Chapter 37: Activity and Exercise Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

MULTIPLE CHOICE

1. A client has been prescribed bed rest for a prolonged time. To specifically promote the use of resistive isometric exercise for the client, the nurse will initiate:

1.

Quadriceps setting

2.

Gluteal muscle contraction

3.

Moving the arms and legs in circles

4.

Pushing against a footboard

ANS: 4

Resistive isometric exercises are those in which the individual contracts the muscle while pushing against a stationary object or resisting the movement of an object. An example of a resistive isometric exercise is pushing against a footboard. Quadriceps setting is an example of an isometric exercise. Gluteal muscle contraction is an example of an isometric exercise. Moving the arms and legs in a circle is an example of isotonic exercise.

DIF: A REF: 788 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

2. The nurse is assessing the body alignment of an alert and mobile client. The first action that the nurse should take is to:

1.

Observe gait

2.

Put the client at ease

3.

Determine activity tolerance

4.

Determine range of joint motion

ANS: 2

The first step in assessing body alignment is to put the client at ease so unnatural or rigid positions are not assumed. When assessing body alignment, the first action of the nurse is to put the client at ease. Later, the nurse may assess the clients gait to observe the clients balance, posture, and ability to walk without assistance. Activity tolerance is the kind and amount of exercise or activity a person is able to perform. It is not the first step in assessing a clients body alignment. Assessing ROM is one of the first assessment techniques used to determine the degree of damage or injury to a joint. It is not the first step in assessing a clients body alignment.

DIF: A REF: 787 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

3. An average-size male client has right-sided hemiparesis. The nurse helps this client to walk by:

1.

Standing at his left side and holding his arm

2.

Standing at his left side and holding one arm around his waist

3.

Standing at his right side and holding his arm

4.

Standing at his right side and holding one arm around his waist

ANS: 4

The nurse provides support at the waist so the clients center of gravity remains midline. The nurse should be on the clients weaker side to assist him with ambulation. The nurse should hold onto the clients waist, not his arm, and should be on his weaker side, not his strong side. The nurse should be on the clients weaker side. The nurse should hold onto the clients waist to help steady him in maintaining his center of gravity midline so that he does not lose his balance and fall.

DIF: A REF: 794 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

4. The nurse is working with a client who has left-sided weakness. After instruction, the nurse observes the client ambulate in order to evaluate the use of the cane. Which action indicates that the client knows how to use the cane properly?

1.

The client keeps the cane on the left side.

2.

Two points of support are kept on the floor at all times.

3.

There is a slight lean to the right when the client is walking.

4.

After advancing the cane, the client moves the right leg forward.

ANS: 2

Two points of support, such as both feet or one foot and the cane, should be on the floor at all times. The cane should be kept on the stronger side, the clients right side. The client should keep his or her body upright and midline. Leaning can cause the client to lose his or her balance and fall. After advancing the cane, the client should move the weaker leg, the clients left leg, forward to the cane.

DIF: A REF: 803 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

5. A client with a fractured left femur has been using crutches for the past 4 weeks. The physician tells the client to begin putting a little weight on the left foot when walking. Which of the following gaits should the client be taught to use?

1.

Two-point

2.

Three-point

3.

Four-point

4.

Swing-through

ANS: 1

The two-point gait requires at least partial weight bearing on each foot. The client moves a crutch at the same time as the opposing leg, so that the crutch movements are similar to arm motion during normal walking. In a three-point gait, weight is borne on both crutches and then on the uninvolved leg. The four-point gait gives stability to the client but requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. This client is only supposed to use partial weight bearing, so this gait would not be appropriate. Paraplegics who wear weight-supporting braces on their legs use the swing-through gait. It would not be appropriate for this client.

DIF: A REF: 805 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

6. The client needs to use crutches at home, and will have to manage going up and down a short flight of stairs. The nurse evaluates the use of an appropriate technique if the client:

1.

Uses a banister or wall for support when descending

2.

Uses one crutch for support while going up and down

3.

