fundamentals of nursing exam 2
complete questions and answers
How does the nurse maintain a low center of gravity while transferring the patient from
the bed to the chair?
a. The nurse ties the gait belt loosely around the patient's waist.
b. The nurse stands with the knees slightly bent and legs spread apart.
c. The nurse bends at the waist when setting the patient's feet on the floor.
d. The nurse leans backward slightly when helping the patient to stand. -ANSb. The
nurse stands with the knees slightly bent and legs spread apart.
Which instruction directs the patient to perform an isometric exercise?
a. "Use the trapeze to lift your upper body off the bed."
b. "Tighten and hold your stomach muscles for 15 seconds."
c. "Close your fists and squeeze them tightly, release and repeat."
d. "Lift your buttocks off the bed by pushing against the mattress." -ANSb. "Tighten and
hold your stomach muscles for 15 seconds."
The nurse is caring for a patient with a traumatic injury to the cerebellum. Which
assessment finding will be expected as a result?
a. The patient sways from side to side when walking.
b. The patient's ligaments are weak and easily ruptured.
c. The patient has fine tremors with purposeful movement.
d. The patient's joints are reddened, swollen, and warm to touch. -ANSa. The patient
sways from side to side when walking.
What is the priority nursing diagnosis for a patient with osteoporosis?
a. Risk for injury (fracture) related to fragile bone tissue
b. Activity intolerance related to pain and joint stiffness
c. Impaired tissue integrity related to red, swollen, painful joints
d. Fatigue related to chronic inflammatory destruction of tissues -ANSa. Risk for injury
(fracture) related to fragile bone tissue
Which assessment finding is expected for a patient who suffered a left-sided thrombotic
stroke?
a. Bilateral footdrop
b. Fine tremors of the hands
c. Curvature of the lumbar spine
d. Weakness of the right arm and leg -ANSd. Weakness of the right arm and leg
The nurse is caring for a patient with right-sided hemiplegia after a stroke. Which is the
appropriate goal for the diagnosis impaired transfer ability related to insufficient muscle
strength?
,a. The patient will safely transfer from bed to chair with the assistance of one person.
b. The patient will verbalize feelings about physical limitations due to immobility.
c. The nurse will reposition the patient every 2 hours and pad bony prominences.
d. The nurse will utilize a gait belt around the patient's low back for all transfers. -ANSa.
The patient will safely transfer from bed to chair with the assistance of one person.
The nurse is caring for a patient with arthritis who wants to exercise but finds it difficult
due to joint pain and stiffness. Which nursing diagnosis is appropriate for this patient?
a. Activity intolerance related to exertional discomfort
b. Noncompliance related to lack of motivation to exercise
c. Unilateral neglect related to health beliefs about chronic illness
d. Powerlessness related to expressions of uncertainty about benefits of exercise -
ANSa. Activity intolerance related to exertional discomfort
Which is the priority intervention for a patient with the nursing diagnosis of impaired
physical mobility related to muscle weakness and neuromuscular impairment?
a. Allow the patient to decide when and how far to ambulate each day.
b. Utilize a walker, gait belt, and two nursing staff members for ambulation.
c. Suggest a variety of physical activities to encourage patient engagement.
d. Encourage the patient to use positive self-talk to gradually increase strength. -ANSb.
Utilize a walker, gait belt, and two nursing staff members for ambulation.
Which is an appropriate goal for a patient with the nursing diagnosis of sedentary
lifestyle related to generalized weakness and fatigue?
a. The patient will identify barriers that limit social interactions.
b. The patient will increase physical activity to 3500 steps daily.
c. The patient will use a pain rating scale to identify levels of discomfort.
d. The patient will verbalize the risks of continuing noncompliance with treatment. -
ANSb. The patient will increase physical activity to 3500 steps daily.
Which exercises are appropriate for a quadriplegic patient?
a. Active range-of-motion exercises
b. Weight-bearing exercises
c. Aerobic exercises
d. Passive range-of-motion exercises -ANSd. Passive range-of-motion exercises
Which action by the nurse demonstrates correct use of a gait belt?
a. The patient holds on to the gait belt during transfer to the chair.
b. The gait belt is used to lift the patient whose legs are too weak to stand.
c. The gait belt is tied loosely around the patient's waist just above the hips.
d. The nurse follows behind the patient holding onto the gait belt during ambulation. -
ANSd. The nurse follows behind the patient holding onto the gait belt
Which action demonstrates correct use of a cane by a patient following a left leg injury?
a. The patient holds the cane securely in the left hand.
b. The patient uses the cane when stepping forward with the right leg.
