BASIC PHYSICAL CARE EXAM

1. The nurse at an outpatient surgical clinic witnesses client signatures. When obtaining signatures , which clients can sign their own consent for a procedure/surgery? Select all that apply.
a) A 7 year old who needs an open reduction internal fixation (ORIF) of the right arm.
b) A 62 year old with macular degeneration who is ordered a routine colonoscopy.
c) A married 17 year old who requires a cholecystectomy for relief of pain and nausea
d) A 16 year old who is obtaining an elective breast reduction for back relief.
2. A nurse is developing a care plan for a client with injury to the frontal lobe of the brain. Which nursing actions would be included as part of the care plan? Select all that apply.
a) Keep instruction simple and brief because the client will have difficulty concentrating .
b) Speak clearly and slowly because the client will have difficult hearing .
c) Assist with bathing and toileting because the client will have vision disturbances.
d) Orient the client to person, place and time as needed because the client will have memory problems.
e) Assess vital signs frequently throughout the nursing shift because vital body functions will be affected.
3. A nurse, assigned to a child with emphysema, is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply.
a) Reduce fluid intake to less than 850 ml per shift.
b) Teach diaphragmatic, pursed-lip breathing.
c) Administer low -flow oxygen as needed.
d) Maintain the client in a supine position as much as possible.
e) Encourage alternating client activity with rest periods.
f) Teach the use of postural drainage and chest physiotheraphy.
4. A neonatal nurse is assessing a 2 week old's pain level following an open-heart surgery. To assess the pain level using an age-appropriate scale, which scales would be appropriate? Select all that apply.
a) Numerical 0 to 10 scale
b) FLACC scale
c) Wong-Baker FACES Pain Rating Scale
d) Visual analog scale
e) NIPS
5. A nurse is caring for a client who underwent surgical repair of the detached retina in the right eye. Which nursing interventions would the nurse perform postoperatively? Select all that apply.
a) Place the client in a prone position.
b) Approach the client from the left side.
c) Encourage deep breathing and coughing.
d) Discourage the client from bending down.
e) Orient the client to the environment.
f) Administer a stool softener.
6. A nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate? Select all that apply.
a) Instill isotonic eyedrops as necessary.
b) Provide several small, well balanced-meals.
c) Provide regular rest periods.
d) Keep the environment warm.
e) Encourage frequent visitors.
f) Weigh the client daily.
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