Advances the crutches first to ascend the stairs

4.

Advances the affected leg after moving the crutches to descend the stairs

ANS: 4

To descend stairs, the crutches are placed on the stairs and the client moves the affected leg, then the unaffected leg to the stairs with the crutches. The client should continue to use the crutches for support, not the banister or wall. The client should continue to use both crutches for support when going up or down stairs. When ascending stairs, the client moves the unaffected leg up the stair, then the crutches and affected leg.

DIF: A REF: 805 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

7. While ambulating in the hallway of a hospital, the client complains of extreme dizziness. The nurse, alert to a syncopal episode, should first:

1.

Support the client and walk quickly back to the room

2.

Lean the client against the wall until the episode passes

3.

Lower the client gently to the floor

4.

Go for help

ANS: 3

If the client has a syncopal episode or begins to fall, the nurse should assume a wide base of support with one foot in front of the other, supporting the clients weight, and then extend the leg, allowing the client to slide against the leg while gently lowering the client to the floor and protecting the clients head. The nurse should not attempt to walk the client quickly back to the room. The nurse should not lean the client against a wall as the client may fall. The nurse should not leave the client alone and go for help.

DIF: A REF: 802 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

8. A client is admitted to the medical unit following a CVA (stroke). There is evidence of left-sided hemiparesis and the nurse will be following up on range-of-motion and other exercises performed in physical therapy. The nurse correctly teaches the client and family members which one of the following principles of range-of-motion exercises?

1.

Flex the joint to the point of discomfort.

2.

Work from proximal to distal joints.

3.

Move the joints quickly.

4.

Provide support for distal joints.

ANS: 1

Flexing the knees and keeping the feet wide apart provide a broad base of support and increase stability. The nurse should position himself or herself close to the client or object being lifted to minimize the force (10 pounds held at waist height close to the body is equal to 100 pounds held at arms length). Having the client or object close to the center of gravity also helps maintain balance. Twisting should be avoided because it increases the risk of back injury. The leg muscles should be used for lifting or moving. They are stronger, larger muscles capable of greater work without injury.

DIF: A REF: 794 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

9. Nurses need to implement appropriate body mechanics in order to prevent injury to themselves and their clients. Which principle of body mechanics should the nurse incorporate into client care?

1.

Flex the knees and keep the feet wide apart.

2.

Assume a position far enough away from the client.

3.

Twist the body in the direction of movement.

4.

Use the strong back muscles for lifting or moving.

ANS: 1

The correct answer is to flex the knees and keep the feet wide apart. This will create a wide base of support, providing greater stability for the nurse and reducing the risk of back injury. The nurse should be positioned close to the client and use the arms and legs. Dividing balanced activity between arms and legs reduces the risk of back injury. Facing the direction of movement prevents abnormal twisting of the spine, also reducing the risk of back injury.

DIF: C REF: 801 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe and Effective Care Environment

10. The nurse is presenting a teaching session on exercise for a group of corporate executives. An appropriate recommendation is that

1.

Continuous activity is required in order for the exercise to be worthwhile

2.

3000 to 4000 calories may be easily expended each week

3.

Lower-intensity activities need to be done more often for value

4.

Only formal exercise activities are counted in a regular plan

ANS: 3

Lower intensity activities should be done more often, for longer periods of time, or both. The activity does not have to be continuous; benefits can be realized with short bouts of activity over the course of the day. Answer 2 is inaccurate; 1000 to 1400 calories may be easily expended each week. All types of activity can be applied in an exercise plan; it does not have to be formal exercises.

DIF: A REF: 788 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

11. Following an assessment of the client, the nurse identifies the nursing diagnosis activity intolerance related to increased weight gain and inactivity. An outcome identified by the nurse should be:

1.

Resting heart rate will be 90 to 100 beats/minute

2.

Blood pressure will be maintained between 140/80 and 160/90 mm Hg

3.

Exercise will be performed 3 to 4 times over the next 2 weeks

4.