,c. The patient's left leg and cane move forward together when walking.
d. The patient leans slightly to the left when advancing the cane forward. -ANSc. The
patient's left leg and cane move forward together when walking.
Which action demonstrates correct use of crutches by a patient following a left leg
injury?
a. The handgrips are set so that the axillae fully support the patient's body weight.
b. The patient looks down at the floor when taking each step with the crutches.
c. The patient moves the crutches approximately 12 inches forward with each step.
d. The patient's elbows are flexed at a 45-degree angle when holding the handgrips. -
ANSc. The patient moves the crutches approximately 12 inches forward with each step.
Which is the safest method for a patient with a left leg injury to navigate up a set of
stairs?
a. Sit down on the stairs and use the right leg to lift the body up each step.
b. Use a gait belt, the left handrail, and a crutch under the right arm.
c. Securely place both crutches on the next step and swing the body upward.
d. Bend the knee of the right leg when lifting the left leg up to the next step. -ANSa. Sit
down on the stairs and use the right leg to lift the body up each step.
Which task may be delegated to the nursing assistant?
a. Determine the patient's need for a low-air-loss mattress overlay.
b. Assess the patient's legs for the presence of thromboembolism.
c. Teach the patient about the contractures and the benefits of resting hand splints.
d. Reposition the patient at least every 2 hours using pillows and foam wedges. -ANSd.
Reposition the patient at least every 2 hours using pillows and foam wedges.
Which action by the nurse demonstrates correct technique for repositioning the patient
in bed?
a. The nurse's knees are kept stiff to enhance lifting strength potential.
b. The nurse's abdominal muscles are relaxed to prevent back injury.
c. The nurse's pelvis is tucked inward to maintain balance during the procedure.
d. The nurse's torso twists with the patient to facilitate upper extremity muscle use. -
ANSc. The nurse's pelvis is tucked inward to maintain balance during the procedure.
The nurse has just completed teaching the patient about how to use crutches safely.
Which statement by the nurse will help determine that the teaching was effective?
a. "Now I want to see you walk using the crutches correctly."
b. "Here are written instructions in case you forget my directions."
c. "I will make a note in the chart that you were taught how to use crutches."
d. "Please let me know if you have any questions about how to use crutches." -ANSa.
"Now I want to see you walk using the crutches correctly."
Which exercise program should be avoided by a patient with osteoporosis?
a. Yoga
b. Tai chi
, c. Tennis
d. Water aerobics -ANSc. Tennis
Which term best describes the relationship between the hamstring and quadriceps
muscles?
a. Synergistic
b. Ergonomic
c. Antigravity
d. Antagonistic -ANSd. Antagonistic
Which action is appropriate for transferring a hemiplegic patient from the bed to the
wheelchair?
a. The nurse ensures that the wheelchair brakes are locked before helping the patient
to stand.
b. The patient's arms are placed around the nurse's neck before the patient is helped
to stand.
c. The nurse secures the gait belt under the patient's arms and uses it to lift the patient
to a standing position.
d. The nurse's legs are kept straight and close together to avoid tripping the patient
during the transfer. -ANSa. The nurse ensures that the wheelchair brakes are locked
before helping the patient
to stand.
Which action by the patient indicates appropriate use of the walker?
a. The patient leans over the walker when rising to a standing position.
b. The patient's elbows are bent at a 45-degree angle when holding onto the walker.
c. The patient ensures that the walker is locked in the open position before using it.
d. The patient looks down at the walker when walking to keep from kicking it -ANSc.
The patient ensures that the walker is locked in the open position before using it.
Which equipment should the nurse utilize when ambulating a patient with a history of
severe COPD?
a. Penlight
b. Stethoscope
c. Pulse oximeter
d. Doppler ultrasound -ANSc. Pulse oximeter
The nurse is caring for a patient with right-sided hemiplegia. Which intervention will help
prevent damage to the patient's right shoulder?
a. Place the patient's right arm in a sling whenever the patient is sitting upright.
b. Set up the patient's meal trays so that all food is within easy reach for the left arm.
c. Elevate the head of the patient's bed at least than 30 degrees in the lateral position.
d. Assess for increased joint resistance when repositioning the patient. -ANSa. Place
the patient's right arm in a sling whenever the patient is sitting upright.
complete questions and answers
How does the nurse maintain a low center of gravity while transferring the patient from
the bed to the chair?
a. The nurse ties the gait belt loosely around the patient's waist.
b. The nurse stands with the knees slightly bent and legs spread apart.
c. The nurse bends at the waist when setting the patient's feet on the floor.
d. The nurse leans backward slightly when helping the patient to stand. -ANSb. The
nurse stands with the knees slightly bent and legs spread apart.
