Question 1

A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?

Accepted Answer

Answer reason: Elevating the head of the bed also improves lung expansion and ventilation-perfusion matching, making breathing more efficient during rest. Supine positioning tends to worsen orthopnea by increasing venous return and promoting fluid redistribution to the lungs. Low Fowler’s provides less thoracic expansion and preload reduction than a more upright position, so it is less effective for symptomatic relief when resting.

Question 2

A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?

Accepted Answer

Answer reason: " Milwaukee bracing for scoliosis typically requires prolonged therapy with a wearing schedule based on curve severity and growth remaining, often extending well beyond a few months. Assuming a fixed short duration suggests misunderstanding and can lead to poor adherence and inadequate curve control. Daily skin inspection is appropriate to detect pressure areas early, and braces are commonly prescribed for near-continuous wear (often 23 hours/day). Removing the brace briefly for hygiene is commonly allowed per provider instructions, so that statement is not inherently incorrect.

Question 3

The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend?

Accepted Answer

Answer reason: Isometric contractions tighten the muscle without moving the joint, helping maintain muscle strength and venous return and reducing the risks of disuse atrophy and thrombosis. Range-of-motion and isotonic exercises involve joint motion and are typically directed to joints not immobilized (e.g., toes/hip if free) rather than the casted segment. Aerobic exercise is not a targeted exercise for the casted limb and does not address maintaining strength in the immobilized muscles.

Question 4

The nurse is caring for a 5 year-old child who has the left leg in skeletal traction. Which of the following activities would be an appropriate diversional activity?

Accepted Answer

Answer reason: Handheld games keep the child engaged while maintaining the required immobilization and allowing safe positioning in bed. Options involving leg kicking or active whole-body movement can increase shifting and jeopardize the traction setup. Throwing activities also encourage trunk and limb movement that can inadvertently pull against the traction apparatus.

Question 5

What is the most important aspect to include when developing a home care plan for a client with severe arthritis?

Accepted Answer

Answer reason: Home care focuses on ROM exercises, energy conservation, assistive devices, and environmental modifications to reduce pain while maximizing safe movement and self-care. Anticipating side effects and ensuring medication adherence are important but support the broader goal of preserving function rather than replacing it. Coping support helps adjustment, yet without functional maintenance the client is at higher risk for immobility complications, falls, and loss of ADLs.

Question 6

The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize?

Accepted Answer

Answer reason: Ambulation also counters immobilization-related hypercalcemia, a common risk when pain and weakness reduce activity. High calcium intake from dairy would worsen the problem rather than prevent it. Fluid restriction increases the risk of dehydration and renal stone formation; hydration (not restriction) supports renal calcium excretion, and tetany is more associated with hypocalcemia than hypercalcemia.

Question 7

A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?

Accepted Answer

Answer reason: Bed rest creates sustained unrelieved pressure, and malnutrition reduces subcutaneous padding and impairs collagen synthesis and wound healing, making skin breakdown more likely and more severe. Advanced age further increases vulnerability due to thinner skin and reduced microcirculation. While incontinence and wheelchair use are meaningful risks, they are typically mitigated more effectively with skin care and repositioning compared with the combined, high-impact risks of immobility plus malnutrition. The ambulatory diabetic client has risk from microvascular disease, but mobility substantially lowers the primary driver of pressure injury formation.

Question 8

The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?

Accepted Answer

Answer reason: A pressure-reducing surface is a primary preventive intervention that can be implemented right away and directly addresses this time-sensitive safety risk. Adequate fluids, nutrition, and incontinence skin products support skin integrity, but they do not substitute for offloading pressure, which is the key mechanism of ulcer formation. Prioritizing pressure redistribution reduces preventable complications (skin breakdown, infection, delayed rehab) while other supportive measures are added to the overall plan.

Question 9

The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?

