drawn from the mother even if she is
anemic.

20. Answer: D. The client’s bowel habits were not discussed.

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