Achievement of a rating of 3 for activity endurance

ANS: 3

An appropriate outcome for activity intolerance related to increased weight gain and inactivity is that the client will perform exercise 3 to 4 times over the next 2 weeks. This outcome is realistic, measurable, and addresses the problem. A resting heart rate of 90-100 beats/minute is too high, and it does not address the need to increase activity. This outcome does not state whether this blood pressure is at rest or after exercising. It also does not address the need to increase activity. A more appropriate outcome is that the client will increase his or her activity (over the next 2 weeks).

DIF: A REF: 796 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

12. The primary purpose for placing an immobile clients arms across his or her chest when preparing to transfer the client up in the bed is to:

1.

Increase the stability of the clients body

2.

Protect the clients arms from being hurt during the transfer

3.

Produce a more compact form that facilitates the transfer

4.

Reduce the amount of body surface area that is in contact with the bed.

ANS: 4

The greater the surface area of the object you are moving, the greater the friction. For example, when a client is unable to assist in moving up in bed, place the clients arms across the chest. This decreases surface area and reduces friction.

DIF: A REF: 788 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

13. Which of the following nursing interventions is likely to have the most impact on reducing friction when positioning an immobile client?

1.

Involving at least two personnel in the actual transfer

2.

Lubricating all body parts that are in contact with the bed

3.

Dressing the bed with a lift sheet to be use during the transfer

4.

Thoroughly explaining the process to the client before the move

ANS: 3

The use of the more common lift sheet reduces friction because the client is more easily moved along the beds surface. Lubricating the body will not reduce friction if the body is improperly handled. The remaining options are not incorrect but do not have an impact on the risk of friction damage to the client as does using the lift sheet.

DIF: C REF: 788 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

14. A postmenopausal client is experiencing mild osteopenia and has been encouraged to walk 1 mile daily. Which of the following statements made by the client shows the best understanding of the positive effects of exercise on her condition?

1.

It makes me stronger and healthier.

2.

It helps make all my bones stronger.

3.

Walking increases the muscle mass in my legs.

4.

Regular walking improves my stamina and endurance.

ANS: 2

Regular physical activity and exercise enhances functioning of all body systems, including cardiopulmonary functioning (endurance), musculoskeletal fitness (flexibility and bone integrity), weight control and maintenance (body image), and psychological well-being. Osteopenia, the precursor of osteoporosis, results in weakened bones that are easily damaged. Walking helps stimulate bone cell production, which in turns helps produce stronger bones. While the other options are not incorrect, they do not address the issue of osteopenia.

DIF: C REF: 788 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

15. A client who is confined to a wheelchair is encouraged to engage in resistive isometric exercises to increase muscle strength and decrease the development of pressure ulcers. Which of the following is the most appropriate example of such an exercise for this client?

1.

Hip lifting

2.

Gluteal contraction

3.

Foot pressure off-loading

4.

Bicep-tricep compression

ANS: 1

An example of a resistive isometric exercises is hip lifting. In hip lifting, the client, who is in a sitting position, pushes with the hands against a surface such as the seat of a chair and raises the hips. Resistive isometric exercises help promote muscle strength and provide sufficient stress against bone to promote osteoblastic activity while temporarily reducing the pressure that can damage skin and produce pressure ulcers. The remaining options are primarily directed towards muscle strengthening, not pressure reduction.

DIF: C REF: 788 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

16. The nurse is caring for a client diagnosed with bilateral middle ear infections. Which of the following statements made by the nurse best reflects an understanding of the effects of this condition on the clients ability to move appropriately?

1.

He hasnt reported any nausea or vomiting.

2.

His ability to hear doesnt seem to be affected.

3.

Ill identify the client as a high falls risk by noting it on his Kardex.

4.

I believe he is capable of using his call bell when he needs assistance.

ANS: 3

Within the inner ear are the semicircular canals, three fluid-filled structures that assist in maintaining balance. An inner ear infection would interfere with the proper functioning of the semicircular canals and place the client at risk for falling. The remaining options do not deal as directly with mobility.