Accepted Answer

Answer reason: Nursing care prioritizes maintaining independence and dignity while supporting functional ability, especially for activities of daily living. Rushing the client or having others complete the task unnecessarily increases dependence and can heighten anxiety, which may further worsen motor performance. Teaching adaptive strategies can be helpful, but the immediate best action when time is the issue is to build extra time into the schedule and permit completion at the client’s pace.

Question 10

Which client is at highest risk for developing a pressure ulcer?

Accepted Answer

Answer reason: Unilateral paresthesia reduces protective sensation and repositioning effectiveness, so pressure can persist over bony prominences without the client noticing discomfort. Urine and stool incontinence adds continuous moisture and enzymatic/chemical irritation, accelerating maceration and increasing bacterial burden, which markedly raises ulcer risk. Compared with isolated immobility (e.g., traction or coma) or vascular disease with some ambulation, the concurrent sensory deficit plus incontinence represents a more potent, synergistic risk profile requiring aggressive prevention.

Question 11

Which statement best describes the effects of immobility in children?

Accepted Answer

Answer reason: Hospitalized children also have smaller physiologic reserves and are more vulnerable to complications like atelectasis, constipation, and deconditioning with shorter durations of bedrest. The option stating effects are “similar to adults” is incomplete because it ignores the heightened developmental impact and faster onset of complications in pediatric patients. Immobility can affect development, but it does not universally prevent language and fine motor progression in all cases, making that statement too absolute.

Question 12

You are caring for an older patient who is on complete bedrest. What interventions would you take to prevent respiratory complications?

Accepted Answer

Answer reason: Regular repositioning improves ventilation-perfusion matching, promotes deeper breathing, and helps mobilize secretions so they can be cleared. It is a direct, preventive nursing intervention for bedrest-related pulmonary complications. Routine vital signs may detect deterioration but does not prevent it, and restricting fluids can thicken secretions and worsen airway clearance. Bearing down with breath-holding resembles a Valsalva maneuver, which does not prevent respiratory complications and may cause hemodynamic instability in older adults.

Question 13

What is the most important nursing intervention for the prevention and treatment of pressure ulcers in an older, immobilized client?

Accepted Answer

Answer reason: Pressure ulcers primarily result from prolonged unrelieved pressure that impairs capillary blood flow, causing ischemia and tissue breakdown. Regular repositioning is the most effective foundational intervention because it directly removes pressure from bony prominences and restores perfusion on a scheduled basis (e.g., at least every 2 hours, individualized to risk and support surface). Support surfaces can reduce interface pressure but do not replace the need for turning, so they are adjunctive rather than the single most important action. Massage over pressure points is avoided because it can further damage fragile, ischemic tissue and worsen breakdown.

Question 14

A client with episodes of vertigo who has a fractured leg has been ordered crutches and not to bear weight on the affected extremity. The most appropriate crutch-walking gait the nurse should teach the client is the?

Accepted Answer

Answer reason: A four-point gait provides the widest base of support because three points contact the ground at all times, which is especially important for a client with vertigo. It also allows the affected leg to remain non–weight bearing while advancing the crutches and the unaffected leg in a controlled, stepwise manner. In contrast, swing-through and two-point patterns are faster and require better balance and coordination, increasing risk for loss of balance in vertigo.

Question 15

Following a left above-knee amputation with delayed prosthesis fitting, the nurse instructs the client about the importance of lying prone. Which of the following responses by the client indicates to the nurse that teaching is successful?

Accepted Answer

Answer reason: ” Prone positioning after an above-knee amputation is primarily used to prevent hip flexion contractures caused by prolonged sitting and keeping the hip flexed. Maintaining hip extension preserves range of motion needed for later prosthetic fitting and effective gait training. Swelling control is better addressed with appropriate residual-limb wrapping and positioning that avoids dependent edema; routine stump elevation in a chair can actually promote hip flexion contracture risk. Pressure-injury prevention is not the main rationale for prone positioning and can be managed with turning schedules and pressure-relieving surfaces.

Question 16

Best method to prevent foot drop in client on bed rest is to use?