Which instruction directs the patient to perform an isometric exercise?
a. "Use the trapeze to lift your upper body off the bed."
b. "Tighten and hold your stomach muscles for 15 seconds."
c. "Close your fists and squeeze them tightly, release and repeat."
d. "Lift your buttocks off the bed by pushing against the mattress." -ANSb. "Tighten and
hold your stomach muscles for 15 seconds."
The nurse is caring for a patient with a traumatic injury to the cerebellum. Which
assessment finding will be expected as a result?
a. The patient sways from side to side when walking.
b. The patient's ligaments are weak and easily ruptured.
c. The patient has fine tremors with purposeful movement.
d. The patient's joints are reddened, swollen, and warm to touch. -ANSa. The patient
sways from side to side when walking.
What is the priority nursing diagnosis for a patient with osteoporosis?
a. Risk for injury (fracture) related to fragile bone tissue
b. Activity intolerance related to pain and joint stiffness
c. Impaired tissue integrity related to red, swollen, painful joints
d. Fatigue related to chronic inflammatory destruction of tissues -ANSa. Risk for injury
(fracture) related to fragile bone tissue
Which assessment finding is expected for a patient who suffered a left-sided thrombotic
stroke?
a. Bilateral footdrop
b. Fine tremors of the hands
c. Curvature of the lumbar spine
d. Weakness of the right arm and leg -ANSd. Weakness of the right arm and leg
The nurse is caring for a patient with right-sided hemiplegia after a stroke. Which is the
appropriate goal for the diagnosis impaired transfer ability related to insufficient muscle
strength?
,a. The patient will safely transfer from bed to chair with the assistance of one person.
b. The patient will verbalize feelings about physical limitations due to immobility.
c. The nurse will reposition the patient every 2 hours and pad bony prominences.
d. The nurse will utilize a gait belt around the patient's low back for all transfers. -ANSa.
The patient will safely transfer from bed to chair with the assistance of one person.
The nurse is caring for a patient with arthritis who wants to exercise but finds it difficult
due to joint pain and stiffness. Which nursing diagnosis is appropriate for this patient?
a. Activity intolerance related to exertional discomfort
b. Noncompliance related to lack of motivation to exercise
c. Unilateral neglect related to health beliefs about chronic illness
d. Powerlessness related to expressions of uncertainty about benefits of exercise -
ANSa. Activity intolerance related to exertional discomfort
Which is the priority intervention for a patient with the nursing diagnosis of impaired
physical mobility related to muscle weakness and neuromuscular impairment?
a. Allow the patient to decide when and how far to ambulate each day.
b. Utilize a walker, gait belt, and two nursing staff members for ambulation.
c. Suggest a variety of physical activities to encourage patient engagement.
d. Encourage the patient to use positive self-talk to gradually increase strength. -ANSb.
Utilize a walker, gait belt, and two nursing staff members for ambulation.
Which is an appropriate goal for a patient with the nursing diagnosis of sedentary
lifestyle related to generalized weakness and fatigue?
a. The patient will identify barriers that limit social interactions.
b. The patient will increase physical activity to 3500 steps daily.
c. The patient will use a pain rating scale to identify levels of discomfort.
d. The patient will verbalize the risks of continuing noncompliance with treatment. -
ANSb. The patient will increase physical activity to 3500 steps daily.
Which exercises are appropriate for a quadriplegic patient?
a. Active range-of-motion exercises
b. Weight-bearing exercises
c. Aerobic exercises
d. Passive range-of-motion exercises -ANSd. Passive range-of-motion exercises
Which action by the nurse demonstrates correct use of a gait belt?
a. The patient holds on to the gait belt during transfer to the chair.
b. The gait belt is used to lift the patient whose legs are too weak to stand.
c. The gait belt is tied loosely around the patient's waist just above the hips.
d. The nurse follows behind the patient holding onto the gait belt during ambulation. -
ANSd. The nurse follows behind the patient holding onto the gait belt
Which action demonstrates correct use of a cane by a patient following a left leg injury?
a. The patient holds the cane securely in the left hand.
b. The patient uses the cane when stepping forward with the right leg.