DIF: C REF: 788 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

17. An obese quadriplegic client has requested being transferred to a chair so he can be fed lunch sitting upright. Which of the following statements made by the ancillary personnel assigned the task reflects the best understanding of the implementation of this transfer?

1.

Ill reserve the mechanical lift for right before lunch.

2.

Ill certainly need someone to help me with this transfer.

3.

Eating in an upright position will certainly make lunch more enjoyable for him.

4.

Maybe he would enjoy being transferred into the dayroom to eat with the others.

ANS: 1

Mechanical lifts and lift teams are essential when the client is unable to assist. The clients weight makes the mechanical lift the most appropriate option for the transfer. The remaining options are not directly related to the implementation of the actual transfer.

DIF: C REF: 789 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

18. During a musculoskeletal assessment of a 20-month-old toddler, the nurse expects to observe:

1.

A swayback and outwardly turned feet

2.

A spine that is flexed and lacking anteroposterior curves

3.

Widened hips and fat deposits on the thighs and buttocks

4.

A stance with moderately spaced foot placement and a slightly rounded abdomen

ANS: 1

The toddlers posture is awkward because of the slight swayback and protruding abdomen. As the child walks, the legs and feet are usually far apart and the feet are slightly everted (turned outward).

DIF: A REF: 789 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

19. The nurse recognizes that the older adults tendency to take smaller steps with feet kept closer together will most likely:

1.

Increase the clients risk of injury resulting from falls

2.

Result in less stress on the clients knees, hips, and ankles

3.

Decrease the amount of energy the client expends on movement

4.

Allow for mobility in spite of the effects of aging on the clients joints

ANS: 1

The older adult may take smaller steps, keeping their feet closer together, which decreases the base of support. Thus body balance is unstable, and they are at greater risk for falls and injuries. The remaining options are not necessarily true.

DIF: A REF: 790 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

20. Which of the following statements made by a woman recently diagnosed with osteoporosis indicates the greatest degree of readiness to begin a daily walking routine?

1.

The tests showed that I have osteoporosis and need to walk.

2.

Ive walked around the local park three times, and that measures 1.75 miles.

3.

My sister has this problem, and she walks one mile a day around her neighborhood.

4.

I can join the spa and use the treadmill when the weather gets too cold to walk outside.

ANS: 2

Recording baseline fitness scores such as pulse rate, how long it takes to walk 1 mile, waist circumference, and body mass index are indicators of readiness. The remaining options do not show the most definite level of readiness as does actually walking.

DIF: C REF: 791 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

21. Which of the following statements made by an older adult reflects the best understanding of the need to exercise no matter ones age?

1.

You are never too old to start exercising.

2.

My grandson and I walk together around the park 3 times a week.

3.

I got my granddaughter a subscription to a runners magazine for her birthday.

4.

Kids today just dont seem to get the exercise we did when I was growing up.

ANS: 2

Strategies for physical activity incorporated early into a childs daily routine may provide a foundation for lifetime commitment to exercise and physical fitness. This answer shows the best understanding of the need to exercise across the life span.

DIF: C REF: 791 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

22. Which of the following nursing assessment questions will best determine the nature of an exercise-related injury?

1.

Do you experience the pain during or after your workout?

2.

Tell me what is included in your typical workout routine.

3.

How long does it hurt after you have stopped exercising?

4.

On a scale of 1 to 10, please rate your postexercise pain for me.

ANS: 2

Questions such as Describe for me your typical daily exercise routine and activity best trigger a discussion that allows for the client to offer information regarding the activities that could be responsible for the injury. The remaining options are more directed toward the pain the client is experiencing.

DIF: C REF: 791 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

23. The nurse encourages a noninsulin-dependent diabetic client to engage in a regular exercise program primarily because to do so will most likely improve the clients:

1.

Gastric motility, thus affecting glucose digestion

2.

