Test Bank for Dewitt’s Fundamental Concepts and Skills for Nursing 6th Edition by Miles Duke

Test Bank for Dewitt’s Fundamental Concepts and Skills for Nursing 6th Edition by Miles Duke

7. A patient has left sided paralysis following a right-sided cerebrovascular accident (CVA). After completing a bed bath, the nurse should begin to change the sheets by: a. lowering both side rails and rolling the patient to the side of the bed. b. asking the patient to roll to his right and hold on to the side rail for support. c. positioning the patient in a supine position with both side rails raised. d. positioning the patient in a side lying position on his left side with the near side rails raised. ANS: D Moving the patient to the left side lying position provides safety for the patient and allows the patient to use his good (right) hand to hold the rail. DIF: Cognitive Level: Analysis REF: p. 327|Skill 20-2 OBJ: Clinical Practice #2 TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 8. An older adult patient is discharged home after hip surgery. The statement that indicates a family member understands discharge safety instructions given by the nurse is: a. “I will install grab bars in the bathroom for both the toilet and bathtub.” b. “I will put all personal items away to prevent my mother from dropping things.” c. “I will dim the lights at night to prevent wakefulness.” d. “I will ensure that my mother takes naps during the day to prevent tiredness.” ANS: A Grab bars in the tub and at the toilet help the person with joint impairment to bathe and toilet safely. Using well-lit areas during the day and night lights at night is helpful to avoid falls. Daytime napping may cause restlessness at night. DIF: Cognitive Level: Analysis REF: p. 330|Box 20-3 OBJ: Theory #4 TOP: Safety KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 9. The nurse in a long-term facility who is making a fall assessment would identify the person most at risk for a fall to be a resident who: a. paces all day in the halls and sleeps well at night. b. had knee replacement surgery 2 days ago and wears a knee brace. c. had a stroke with right-sided weakness 2 weeks ago and is confused. d. uses a walker to ambulate both indoors and outdoors. ANS: C The most common factors predisposing a person to falls are impaired physical mobility, altered mental status, and unavailability of assistance. DIF: Cognitive Level: Analysis REF: p. 329 OBJ: Theory #4