Basic Care and Comfort NCLEX Practice Test Answers and Rationale
1. Answer D. Exercise is important to keep the joints and muscles functioning and to prevent secondary complications. Using the overhead trapeze prevents hazards of immobility by permitting movement in bed and strengthening of the upper extremities in preparation for ambulation. Sitting in a wheelchair would require too great hip flexion initially. Asking her family to visit would not facilitate the resumption of activities. Sitting in a chair would cause too much hip flexion. The client initially needs to be in a low Fowler’s position or taking a few steps (as ordered) with the aid of a walker.
2. Answer A. It is important to measure intake and output, which should equal. Enteral feeding are hyperosmotic agents pulling fluid from cells into vascular bed. Water given before feeding will present a hyperosmotic diuresis. I and O measures assess fluid balance.
3. Answer C. Esophageal varices results from increased portal hypertension. In portal hypertension, the liver cannot accept all of the fluid from the portal vein. The excess fluid will back flow to the vessels with lesser pressure, such as esophageal veins or rectal veins causing esophageal varices or hemorrhoids.
4. Answer A. Elevation of the head of the bed allows gravity to assist in decreasing the backflow of acid into the esophagus. Fluid does not flow uphill. The other three options all increase fluid backflow into the esophagus through position or increasing abdominal pressure.
5. Answer D. Particularly in the elderly adults, therapeutic massage will help improve circulation and muscle tone as well as the personal attention and social interaction that a good massage provides. A massage is contraindicated in any condition where massage to damaged tissue can dislodge a blood clot.
6. Answer C. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. All of the other foods do not affect LES pressure.
7. Answer B. TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to hypertonicity of the solution. Option 1 is incorrect; medication therapy can continue during TPN therapy. Option 3 is incorrect; flushing is not required because the initiation of TPN does not require a client to remain on bed rest during therapy. However, other clinical conditions of the client may affect mobility issues and warrant the client’s being on bed rest.
8. Answer B. Clients who are lactose intolerant can digest frozen yogurt. Yogurt products are formed by bacterial action, and this action assists in the digestion of lactose. The freezing process further stops bacterial action so that limited lactase activity remains. Option 1 is incorrect; elimination of all dairy products can lead to significant clinical deficiencies of other nutrients. Option 3 is incorrect because drinking milk on an empty stomach can exacerbate clinical symptoms. Drinking milk with a meal may benefit the client because other foods, (especially fat) may decrease transit time and allow for increased lactase activity. Option 4 is incorrect because although individual tolerance should be acknowledged, spreading out the use of known dairy products will usually exacerbate clinical symptoms.
9. Answer B. There is potential for a lowered pain tolerance to exist with diminished adaptative capacity.
10. Answer C. Cutaneous stimulation allows the patient to have control over his pain and allows him to be in his own environment. Cutaneous stimulation increases movement and decreases pain.
11. Answer A. Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol.
12. Answer C. Although all of the options above are correct, the first and most important piece of information in this client’s pain assessment is what the client is telling you about the pain –“the client’s report.”
13. Answer B. Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown, decreased metabolism and bone demineralization. Secondary alterations also occur in the cardiovascular, respiratory and renal systems. Similar effects and alterations occur in adults.
14. Answer D. Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats
15. Answer A. Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.
16. Answer A. When a person with weakness on one side uses a cane, there should always be two points of contact with the floor. When Ms. Kelly. moves the cane forward, she has both feet on the floor, providing stability. As she moves the weak leg, the cane and the strong leg provide support. Finally, the cane, which is even with the weak leg, provides stability while she moves the strong leg. She should not hold the cane with her weak arm. The use of the cane requires arm strength to ensure that the cane provides adequate stability when standing on the weak leg. The cane should be held in the left hand, the hand opposite the affected leg. If Ms. Kelly. moved the cane and her strong foot at the same time, she would be left standing on her weak leg at one point. This would be unstable at best; at worse, impossible
17. Answer B. Mayonnaise in tuna salad is high in fat. The whole wheat bread has some fiber. This choice shows a low-fat soup (which would have been higher in fat if made with chicken or beef stock) and high-fiber bread and soup contents (both the vegetables and the legumes). Salad is high in fiber, but hard boiled eggs are high in fat. There is some fiber in the apples and walnuts. The walnuts are high in fat, as is the chicken.
18. Answer A. Stiffness of a joint may indicate the beginning of a contracture and/or early muscle atrophy. Soreness of the gums is not related to immobility. Short-term memory loss is not related to immobility. Decreased appetite is unlikely to be related to immobility.
19. Answer A. Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For the first 4 to 5 months of infancy iron stores laid down for the baby during pregnancy are adequate. When fetal iron stores are depleted, supplemental dietary iron needs to be supplied to meet the infant’s rapid growth needs. Iron deficiency may occur in the infant who drinks mostly milk, which contains no iron, and does not receive adequate dietary iron or supplemental iron. Daily dietary intake is much more related to the diagnosis of iron deficiency anemia than is sociocultural, economic, and educational background of the family. Iron deficiency anemia in an infant is very unlikely to be related to gastrointestinal bleeding. Anemia during pregnancy is unlikely to be the cause of the infant’s iron deficiency anemia. Fetal iron stores are drawn from the mother even if she is anemic.
20. Answer D. Foods high in bulk are appropriate. Exercise should be a part of a bowel training regimen. To assess the client for a bowel training program the factors causing the bowel alteration should be assessed. A routine for bowel elimination should be based on the client’s previous bowel habits and alterations in bowel habits that have occurred because of illness or trauma. The client and the family should assist in the planning of the program which should include foods high in bulk, adequate exercise, and fluid intake of 2500-3000 ml.
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