Respiratory recovery time, thus decreasing breath load

3.

Average cardiac output, thus decreasing resting heart rate

4.

Use of glucose and fatty acids, thus decreasing blood glucose level

ANS: 4

While all the options are correct, regular exercise does tend to increase effective use of glucose and fatty acids; this would be the primary benefit for the diabetic client.

DIF: C REF: 793 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

24. Which of the following assessment questions is most likely to result in pertinent information regarding the clients expectations of the outcomes of a regular exercise program?

1.

What is your greatest barrier to regular exercise?

2.

What is your idea of a workable exercise program?

3.

What do you want to happen from exercising regularly?

4.

How much time can you comfortably dedicate to exercise daily?

ANS: 2

In assessing the clients expectations concerning activity and exercise, first determine the clients perception of what is normal or acceptable in regard to physical fitness. While the remaining options are not incorrect, they are not as likely to provide as much pertinent information regarding expectations.

DIF: C REF: 808 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

25. The nurse has determined that a client reporting general fatigue is experiencing activity intolerance. Which of the following assessment findings, observed after the client ambulates to the bathroom, best confirms this nursing diagnosis?

1.

Dyspnea

2.

Diaphoresis

3.

Hypotension

4.

Mental confusion

ANS: 1

Further review of assessed defining characteristics (e.g., abnormal heart rate or dyspnea) will possibly lead to the definitive diagnosis (activity intolerance). The remaining options may be a result of other factors.

DIF: C REF: 795 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

26. A client with a nursing diagnosis of activity intolerance has developed reddened areas on both heels and his coccyx. Which of the following nursing interventions will most likely have the greatest impact on this diagnosis?

1.

Ambulating him to the bathroom before returning to bed

2.

Encouraging him to change position every 2 hours while in bed

3.

Including active range-of-motion exercises in both AM and PM care

4.

Planning a rest period after AM care but before walking to the dining room for lunch

ANS: 4

Rest periods will allow for the client to recuperate before expending additional energy. The remaining options are more directed towards the skin breakdown problem.

DIF: C REF: 795 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

27. The nurse has delegated the task of ambulating a client who is experiencing activity intolerance. Which of the following statements made by the nurse best reflects an understanding of the nurses role to properly instruct the ancillary personnel regarding this task?

1.

Stop the walking if the client complains of pain or weakness.

2.

Please be sure she has proper footwear on before starting out.

3.

Be sure to document the time spent and the distance she walked.

4.

Take her blood pressure and pulse both before and after walking.

ANS: 1

The assigned staff must be instructed to notify the nurse of client reports of pain or any other condition that might result in physical harm. While the other options are not incorrect, they do not have the priority that the answer has.

DIF: C REF: 796 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

28. A client is discussing an exercise program that includes running 1.5 miles 3 times a week. Which of the following suggestions made by the nurse is most likely to result in minimizing the clients risk for injury?

1.

Stretching before and after running

2.

Alternating running paths every week

3.

Hydrating well with sports drinks during and after running

4.

Wearing running shoes that have been professionally fitted

ANS: 1

The warm-up period usually lasts about 5 to 10 minutes and may include stretching, calisthenics, and/or the aerobic activity performed at a lower intensity. The warm-up activity prepares the body and decreases the potential for injury. While the remaining options contain appropriate suggestions, they are not as directly related to the most common forms of running injuriesmuscle strain.

DIF: C REF: 795 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

29. The first rule of safety when managing client transfers is:

1.

Flex your knees and plant your feet far apart

2.

Keep your back aligned with your neck, pelvis, and feet

3.

Use lift teams or mechanical lifts when the transfer requires it

4.

Always use the large muscles of the arms and legs, not the small muscles of the back

ANS: 3

Use lift teams and patient-handling equipment, such as mechanical lifts, to prevent injury to yourself and the client whenever the client is incapable of helping. While the remaining options are correct, they are not directed towards the primary concernclient and staff safety.

