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CASAL 1 OA Remediation: Questions And Accurate Answers
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CASAL 1 OA Remediation: Questions And Accurate Answers
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CASAL 1 OA Remediation: Questions And AccurateAnswers
Which risk factor would the nurse identify as the most significant indicator for
increased risk for patient falls?
A client with prior history of falling.
A client with visual and hearing impairment.
A client who grabs onto furniture as an ambulatory aid.
A client experiencing urinary incontinence and urgency. Right Ans - A
client who grabs onto furniture as an ambulatory aid.
Rationale
All options are indicators, but according to the Morse Fall Scale Assessment a
client who uses furniture as an ambulatory aid is rated as "30" points versus
prior history of falls is rated as "25 points".
What should the nurse do to demonstrate proper body mechanics when
assisting a client to a standing position from a sitting position? (Select all that
apply.)
Rock their own body weight as they pull the client up towards them.
Keep their own knees locked as they lift the client in a smooth motion.
Stand in front of the client, move their own feet apart and bend at the knees.
While standing behind the client, secure their own arms around the client's
chest and lift upward.
Assess the client and determine whether or not another care provider is
needed to assist. Right Ans - Rock their own body weight as they pull the
client up towards them.
Stand in front of the client, move their own feet apart and bend at the knees.
,Assess the client and determine whether or not another care provider is
needed to assist.
Rationale
Pulling is easier than lifting and the momentum by rocking the nurse's body
uses that body weight to enhance the force of arm muscles. Moving feet apart
widens the base of support and bending knees lowers the center of gravity.
These actions are elements of safe body mechanics. When possible, use teams
to lift clients ast is decreases the incidences of lower back injuries in
healthcare workers and is safer for the client.
What nursing interventions should be implemented for a client whose
absolute neutrophil count (ANC) is below 500?
Admit to a reverse isolation room.
Begin bleeding precaution protocol.
Caution against any cut flowers in client's room.
Screen and limit individuals wishing to visit.
Provide only fresh organic fruits and vegetables. Right Ans - Admit to a
reverse isolation room.
Caution against any cut flowers in client's room.
Screen and limit individuals wishing to visit.
Rationale
The client has neutropenia and is at risk for infection. A reverse isolation,
positive pressure room is teh best choice for these clients. Cut flowers and live
plants, along with fruits and vegetables have been shown to carry organisms
that could cause harm to the immuno-compromised client. Visitors of these
clients need to be limited and screen for possible signs of infection which
could be lethal to an immuno-compromised client.
Which questions are best for the nurse ask to assess for "disuse syndrome" in
clients diagnose with neuromuscular diseases such as muscular dystrophy or
multiple sclerosis? (Select all that apply.)
, What is included in a typical day for you?
Do you feel you are financially stable?
In what part of town is your home located?
How much assistance do you need to move around?
On a scale 1-10, how would you rate overall pain level? Right Ans - What is
included in a typical day for you?
How much assistance do you need to move around?
On a scale 1-10, how would you rate overall pain level?
Rationale
These questions are open-ended and will give insight to the client's activity
level throughout the day and eating habits; whether or not their living
environment is adaptive and supportive; and their perception of discomfort.
The mnemonic "ABCDE", stands for age, body weight, chronic illness,
discomfort, and environment is an easy way to remember risk factors for
"disuse syndrome".
What interventions should the nurse implement for a hospitalized client to
help prevent falls?
Leave the lights on in the client's room at night.
Keep wheels of bed in the locked position.
Place the client's call bell within easy reach.
Make sure to return the bed to its lowest position.
Ensure all four side rails of bed are in upright position. Right Ans - Keep
wheels of bed in the locked position.
Place the client's call bell within easy reach.
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