A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate?
contacting the primary health care provider
placing a small towel under the neck
administering a muscle relaxer
positioning the client on the stomach...
NUR 310 EXAM 4 || Already Passed.
A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which
nursing intervention is most appropriate?
contacting the primary health care provider
placing a small towel under the neck
administering a muscle relaxer
positioning the client on the stomach correct answers placing a small towel under the neck
Explanation:
Kyphotic changes can cause pressure on cervical vertebrae when someone is in a supine position.
Effects of this can be minimized by placing a small towel or cervical pillow under the neck.
Placing the client on the stomach is incorrect, and a muscle relaxer will not help reduce the
pressure caused by the kyphosis. Contacting the health care provider is unnecessary.
The nurse is caring for a client with rectal bleeding. The nurse will place the client into which
position to facilitate rectal examination?
supine
prone
Sims'
Fowler's correct answers Sim's
Explanation:
Sims' position, a semi-prone position, can be used for certain examinations of the rectum and
vagina. The other positions do not allow adequate examination of this area.
The nurse is encouraging the client to use hand rolls to prevent contractures. Which statement by
the client indicates that further teaching is necessary?
"The hand rolls help keep my thumb positioned away from my hand."
"The hand rolls help me develop strength in my grip."
"I can use a rolled-up washcloth if I don't have a hand roll."
"I need to remove the hand roll often to exercise my hand muscles." correct answers "The hand
rolls help me develop strength in my grip."
,Explanation:
Hand rolls prevent contractures (permanently shortened muscles that resist stretching) of the
fingers. They keep the thumb positioned slightly away from the hand and at a moderate angle to
the fingers. The fingers are kept in a slightly neutral position rather than a tight fist. A rolled-up
washcloth or a ball can be used as an alternative to commercial hand rolls. Hand rolls are
removed regularly to facilitate movement and exercise. Hand rolls are not used to strengthen the
grip.
The client is contracting their leg muscles as part of rehabilitation. When the muscles contract,
which element is released into the client's sarcoplasmic reticulum?
Potassium
Calcium
Sodium
Chloride correct answers Calcium
Explanation:
The transmitting activity occurs when calcium is released into the sarcoplasmic reticulum (site of
storage and release for calcium in the muscle), which initiates a complex series of biochemical
events that result in muscle contraction.
The nurse is performing a physical assessment on an adolescent. What assessment priorities are
needed for this age group?
kyphosis
shifted center of gravity
increased need for calcium and vitamin D
scoliosis correct answers scoliosis
Explanation:
Numerous factors, including growth and development, influence a person's posture, movement,
and daily activity level. The adolescent should be assessed for scoliosis (curvature of the spine).
Kyphosis is increased convexity in the thoracic spine from disk shrinkage and decreased height,
common in older adults. A shifted center of gravity occurs during pregnancy (in the adult)
because of the developing fetus. Older adults have an increased need for calcium and vitamin D
related to the risk for osteoporosis.
The nurse is working to increase functional ability of a client who is bedbound. Which assistive
technique should the nurse prioritize in the plan of care?
, trapeze bar
log rolling
pull sheets
trochanter rolls correct answers trapeze bar
Explanation:
Promoting client independence with movement and activity is an important intervention for
clients who are bedbound, especially ones with musculoskeletal problems. Unlike log rolling,
trochanter rolls, and pull sheets, which are nurse-initiated methods, the overhead trapeze is used
by the client.
The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the
client has impaired muscle coordination. The nurse documents the presence of what health
problem?
Ataxia
Tremors
Chorea
Athetosis correct answers Ataxia
Explanation:
Ataxia refers to a lack of muscle coordination. Tremors are rhythmic, repetitive movements.
Chorea is spontaneous, brief, involuntary muscle twitching of the limbs or facial muscles.
Athetosis refers to movement characterized by slow, irregular, twisting motions.
A client expresses concern that there is an increase in urine output after exercising. How would
the nurse address the client's concern? Select all that apply.
Explain that urination after exercise is a result of increased circulation to the kidneys and is a
normal function
Assess cardiovascular function and blood pressure
Ask the client to provide details of the exercise regimen including frequency and type
Perform a 24-hour input and output assessment
Evaluate for diabetes mellitus correct answers EXEPT : Perform a 24-hour input and output
assessment
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