DIF: C REF: 795 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

30. The nurse is discussing the benefits of regular walking with a group of senior citizens. Which of the following statements shows the best understanding of the positive impact of exercise on the older adult?

1.

Remember to warm up and cool down with stretching exercises.

2.

Find a walking partner that will accompany you on a regular basis.

3.

Be sure to hydrate yourself well before, during, and after your walk.

4.

Talk with your health care provider before starting a regular walking program.

ANS: 4

Consult a health care provider before beginning an exercise program, particularly in the presence of heart or lung disease and other chronic illnesses. While the remaining options are not incorrect, they do not show the best overall understanding of the effects of exercise on the body systems of an older adult.

DIF: C REF: 797 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

31. A client who is immobilized in bed due to skeletal traction tells the nurse that they miss their exercise regimen that they had started prior to the accident that resulted in their hospitalization. The nurse knows that which of the following is a good form of exercise that this client can still perform while immobilized?

1.

Isotonic exercise

2.

Isometric contraction

3.

Resistive isometric exercise

4.

Aerobic exercise

ANS: 2

Isometric exercise involves tightening of muscles without moving body parts.

DIF: B REF: 789 OBJ: Application

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort

32. A client who will be going home will need to use crutches for ambulation. Following teaching, the nurse notes that the client complains of pain under his arms. How much room should be between the crutch pad and clients axilla?

1.

Axilla should lightly touch the crutch pad

2.

1 to 2 finger widths from the axilla

3.

3 to 4 finger widths from the axilla

4.

4 to 5 finger widths from the axilla

ANS: 3

3 to 4 finger widths from the axilla prevents pressure on the axilla.

DIF: B REF: 801 OBJ: Application

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

33. When planning care for a client with newly diagnosed hypertension, the nurse knows that which form of exercise would be most beneficial in lowering both systolic and diastolic blood pressure?

1.

Lifting weights

2.

Running

3.

Bicycling

4.

Competitive swimming

ANS: 3

Low-moderate intensity exercise is the most effective in lowering blood pressure. Weight training and high-intensity aerobic exercise seem to have minimal benefit on lowering blood pressure.

DIF: B REF: 788 OBJ: Application

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort

34. In teaching a newly diagnosed 17-year-old client with type 1 diabetes, the nurse knows that the exercise is an important component in care. Which of the following activities would be most appropriate for the previously sedentary client?

1.

Kick-boxing class

2.

Football

3.

Bicycling

4.

Soccer

ANS: 3

Low to moderate intensity exercise is most appropriate for clients with type 1diabetes.

DIF: B REF: 804 OBJ: Application

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance/Health and Wellness

35. A newly diagnosed client with type 2 diabetes expresses concern that he will not be able to maintain his active lifestyle, which includes bicycling. The nurse instructs the client about risks and precautions regarding exercise including which of the following?

1.

To avoid leisurely bicycling day trips

2.

To avoid strenuous bicycling for long periods of time

3.

It is better for them to exercise for 1 to 2 hours once a week than for 20 minutes 3 days per week

4.

As long as he is not participating in strenuous exercise, there is no need to include warm-up or cool-down exercises

ANS: 2

The client with type 2 diabetes can do aerobic exercise at 50% to 75% of maximal oxygen uptake.

DIF: B REF: 808 OBJ: Application

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance/Health and Wellness

36. A client with coronary heart disease has been meeting with a cardiac rehabilitation nurse for the past 5 weeks. The nurse has provided the client with interventions to increase the clients activity level. The client states that they dont know if the exercise program is helping. The nurse can assess the effectiveness of the interventions by:

1.

Comparing baseline vital signs with current vital signs

2.

Weighing the client

3.

Asking the client if he feels that he has met his goals

4.

Telling the client that the exercise will only help if the client has a positive attitude

ANS: 1

To evaluate the effectiveness of nursing interventions to enhance activity and exercise, make comparisons with baseline measures that include blood pressure, pulse, strength, endurance and psychological well-being.