Accepted Answer

Answer reason: A footboard/block placed at the foot of the bed maintains the ankle in neutral dorsiflexion and provides firm support to prevent plantar flexion contracture. This is the standard bedside positioning intervention for patients on prolonged bed rest. Splints can be used in some settings, but the classic nursing preventive measure for bed-rest-related foot drop is using a footboard/block; cradles relieve linen pressure and sandbags mainly support alignment/rotation rather than ankle position.

Question 17

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing difficulty breathing. Which of the following positions should the nurse encourage to improve the client's breathing?

Accepted Answer

Answer reason: Upright “tripod” positioning optimizes ventilation by increasing thoracic expansion and reducing diaphragmatic work, which is especially helpful in COPD with air trapping and accessory muscle use. Supporting the arms stabilizes the shoulder girdle so accessory muscles (e.g., pectoralis) can better assist respiration, decreasing dyspnea. Supine positioning can worsen ventilation by limiting chest expansion and promoting V/Q mismatch. Trendelenburg further impedes diaphragmatic excursion and increases venous return, which can exacerbate breathlessness.

Question 18

A nurse is providing discharge instructions to a client who had total hip replacement surgery. Which of the following statement should the nurse include in the teaching?

Accepted Answer

Answer reason: After total hip arthroplasty, clients must avoid hip flexion beyond 90 degrees and hip adduction to reduce risk of prosthetic dislocation. An elevated toilet seat keeps the hip from flexing excessively when sitting and standing, supporting safe transfers at home. Crossing legs increases adduction and internal rotation risk, which is a classic dislocation precaution violation. Sleeping with legs stacked without an abduction pillow promotes adduction, and positioning to maintain 90-degree hip flexion is unsafe because hip flexion should be limited, not encouraged.

Question 19

The nurse is caring for a client with a pneumothorax. The nurse notes the client is experiencing dyspnea. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: The priority is to improve ventilation and work of breathing using the least invasive, immediately available intervention. Upright positioning maximizes lung expansion, decreases diaphragmatic splinting, and can rapidly reduce dyspnea while further measures are arranged. Oxygen is often appropriate, but positioning is typically the quickest first step that can be initiated instantly while simultaneously assessing severity and preparing escalation. Intubation and chest tube insertion address worsening or persistent respiratory compromise but are not the initial nursing action before basic supportive measures and rapid reassessment.

Question 20

After surgical repair of the client’s hip, which of the following positions would be best for this client?

Accepted Answer

Answer reason: Keeping the hip abducted (often with an abduction pillow) helps maintain the femoral head in the acetabulum and reduces stress on the surgical repair. Adduction is a classic high-risk position for hip dislocation, especially after arthroplasty or repair, and should be avoided. Prone positioning is not the standard protective position immediately after hip surgery and can be difficult and unsafe early post-op. “Subluxated” describes an abnormal joint state rather than a therapeutic position and would indicate a complication.

Question 21

After surgical repair of a ruptured appendix, which position would be the most appropriate?

Accepted Answer

Answer reason: Elevating the head of bed modestly promotes comfort, supports ventilation, and uses gravity to help confine drainage away from the upper abdomen. Full upright positioning can increase tension on abdominal sutures and discomfort. Flat supine positioning tends to worsen abdominal pain and does not aid in limiting peritoneal spread.

Question 22

Which activity may be most helpful for a child who’s allowed full activity after repair of a clubfoot?

Accepted Answer

Answer reason: Water buoyancy decreases weight bearing, reducing pain and the risk of overloading the corrected foot and ankle while still allowing active movement for conditioning. It also supports bilateral leg use and ankle mobility in a controlled way, which helps rebuild gait mechanics. In contrast, prolonged standing and extensive walking increase repetitive weight-bearing forces and may contribute to fatigue or discomfort early in return to full activity.

Question 23

Which technique may assist a 3-month-old client diagnosed with torticollis?