,c. The patient's left leg and cane move forward together when walking.
d. The patient leans slightly to the left when advancing the cane forward. -ANSc. The
patient's left leg and cane move forward together when walking.
Which action demonstrates correct use of crutches by a patient following a left leg
injury?
a. The handgrips are set so that the axillae fully support the patient's body weight.
b. The patient looks down at the floor when taking each step with the crutches.
c. The patient moves the crutches approximately 12 inches forward with each step.
d. The patient's elbows are flexed at a 45-degree angle when holding the handgrips. -
ANSc. The patient moves the crutches approximately 12 inches forward with each step.
Which is the safest method for a patient with a left leg injury to navigate up a set of
stairs?
a. Sit down on the stairs and use the right leg to lift the body up each step.
b. Use a gait belt, the left handrail, and a crutch under the right arm.
c. Securely place both crutches on the next step and swing the body upward.
d. Bend the knee of the right leg when lifting the left leg up to the next step. -ANSa. Sit
down on the stairs and use the right leg to lift the body up each step.
Which task may be delegated to the nursing assistant?
a. Determine the patient's need for a low-air-loss mattress overlay.
b. Assess the patient's legs for the presence of thromboembolism.
c. Teach the patient about the contractures and the benefits of resting hand splints.
d. Reposition the patient at least every 2 hours using pillows and foam wedges. -ANSd.
Reposition the patient at least every 2 hours using pillows and foam wedges.
Which action by the nurse demonstrates correct technique for repositioning the patient
in bed?
a. The nurse's knees are kept stiff to enhance lifting strength potential.
b. The nurse's abdominal muscles are relaxed to prevent back injury.
c. The nurse's pelvis is tucked inward to maintain balance during the procedure.
d. The nurse's torso twists with the patient to facilitate upper extremity muscle use. -
ANSc. The nurse's pelvis is tucked inward to maintain balance during the procedure.
The nurse has just completed teaching the patient about how to use crutches safely.
Which statement by the nurse will help determine that the teaching was effective?
a. "Now I want to see you walk using the crutches correctly."
b. "Here are written instructions in case you forget my directions."
c. "I will make a note in the chart that you were taught how to use crutches."
d. "Please let me know if you have any questions about how to use crutches." -ANSa.
"Now I want to see you walk using the crutches correctly."
Which exercise program should be avoided by a patient with osteoporosis?
a. Yoga
b. Tai chi
, c. Tennis
d. Water aerobics -ANSc. Tennis
Which term best describes the relationship between the hamstring and quadriceps
muscles?
a. Synergistic
b. Ergonomic
c. Antigravity
d. Antagonistic -ANSd. Antagonistic
Which action is appropriate for transferring a hemiplegic patient from the bed to the
wheelchair?
a. The nurse ensures that the wheelchair brakes are locked before helping the patient
to stand.
b. The patient's arms are placed around the nurse's neck before the patient is helped
to stand.
c. The nurse secures the gait belt under the patient's arms and uses it to lift the patient
to a standing position.
d. The nurse's legs are kept straight and close together to avoid tripping the patient
during the transfer. -ANSa. The nurse ensures that the wheelchair brakes are locked
before helping the patient
to stand.
Which action by the patient indicates appropriate use of the walker?
a. The patient leans over the walker when rising to a standing position.
b. The patient's elbows are bent at a 45-degree angle when holding onto the walker.
c. The patient ensures that the walker is locked in the open position before using it.
d. The patient looks down at the walker when walking to keep from kicking it -ANSc.
The patient ensures that the walker is locked in the open position before using it.
Which equipment should the nurse utilize when ambulating a patient with a history of
severe COPD?
a. Penlight
b. Stethoscope
c. Pulse oximeter
d. Doppler ultrasound -ANSc. Pulse oximeter
The nurse is caring for a patient with right-sided hemiplegia. Which intervention will help
prevent damage to the patient's right shoulder?
a. Place the patient's right arm in a sling whenever the patient is sitting upright.
b. Set up the patient's meal trays so that all food is within easy reach for the left arm.
c. Elevate the head of the patient's bed at least than 30 degrees in the lateral position.
d. Assess for increased joint resistance when repositioning the patient. -ANSa. Place
the patient's right arm in a sling whenever the patient is sitting upright.