DIF: B REF: 808 OBJ: Application

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance/Health Promotion Programs

37. Passive range-of-motion exercises are most important for which of the following clients?

1.

Pediatric client with a broken femur

2.

Diabetic client with a total knee replacement

3.

Unconscious client in ICU

4.

Elderly client with a bowel obstruction

ANS: 3

The nurse should perform passive range of motion exercises with this client because the client cannot perform the exercises alone. These clients in the remaining options should be encouraged to perform active range-of-motion exercises.

DIF: B REF: 808 OBJ: Application

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort

38. One of the most debilitating health hazards among nurses is musculoskeletal injuries. In order to eliminate these injuries, the American Nurses Association is advocating which of the following?

1.

Mandate that physical therapists do all patient transfers.

2.

Require minimum staffing levels in health care organizations.

3.

Request the use of assistive equipment and devices.

4.

Require a minimum number of staff to be involved in all patient transfers.

ANS: 3

The use of assistive equipment and continued use of proper body mechanics can significantly reduce the risk of musculoskeletal injuries.

DIF: C REF: 808 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

39. The nurse is working with a nursing assistive personnel to provide care for a group of clients. The nurse can delegate which of the following activities to the nursing assistive personnel?

1.

Assess for medical limitations before beginning the exercise activity.

2.

Teach the clients breathing skills to help reduce their anxiety.

3.

Obtain preexercise and postexercise vital signs.

4.

Document the clients progress.

ANS: 3

The nursing assistive personnel can obtain vital signs and report them to the nurse. Answers 1, 2, and 4 are activities that are nursing responsibilities and should never be delegated.

DIF: B REF: 800 OBJ: Application

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Management of Care

40. A client with cancer expresses interest in increasing his activity level. The nurse begins by assessing baseline data regarding the clients current activity patterns. The nurse uses professional standards to develop a plan of care for this client. Professional standards are important because they:

1.

Are developed by government agencies

2.

Establish scientifically proven guidelines

3.

Shift responsibility for the plan of care from the nurse

4.

Are required by all healthcare organizations

ANS: 2

Standards of care often establish scientifically proven guidelines for selecting effective nursing interventions.

DIF: C REF: 800 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

41. When moving a client who is unable to assist, what is the most important principle for the nurse to remember to avoid injury?

1.

Face opposite of the direction of movement.

2.

Keep your feet close together.

3.

The higher the center of gravity, the greater the stability of the nurse.

4.

Try to avoid lifting the patient if possible.

ANS: 4

Leverage, rolling, turning or pivoting requires less work than lifting. Facing the direction of movement prevents abnormal twisting of the spine. The wider the base of support, the greater stability of the nurse. The lower the center of gravity, the greater stability of the nurse.

DIF: C REF: 799 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe and Effective Care Environment/Safety and Infection Control

MULTIPLE RESPONSE

1. When discussing the benefits of physical activity and exercise with a client, the nurse identifies which of the following as a positive outcome to the client? (Select all that apply.)

1.

Stress management

2.

Enhanced cardiac output

3.

Improved bone integrity

4.

Facilitation of weight control

5.

Increased cognitive function

6.

Increased musculoskeletal flexibility

ANS: 1, 2, 3, 4, 6

Regular physical activity and exercise enhances functioning of all body systems, including cardiopulmonary functioning (endurance), musculoskeletal fitness (flexibility and bone integrity), weight control and maintenance (body image), and psychological well-being. Effects on cognitive function are not consistent.

DIF: A REF: 795 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

2. The general goal of exercise and activity for all clients is to: (Select all that apply.)

1.

Encourage weight loss

2.

Improve joint flexibility

3.

Minimize social isolation

4.

Improve motor function

5.

Foster personal independence

6.

Maintain the optimal level of function

ANS: 3, 5

The general goal related to exercise and activity is to improve or maintain the clients motor function and independence. While the other options are not inappropriate, they do not reflect the general goals for all clients.

DIF: C REF: 790 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care & Comfort/Mobility/Immobility

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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