Accepted Answer

Answer reason: Parent-performed, therapist-taught neck stretching and active/passive ROM promotes lengthening of the affected muscle and improves head rotation and lateral flexion over time. Simply placing the infant in a particular resting position does not reliably correct the contracture and may not address asymmetrical muscle function. Massage can be soothing, but without stretching/ROM it is less effective at correcting the movement limitation driving the condition.

Question 24

Which activity in a client with muscular dystrophy should a nurse anticipate the client having difficulty with first?

Accepted Answer

Answer reason: Because upright posture and gait require strong proximal lower-limb muscles, difficulty rising to stand and maintaining standing balance occurs early. Sitting generally requires less lower-extremity strength and can be maintained longer as weakness progresses. Bulbar (swallowing) and respiratory muscle involvement are usually later findings, though they become major complications as the disease advances.

Question 25

To promote safe transfers in a client with muscular dystrophy, a nurse should teach exercises to maintain which muscles?

Accepted Answer

Answer reason: The quadriceps are the primary knee extensors, so maintaining their strength directly improves the client’s ability to bear weight, stand, and transfer with less risk of buckling and falls. In muscular dystrophy, progressive proximal weakness makes functional tasks harder, so focusing on muscles most critical for stance and transfers preserves independence longer. By contrast, calf or hamstring strength alone does not provide the same knee-stabilizing power needed for safe standing transfers.

Question 26

A 13-year old with structural scoliosis has Harrington rods inserted. Which position would be best during the postoperative period?

Accepted Answer

Answer reason: Side positioning supports neutral alignment and helps decrease pressure on the incision and posterior spinal structures, while also promoting comfort and pulmonary expansion. Turning can be done using log-rolling, which is standard to prevent vertebral rotation and protect the hardware and fusion. In contrast, higher Fowler positions increase hip flexion and can contribute to discomfort and increased stress on the spine in the early postoperative period.

Question 27

A client has a broken lower leg with a nonweightbearing cast. Which crutch gait would be most appropriate for the nurse to teach?

Accepted Answer

Answer reason: A nonweightbearing extremity must be kept completely off the ground while ambulating, so the gait pattern must shift body weight to the crutches and the unaffected leg. The three-point gait advances both crutches together, then the unaffected leg moves forward, preventing any weight from being placed on the injured leg. Two-point and four-point gaits are designed for partial weight-bearing or bilateral weakness and typically involve alternating limb loading. Swing-through is more commonly used for bilateral lower-extremity impairment (e.g., paralysis) and is not the standard teaching pattern for unilateral nonweightbearing fractures.

Question 28

Which complication of immobility is most potentially life-threatening?

Accepted Answer

Answer reason: Immobility promotes venous stasis, increasing clot formation in the deep veins, which can embolize to the lungs and cause a pulmonary embolism with sudden hypoxemia, hemodynamic collapse, and death. This makes it the most immediately life-threatening complication compared with other immobility effects. Orthostatic hypotension can cause falls and syncope but is typically managed with gradual position changes and is less likely to be fatal. UTIs and pressure ulcers can become severe (e.g., sepsis), but they usually develop over time and are generally less acute than a PE risk from a DVT.

Question 29

When protective isolation isn’t indicated, a nurse plans which activity for a child receiving chemotherapy?

Accepted Answer

Answer reason: g., severe fatigue, orthostatic symptoms, uncontrolled pain, or critical cytopenias with bleeding risk). Since protective isolation is not needed, there is no isolation-related restriction on ambulation or participation in usual activities within the child’s energy limits. Allowing self-paced activity supports conditioning, appetite, mood, bowel function, and reduces deconditioning. The more restrictive options imply unnecessary immobility, which can increase weakness and complications without improving safety in the absence of other contraindications.

Question 30

The nurse is collaborating with the orthopaedic technician regarding interventions to reduce the roughness of a cast. What is the best intervention?

Accepted Answer

Answer reason: Petaling involves padding and taping the cast edges to create a smooth border that prevents skin irritation and breakdown from friction. This is the direct, standard intervention specifically aimed at reducing cast roughness at the margins that commonly rub against soft tissue. Breaking off rough areas can compromise cast integrity and create jagged edges that worsen abrasion risk. Elevation and distributing pressure address swelling and pressure-related complications, not the surface roughness of the cast edge.

