204 Exam 2 review Questions With
100% Solved Solutions
The nurse knows changes in which body system affect overall mobility increasing the
propensity of falling?
a. Neurologic
b. Hepatic
c. Cardiopulmonary
d. Musculoskeletal - SOLVED ANSWER-d. Musculoskeletal
Impairments in the musculoskeletal system can impact mobility through restrictions of
range of motion and strength, increasing the chances of falling. Changes to the
neurologic system can impair cognitive functioning, changes to the hepatic system can
affect mental status, and changes to the cardiopulmonary system can affect activity
tolerance.
The nurse is educating the patient about the proper disposal of medications in the
home. Which statement by the patient indicates a good understanding of the
information?
a. "Remove the label from the bottle and throw in the trash."
b. "Flush the medication down the disposal."
c. "Mix the medications with kitty litter, place the mixture in a jar, and put the jar in the
trash."
d. "Dissolve the medication in water and pour down the drain." - SOLVED ANSWER-c.
"Mix the medications with kitty litter, place the mixture in a jar, and put the jar in the
trash."
Flushing or pouring the medication down the drain can contaminate the water system.
Throwing the medication in the trash poses potential for someone to remove the
,medication and use it. This can be avoided by mixing it with an undesirable substance
like kitty litter or coffee grounds.
The nurse is visiting a patient with cardiac disease who has been experiencing
increased episodes of shortness of breath when exercise is attempted. The nurse is
concerned that the patient's decrease in activity may lead to which outcome?
a. Orthostatic hypotension
b. Increase risk of heart disease
c. Loss of short-term memory
d. Worsening shortness of breath - SOLVED ANSWER-a. Orthostatic hypotension
Inactivity in patients with cardiopulmonary disease can lead to an unsafe drop in blood
pressure with position changes, or orthostatic hypotension. The patient already has
heart disease. Loss of short-term memory is not related to the shortness of breath. The
lack of activity is not likely to worsen the shortness of breath; improving activity level
may help things eventually.
The nurse is teaching a student nurse about restraint use in patients. Which statement
by the student nurse indicates a learning need regarding restraints?
a. "Having all four side rails up on the bed is considered a restraint."
b. "The use of restraints has been shown to decrease fall-related injuries."
c. "Death has been associated with the use of restraints."
d. "Medications administered to control behavior are considered a chemical restraint." -
SOLVED ANSWER-b. "The use of restraints has been shown to decrease fall-related
injuries."
Restraints may be physical or chemical. A physical restraint is a mechanical or physical
device, such as material or equipment attached or adjacent to the patient's body, used
to restrict movement. Examples of physical restraints are wrist or ankle restraints, a
jacket or vest, and side rails. A medication that is administered to a patient to control
,behavior is a chemical restraint. The use of restraints has been associated with patient
injury including death and does not prevent patient falls.
The patient has a nursing diagnosis of Risk for Falls. The nurse identifies which goal to
be most important?
a. Patient will ambulate twice a day.
b. Patient will have no symptoms of infection.
c. Patient will perform activities of daily living.
d. Patient will have no injuries during hospital stay. - SOLVED ANSWER-d. Patient will
have no injuries during hospital stay.
All the goals except lack of infection are appropriate for a patient with a Risk for Falls
diagnosis; however, the most important goal is for the patient to have no injuries during
the hospitalization.
Which collaborative team member would be most effective in assisting the nurse to
identify medication alternatives that are less likely to cause drowsiness and dizziness to
reduce the risk of falls in the elderly patient?
a. Nursing case manager
b. Charge nurse
c. Physical therapist
d. Pharmacist - SOLVED ANSWER-d. Pharmacist
The nurse collaborates with the pharmacist and health care provider to identify and
implement safe medication alternatives for older adults to minimize side effects such as
drowsiness, dizziness, and orthostatic hypotension, which can increase fall risk.
Although case managers and charge nurses might have some experience in this area,
pharmacists are educated to focus on medication. Physical therapists evaluate the
patient's ability to perform and maintain balance during routine activities such as sitting,
standing, and walking.
, The nurse is concerned about helping the patient find resources to obtain assistive
equipment to be used in the home. Which team member should the nurse contact first?
a. Occupational therapist
b. Physical therapist
c. Health care provider
d. Social worker - SOLVED ANSWER-d. Social worker
The nurse should collaborate with the social worker to identify community resources for
obtaining assistive equipment. The social worker facilitates contact with insurance
companies or other agencies to assist with the financing of recommended therapeutic
assistive and specialty devices. Occupational therapists evaluate the patient for safe
performance of activities of daily living (ADLs) such as bathing, dressing, and grooming,
and they make recommendations to enhance safe performance of these activities, such
as the use of specialty equipment (e.g., grippers for pants, oversized shoehorns).
Physical therapists evaluate the patient's ability to perform and maintain balance during
routine activities such as sitting, standing, and walking. They make recommendations
for assistive devices such as canes and walkers to promote safe performance of these
activities. Health care providers order the equipment.
Which statement by the patient indicates to the nurse a teaching need regarding safety
in the home?
a. "I will put a night-light in every room."
b. "I will not use an extension cord to plug in multiple items."
c. "I will wash my throw rugs in the bathroom regularly."
d. "I will keep all cleaning supplies out of reach of children." - SOLVED ANSWER-c. "I
will wash my throw rugs in the bathroom regularly."
Throw rugs present a fall or tripping hazard. Night-lights help light halls to prevent falls,
extension cords can present a trip hazard, and cleaning supplies can contain poisonous
materials.
