NUR 341 FINAL EXAM QUESTIONS
WITH 100% OUTLINED ANSWERS
\.A client has been on prolonged bed rest, and the nurse is observing for signs associated with
immobility. In assessment of the client, the nurse is alert to a(n):
A. Increased blood pressure
B. Decreased heart rate
C. Increased urinary output
D. Decreased peristalsis - Answer-✔D. Decreased peristalsis
\.A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident
(stroke). In planning care for this client, the nurse implements which one of the following as an
appropriate intervention?
A. Encourage an even gait when walking in place.
B. Assess the extremities for unilateral swelling and muscle atrophy.
C. Encourage holding the breath frequently to hyperinflate the client's lungs.
D. Teach the use of a two-point crutch technique for ambulation. - Answer-✔B. Assess the
extremities for unilateral swelling and muscle atrophy.
\.Two nurses are standing on opposite sides of the bed to move the client up in bed with a
drawsheet. Where should the nurses be standing in relation to the client's body as they prepare
for the move?
A. Even with the thorax
B. Even with the shoulders
, C. Even with the hips
D. Even with the knees - Answer-✔B. Even with the shoulders
\.The best approach for the nurse to use to assess the presence of thrombosis in an immobilized
client is to:
A. Measure the calf and thigh circumferences
B. Attempt to elicit Homans' sign
C. Palpate the temperature of the feet
D. Observe for a loss of hair and skin turgor in the lower legs - Answer-✔A. Measure the calf
and thigh circumferences
\.A client is getting up for the first time after a period of bed rest. The nurse should first:
A. Assess respiratory function
B. Obtain a baseline blood pressure
C. Assist the client with sitting at the edge of the bed
D. Ask the client if he or she feels light-headed - Answer-✔B. Obtain a baseline blood pressure
\.To provide for the psychosocial needs of an immobilized client, an appropriate statement by
the nurse is which of the following?
A. "The staff will limit your visitors so that you will not be bothered."
B. "A roommate can be a real bother. You'd probably rather have a private room."
C. "Let's discuss the routine to see if there are any changes we can make."
D. "I think you should have your hair done and put on some makeup." - Answer-✔C. "Let's
discuss the routine to see if there are any changes we can make."
\.Which of the following is the most important to consider when assisting the client in passive
range-of-motion exercises?
WITH 100% OUTLINED ANSWERS
\.A client has been on prolonged bed rest, and the nurse is observing for signs associated with
immobility. In assessment of the client, the nurse is alert to a(n):
A. Increased blood pressure
B. Decreased heart rate
C. Increased urinary output
D. Decreased peristalsis - Answer-✔D. Decreased peristalsis
\.A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident
(stroke). In planning care for this client, the nurse implements which one of the following as an
appropriate intervention?
A. Encourage an even gait when walking in place.
B. Assess the extremities for unilateral swelling and muscle atrophy.
C. Encourage holding the breath frequently to hyperinflate the client's lungs.
D. Teach the use of a two-point crutch technique for ambulation. - Answer-✔B. Assess the
extremities for unilateral swelling and muscle atrophy.
\.Two nurses are standing on opposite sides of the bed to move the client up in bed with a
drawsheet. Where should the nurses be standing in relation to the client's body as they prepare
for the move?
A. Even with the thorax
B. Even with the shoulders
, C. Even with the hips
D. Even with the knees - Answer-✔B. Even with the shoulders
\.The best approach for the nurse to use to assess the presence of thrombosis in an immobilized
client is to:
A. Measure the calf and thigh circumferences
B. Attempt to elicit Homans' sign
C. Palpate the temperature of the feet
D. Observe for a loss of hair and skin turgor in the lower legs - Answer-✔A. Measure the calf
and thigh circumferences
\.A client is getting up for the first time after a period of bed rest. The nurse should first:
A. Assess respiratory function
B. Obtain a baseline blood pressure
C. Assist the client with sitting at the edge of the bed
D. Ask the client if he or she feels light-headed - Answer-✔B. Obtain a baseline blood pressure
\.To provide for the psychosocial needs of an immobilized client, an appropriate statement by
the nurse is which of the following?
A. "The staff will limit your visitors so that you will not be bothered."
B. "A roommate can be a real bother. You'd probably rather have a private room."
C. "Let's discuss the routine to see if there are any changes we can make."
D. "I think you should have your hair done and put on some makeup." - Answer-✔C. "Let's
discuss the routine to see if there are any changes we can make."
\.Which of the following is the most important to consider when assisting the client in passive
range-of-motion exercises?