Question 31

A toddler is immobilized with traction to the legs. Which play activity would be appropriate for the nurse to include in the plan of care for this child?

Accepted Answer

Answer reason: Toddlers benefit from simple, manipulative, repetitive activities that use upper-extremity gross motor skills and provide a safe outlet for energy and frustration while confined. This option can be positioned within reach, is developmentally appropriate for a toddler, and does not require ambulation or leg movement. A common distractor is the pull toy, which encourages walking/pulling and could jeopardize traction and safety.

Question 32

The nurse instructs a client with a hip-spica cast to avoid gas-forming foods. The client asks the nurse what can happen if the food is consumed. What is the best response by the nurse?

Accepted Answer

Answer reason: Gas-forming foods increase intestinal gas, which can cause uncomfortable bloating and pressure that the rigid cast cannot accommodate well. This can worsen pain, impair breathing comfort, and increase risk of decreased appetite or nausea. While passing gas may occur, the clinically relevant complication the nurse is trying to prevent in a spica cast is significant abdominal bloating that can create pressure and discomfort under the cast.

Question 33

The nurse is planning care for a client undergoing chemotherapy. What is the most important instruction for the nurse to give the client?

Accepted Answer

Answer reason: During chemotherapy, fatigue and deconditioning are common, and maintaining functional mobility helps preserve strength, endurance, and cardiopulmonary reserve while reducing complications of immobility (atelectasis, constipation, venous thromboembolism). This instruction individualizes activity to the client’s daily symptoms, vital signs, and tolerance, promoting safety without unnecessary restriction. Routine bed rest is not indicated and can worsen weakness and increase risk for complications. If thrombocytopenia or severe anemia develops, activity may need modification, but the safest default teaching is graded activity based on tolerance and clinical status.

Question 34

A client with a right stroke has a flaccid left side. Which intervention would best prevent shoulder subluxation?

Accepted Answer

Answer reason: Flaccid hemiplegia after stroke causes loss of shoulder muscle support, allowing the humeral head to drop and partially dislocate due to gravity. Proper support of the affected upper extremity in a sling maintains alignment of the glenohumeral joint and reduces traction on the capsule and ligaments during upright positioning and transfers. Wrist splinting targets distal joint positioning and does not address the primary problem at the shoulder. Range-of-motion can help prevent contractures, but it does not provide continuous mechanical support needed to prevent subluxation in a flaccid arm.

Question 35

Which observation by a nurse indicates that an 18-month-old in Bryant’s traction is properly positioned?

Accepted Answer

Answer reason: Bryant’s traction requires the child’s buttocks/hips to be just off the mattress so the body provides countertraction and the pull remains effective. If the hips rest on the bed or on a pillow, traction is reduced and alignment can be lost. Elevating the hips excessively (e.g., well above the heart) increases risk of impaired circulation and skin/nerve compromise. Proper positioning is therefore indicated by slight hip elevation while maintaining neurovascular integrity and correct line of pull.

Question 36

Which intervention should a nurse perform in a 4-year-old child in Buck's traction?

Accepted Answer

Answer reason: Maintaining continuous traction alignment while preventing immobility complications is the key nursing priority with Buck’s traction. Regular repositioning (while keeping the limb aligned and traction uninterrupted) helps prevent skin breakdown, pressure injury, atelectasis, and neurovascular compromise in an immobilized child. Pin-site care is specific to skeletal traction with pins/wires, not Buck’s (skin) traction. Weights should not be routinely released because that interrupts therapeutic traction and can worsen pain/spasm and alignment.

Question 37

Which nursing intervention can be implemented to prevent foot drop in a casted leg?