100% Solved Solutions
The nurse knows changes in which body system affect overall mobility increasing the
propensity of falling?
a. Neurologic
b. Hepatic
c. Cardiopulmonary
d. Musculoskeletal - SOLVED ANSWER-d. Musculoskeletal
Impairments in the musculoskeletal system can impact mobility through restrictions of
range of motion and strength, increasing the chances of falling. Changes to the
neurologic system can impair cognitive functioning, changes to the hepatic system can
affect mental status, and changes to the cardiopulmonary system can affect activity
tolerance.
The nurse is educating the patient about the proper disposal of medications in the
home. Which statement by the patient indicates a good understanding of the
information?
a. "Remove the label from the bottle and throw in the trash."
b. "Flush the medication down the disposal."
c. "Mix the medications with kitty litter, place the mixture in a jar, and put the jar in the
trash."
d. "Dissolve the medication in water and pour down the drain." - SOLVED ANSWER-c.
"Mix the medications with kitty litter, place the mixture in a jar, and put the jar in the
trash."
Flushing or pouring the medication down the drain can contaminate the water system.
Throwing the medication in the trash poses potential for someone to remove the
,medication and use it. This can be avoided by mixing it with an undesirable substance
like kitty litter or coffee grounds.
The nurse is visiting a patient with cardiac disease who has been experiencing
increased episodes of shortness of breath when exercise is attempted. The nurse is
concerned that the patient's decrease in activity may lead to which outcome?
a. Orthostatic hypotension
b. Increase risk of heart disease
c. Loss of short-term memory
d. Worsening shortness of breath - SOLVED ANSWER-a. Orthostatic hypotension
Inactivity in patients with cardiopulmonary disease can lead to an unsafe drop in blood
pressure with position changes, or orthostatic hypotension. The patient already has
heart disease. Loss of short-term memory is not related to the shortness of breath. The
lack of activity is not likely to worsen the shortness of breath; improving activity level
may help things eventually.
The nurse is teaching a student nurse about restraint use in patients. Which statement
by the student nurse indicates a learning need regarding restraints?
a. "Having all four side rails up on the bed is considered a restraint."
b. "The use of restraints has been shown to decrease fall-related injuries."
c. "Death has been associated with the use of restraints."
d. "Medications administered to control behavior are considered a chemical restraint." -
SOLVED ANSWER-b. "The use of restraints has been shown to decrease fall-related
injuries."
Restraints may be physical or chemical. A physical restraint is a mechanical or physical
device, such as material or equipment attached or adjacent to the patient's body, used
to restrict movement. Examples of physical restraints are wrist or ankle restraints, a
jacket or vest, and side rails. A medication that is administered to a patient to control
,behavior is a chemical restraint. The use of restraints has been associated with patient
injury including death and does not prevent patient falls.
The patient has a nursing diagnosis of Risk for Falls. The nurse identifies which goal to
be most important?
a. Patient will ambulate twice a day.
b. Patient will have no symptoms of infection.
c. Patient will perform activities of daily living.
d. Patient will have no injuries during hospital stay. - SOLVED ANSWER-d. Patient will
have no injuries during hospital stay.
All the goals except lack of infection are appropriate for a patient with a Risk for Falls
diagnosis; however, the most important goal is for the patient to have no injuries during
the hospitalization.
Which collaborative team member would be most effective in assisting the nurse to
identify medication alternatives that are less likely to cause drowsiness and dizziness to
reduce the risk of falls in the elderly patient?
a. Nursing case manager
b. Charge nurse
c. Physical therapist
d. Pharmacist - SOLVED ANSWER-d. Pharmacist
The nurse collaborates with the pharmacist and health care provider to identify and
implement safe medication alternatives for older adults to minimize side effects such as
drowsiness, dizziness, and orthostatic hypotension, which can increase fall risk.
Although case managers and charge nurses might have some experience in this area,
pharmacists are educated to focus on medication. Physical therapists evaluate the
patient's ability to perform and maintain balance during routine activities such as sitting,
standing, and walking.
, The nurse is concerned about helping the patient find resources to obtain assistive
equipment to be used in the home. Which team member should the nurse contact first?
a. Occupational therapist
b. Physical therapist
c. Health care provider
d. Social worker - SOLVED ANSWER-d. Social worker
The nurse should collaborate with the social worker to identify community resources for
obtaining assistive equipment. The social worker facilitates contact with insurance
companies or other agencies to assist with the financing of recommended therapeutic
assistive and specialty devices. Occupational therapists evaluate the patient for safe
performance of activities of daily living (ADLs) such as bathing, dressing, and grooming,
and they make recommendations to enhance safe performance of these activities, such
as the use of specialty equipment (e.g., grippers for pants, oversized shoehorns).
Physical therapists evaluate the patient's ability to perform and maintain balance during
routine activities such as sitting, standing, and walking. They make recommendations
for assistive devices such as canes and walkers to promote safe performance of these
activities. Health care providers order the equipment.
Which statement by the patient indicates to the nurse a teaching need regarding safety
in the home?
a. "I will put a night-light in every room."
b. "I will not use an extension cord to plug in multiple items."
c. "I will wash my throw rugs in the bathroom regularly."
d. "I will keep all cleaning supplies out of reach of children." - SOLVED ANSWER-c. "I
will wash my throw rugs in the bathroom regularly."
Throw rugs present a fall or tripping hazard. Night-lights help light halls to prevent falls,
extension cords can present a trip hazard, and cleaning supplies can contain poisonous
materials.
