ATI Material for Test 3, Mobility: Activity and Exercise, Pain and Comfort and Rest and Sleep (Test 3), Test 3 Material
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ATI Material for Test 3, Mobility: Activity and Exercise, Pain and Comfort and Rest and Sleep (Test 3), Test 3 Material
A nurse in a provider's office is caring for a client who states that, for the past week, "I have felt tired during the day and cannot sleep at night." Which of the following res...
ATI Material for Test 3, Mobility: Activity and Exercise,
Pain and Comfort and Rest and Sleep (Test 3), Test 3
Material
A nurse in a provider's office is caring for a client who states that, for the past
week, "I have felt tired during the day and cannot sleep at night." Which of the
following responses should nurse asks when collecting clients about the client's
difficulty sleeping?
> "Have your working hours changed recently?"
> "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?"
> "Has anyone ever told you that you seem to stop breathing for a few seconds while
you are asleep?"
> "Tell me about any personal stress you are experiencing."
A nurse is talking with a client about ways to help sleep and rest. Which of the
following recommendations should the nurse give to the client to promote sleep
and rest?
> Practice muscle relaxation techniques
> Exercise each morning
> Alter the sleep environment for comfort
> Limit fluid intake at least 2 hours before bedtime
A nurse is caring for a client who has been following the facility's routine and
bathing in the morning. However, at home, the client always takes a warm bath
just before bedtime. Now the client is having difficulty sleeping at night. Which of
the following actions should the nurse take first?
Allow the client to take a bath in the evening
A nurse is preparing a presentation at a local community center about sleep
hygiene. When explaining rapid eye movement (REM) sleep, which of the
following characteristics should the nurse include?
> REM sleep provides cognitive restoration
> It is difficult to awaken a person in REM sleep
> Vivid dreams are common during REM sleep
A nurse is instructing a client who has narcolepsy about measures that might
help with self-management. Which of the following statements should the nurse
identify as an indication that the client understands the instructions?
"I'll take short nap whenever I feel a little sleepy."
A nurse at a clinic is collecting data about pain from a client who reports severe
abdominal pain. The nurse asks the client if there has been any accompanying
nausea and vomiting. Which of the following pain characteristics is the nurse
attempting to determine?
Presence of associated manifestations
A nurse is collecting data from a client who is reporting pain despite taking
analgesia. Which of the following actions should the nurse take to determine the
intensity of the client's pain?
Offer the client a pain scale to measure their pain
,A nurse is discussing the care of a group of clients with a newly licensed nurse.
Which of the following clients should the newly licensed nurse identify as
experiencing chronic pain?
A client who has episodic back pain following a fall 2 years ago.
A nurse is monitoring a client for adverse effects following the administration of
an opioid. Which of the following effects should the nurse identify as an adverse
effect of opioids?
> Bradypnea
> Orthostatic hypotension
> Nausea
A nurse is caring for a client who is receiving morphine via a patient-controlled
analgesia (PCA) infusion device after abdominal surgery. Which of the following
statements indicates that the client knows how to use the device?
"I should tell the nurse if the pain doesn't stop while I am using this device."
A nurse is caring for a client who is receiving enteral tube feedings due to
dysphagia. Which of the following bed positions should the nurse use for safe
use for safe care of this client?
Semi-fowler's
A nurse is caring for a client who is sitting in a chair and asks to return to bed.
Which of the following actions is the nurse's priority at this time?
Determine the client's ability to help with the transfer.
A nurse is instructing a client who has COPD about using the orthopneic position
to relieve shortness of breath. Which of the following statements should the
nurse make?
"Have a table beside your bed so you can sit on the bedside and rest your arms on the
table?"
A nurse manager is reviewing guidelines for preventing injury with staff nurses.
Which of the following instructions should the nurse manager include?
> Request assistance when repositioning a client
> Avoid twisting your spine or bending at the waist
> Use smooth movements when lifting and moving clients
A nurse educator is reviewing proper body mechanics during employee
orientation. Which of the following statements should the nurse identify as an
indication that an attendee understands the teaching?
> "The lower my center of gravity, the more stability I have."
> "To broaden my base of support, I should spread my feet apart."
> "When I lift an object, I should hold it as close to my body as possible."
A nurse is caring for a client who has been sitting in a chair for 1 hour. Which of
the following complications is the greatest risk to the client?
Pressure injury
A nurse is caring for a client who is postoperative. Which of the following
interventions should the nurse take to reduce the risk of thrombus development?
> Apply elastic stockings
> Assist the client to change positions often
A nurse is planning care for a client who is on bed rest. Which of the following
interventions should the nurse plan to implement?
, Encourage the client to perform antiembolic exercises every 2 hours
A nurse is evaluating a client's understanding of the use of a sequential
compression device. Which of the following client statements indicated client
understanding?
"This device will keep the blood pumping through my leg."
A nurse is instructing a client, who has an injury of the left lower extremity, about
the use of a cane. Which of the following instructions should the nurse include?
> Hold the can on the right side
> Keep two points of support on the floor
> After advancing the cane, move the weaker leg forward
Mobility
A state or quality of being mobile or movable
Mobility Is Dependent on
• Underlying skeletal stability
• Muscle strength
• Neuromuscular coordination
• Joint function
• Adequate oxygenation
• Perfusion
• Cognition
• Adequate Energy
• Age
Immobility
The inability to move
NANDA
A state in which the individual experiences a limitation of ability for independent physical
movement
Risk of Complications with Mobility
Increases with the degree of immobility and the length of time of immobilization
7 days
Needed to restore function lost after 1 day of bed rest
Exercise Promotes
> Muscle Strength
> Maintains joint flexibility
> Improves respiratory, cardiovascular, and circulatory status
ROM Exercises
Designed to prevent contractures
Types of Exercise
Aerobic and anaerobic
Aerobic Exercise
Sustained exercise that increases heart and lung fitness; may also alleviate depression
and anxiety
Anaerobic Exercise
Intense short bursts of activity in which the muscles work so hard that they produce
energy without using oxygen
Isotonic
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