Accepted Answer

Answer reason: Foot drop results from prolonged plantar flexion and immobility causing weakness/contracture of ankle dorsiflexors and shortening of the Achilles tendon. Maintaining the ankle in a neutral, functional position reduces the risk of contracture and preserves proper alignment while the limb is immobilized in a cast. A right angle (90°) is the standard neutral position for preventing plantar-flexion deformity and supporting safe future weight bearing and gait. Forty-five degrees still leaves the ankle significantly plantar-flexed and does not adequately prevent the complication, while bed rest and warmth do not address joint positioning.

Question 38

A nurse is reviewing principles of good body mechanics with a student nurse. Which of the following techniques should be emphasized?

Accepted Answer

Answer reason: Using the legs (with a wide base of support and knees flexed) allows force generation from large muscle groups while keeping the back in neutral alignment. Bending from the waist increases lumbar flexion and shear forces, raising risk for back injury. Stretching to reach an object shifts the center of gravity outside the base of support and promotes poor alignment, increasing injury risk. While pushing can be preferable to pulling in some situations, the key emphasized principle here is leveraging the legs to reduce back stress.

Question 39

Which observation indicates to a nurse that a client understands his instructions on crutch walking?

Accepted Answer

Answer reason: Safe crutch ambulation requires weight bearing through the hands and wrists to avoid compressing neurovascular structures in the axilla. Allowing the axillae to rest on the crutches can injure the brachial plexus and axillary vessels, so it indicates incorrect technique. Proper fitting and gait also involve placing the crutches only a short distance in front of the feet (about 6 inches/15 cm), not 12 inches/30.5 cm. Using long strides is unsafe because it increases instability and fall risk; short, controlled steps maintain balance and proper sequencing.

Question 40

Which statement is an example of a key element in the nursing care plan?

Accepted Answer

Answer reason: Nursing care plans include measurable, time-bound patient-centered outcomes that guide and evaluate nursing interventions. This option states a specific behavior (ambulate), includes an objective measure (30’/9 m), and sets a timeframe (by discharge), making it a clear goal/outcome statement. In contrast, several other options read like provider orders or conditional medical management directives rather than a nursing outcome. A well-written outcome also supports mobility promotion and tracking functional progress over the hospitalization.

Question 41

The nurse is providing discharge teaching for a client with osteoarthritis. What is the most important information for the nurse to include?

Accepted Answer

Answer reason: Osteoarthritis management focuses on preserving joint function while minimizing pain and inflammation through balanced activity and rest. Activity pacing helps prevent symptom flares by avoiding prolonged or repetitive joint stress and incorporating rest periods, which improves functional endurance. Remaining sedentary promotes stiffness, muscle weakness, and reduced joint mobility, worsening disability over time. A generic “normal level of activity” is less safe because it may encourage overuse without attention to limits or rest. Vigorous exercise can aggravate joint pain and is not the priority compared with low-impact conditioning and pacing strategies.

Question 42

A client has decided on conservative treatment for a herniated nucleus pulposus. The nurse anticipates that the treatment will include which of the following?

Accepted Answer

Answer reason: Short-term activity modification/relative rest, analgesics (often NSAIDs and/or other prescribed pain control), and physical therapy to improve core strength, posture, and mobility are standard first-line measures. Surgical interventions and spinal fusion are reserved for refractory pain, progressive neurologic deficits, or red-flag complications such as cauda equina syndrome. Strenuous exercise early can aggravate symptoms and increase mechanical stress on the affected disc and nerve roots.

Question 43

While caring for a client after a left hip replacement, the nurse determines that discharge teaching has been effective when the client states?

Accepted Answer

Answer reason: ” After total hip arthroplasty, early mobilization is encouraged to reduce complications such as venous thromboembolism, atelectasis, and deconditioning, but activity is typically progressed with specific weight-bearing limits ordered by the surgeon. A statement acknowledging restricted/limited weight bearing demonstrates understanding of safe ambulation expectations during recovery. Bed rest is generally inappropriate because it increases immobility-related risks. Claiming no restrictions or stating absolute non–weight bearing for a fixed long period is not generally accurate across patients and suggests misunderstanding of individualized post-op mobility instructions.

