A client was involved in a multi-car collision six days ago.

Sustained a liver laceration, right rib fracture, and right femur fracture. The liver laceration was repaired.

An intramedullary rod was placed to repair the femur fracture. The client is progressing.

The nurse is implementing the plan of care to increase mobility.

Complete the diagram by dragging from the choices area to specify which type of exercises the client needs, two actions the nurse should take to facilitate the exercises, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

The correct answer is: Type of Exercises: Isometric exercises Isotonic exercises Actions to Take: Support the extremity Encourage active range of motion exercises Parameters to Monitor: Pain level Range of motion Rationale:

Isometric exercises: These exercises involve contracting the muscle without moving the joint. They are beneficial for maintaining muscle strength and preventing muscle atrophy, especially when the client is unable to perform full range of motion exercises due to pain or limited mobility. Isotonic exercises: These exercises involve moving the joint through its full range of motion with muscle contraction. They help improve muscle strength, endurance, and joint mobility. Isotonic exercises are important for clients who are progressing in their recovery and are able to tolerate more movement. Support the extremity: Providing support to the extremity during exercises helps prevent injury and reduces pain. It also ensures that the client performs the exercises correctly and safely. Encourage active range of motion exercises: Active range of motion exercises involve the client moving their own joints through their full range of motion. These exercises help improve joint mobility, muscle strength, and overall function. Encouraging the client to perform these exercises promotes independence and active participation in their recovery. Pain level: Monitoring the client’s pain level is important to ensure that the exercises are not causing excessive discomfort or injury. Pain management is crucial for promoting compliance with the exercise regimen and facilitating recovery. Range of motion: Assessing the client’s range of motion helps determine the effectiveness of the exercises and the progress of the client’s recovery. It also helps identify any limitations or areas that need further attention

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Correct Answer is B

Explanation

Choice A rationale

Identifying effective pain relief measures is important, but it does not directly assess the quality of the pain. This approach focuses on management rather than understanding the pain’s characteristics.

Choice B rationale

Asking the client to describe the pain is the most direct way to assess its quality. This allows the nurse to gather detailed information about the pain’s nature, intensity, and characteristics, which is crucial for accurate diagnosis and treatment.

Choice C rationale

Providing a numeric pain scale helps quantify the pain’s intensity but does not provide qualitative details about the pain’s nature. It is useful for monitoring pain levels over time but not for initial assessment.

Choice D rationale

Observing body language and movement can give clues about pain but is subjective and less reliable than directly asking the client. It should be used as a supplementary method rather than the primary approach.

A. Start collecting the specimen with the next void. B. Begin the collection the next day. C. Observe the sample for sediment. D. Empty the sample into the 24-hour container.

Correct Answer is A

Explanation

Choice A rationale

Starting to collect the specimen with the next void is the correct action. The 24-hour urine collection for creatinine clearance should start with an empty bladder. The first urine of the day is discarded, and the time is noted.

Choice B rationale

Beginning the collection the next day is unnecessary and would delay the process. It is important to start the collection as soon as possible to avoid further delays.

Choice C rationale

Observing the sample for sediment is not relevant to the collection process. The focus should be on starting the collection with the next void.

Choice D rationale

Emptying the sample into the 24-hour container is incorrect because the first urine sample should be discarded to ensure accurate results.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who is having pain in the right upper abdominal area. To assess the quality of the client’s abdominal pain, which approach should the nurse use?

Correct Answer is B

Explanation

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client’s attention on which focus?

A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?