Question 44

An elderly client in a nursing home is particularly susceptible to bone loss. The nurse is aware that bone loss may be caused by which of the following?

Accepted Answer

Answer reason: Nursing-home residents with limited ambulation commonly develop accelerated loss of bone mass because the skeleton is not being regularly stressed. This mechanism is a direct, well-established cause of bone loss in older adults. In contrast, reduced sunlight can contribute to low vitamin D and impaired calcium absorption, but the most direct and consistently tested cause of bone loss here is immobility.

Question 45

When performing stretches with a child who has scoliosis, which technique should be used by the nurse?

Accepted Answer

Answer reason: A slow, sustained stretch promotes relaxation, improves flexibility, and reduces risk of strain or injury in a child with postural asymmetry. Quick, forceful movements toward pain can cause microtrauma and increased guarding, worsening discomfort and limiting range of motion. Very brief holds (3–4 seconds) are generally less effective for improving flexibility compared with a sustained hold.

Question 46

A 9-month-old infant has torticollis with rotation of the head to the left and side bending to the right. The nurse is aware that placing the infant in which position would be most effective for developing muscle lengthening?

Accepted Answer

Answer reason: With rotation to the left and right side-bending, the left SCM is typically shortened; placing the infant in left side-lying encourages the head/neck to fall into the opposite pattern (right rotation and left lateral flexion), which lengthens the tight SCM. Side-lying also facilitates midline head control and reduces compensatory extension compared with prone. Supine or prone alone does not specifically bias the corrective stretch direction as effectively as targeted side-lying.

Question 47

A nurse is instructing a wheelchair-bound client with muscular dystrophy on exercises to best prevent skin breakdown. What is the best information for the nurse to provide?

Accepted Answer

Answer reason: This maneuver provides the most effective pressure relief compared with weight shifts that may not fully unload tissue. In muscular dystrophy, maintaining skin integrity is critical because limited mobility increases duration of pressure and risk of ischemia. Leaning side to side or forward can reduce pressure but often leaves substantial load on seated bony prominences, and gluteal sets improve circulation but do not reliably offload pressure.

Question 48

The client is in skeletal traction with 20 lb of traction applied to a right lower leg fracture. Which intervention should the nurse perform at regular intervals?

Accepted Answer

Answer reason: Regular pin-site care helps prevent local infection (erythema, drainage, loosening) that can progress to osteomyelitis and compromise fracture healing. Traction weights should not be removed routinely because constant pull is required to maintain alignment; removing them disrupts reduction. The affected extremity should not be repositioned in a way that alters the traction line of pull, and while ROM to unaffected joints is beneficial, it is not the key traction-specific intervention that must be performed at regular intervals.

Question 49

A bedridden client develops disuse osteoporosis. Which nursing intervention is most important for this client?

Accepted Answer

Answer reason: Disuse osteoporosis results from decreased mechanical loading, which accelerates bone resorption; the priority intervention is to provide safe, regular movement to stimulate bone and maintain musculoskeletal function. ROM helps preserve joint mobility and muscle strength and supports gradual mobilization, which is the most direct nursing action to address immobility-related bone loss. It also reduces secondary complications of immobility such as contractures and stiffness that further limit weight-bearing activity. Turning/coughing/deep breathing targets pulmonary complications, and leg elevation targets venous stasis—important, but less directly related to preventing progression of disuse bone loss.

Question 50

Which nursing intervention is used during assessment of an elderly client?

Accepted Answer

Answer reason: Older adults commonly have reduced strength, balance, joint mobility, and orthostatic tolerance, so the assessment environment should be adapted to promote safety and comfort. Adjusting the table height and positioning minimizes fall risk, decreases unnecessary exertion, and supports accurate assessment without provoking pain or dizziness. Rapid position changes can precipitate orthostatic hypotension and increase fall risk, making that approach unsafe. Speaking loudly and quickly can worsen comprehension (especially with hearing loss) and is less effective than speaking clearly at a normal pace with appropriate accommodations.

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