Answers and Explanations

Chapter Quiz

The Answer is 4
The LPN/LVN cares for a client diagnosed 6 months ago with a 6th thoracic (T6) spinal cord injury. The client reports a “throbbing headache,” and the client’s face, neck, and upper chest are flushed and diaphoretic. Which action should the LPN/LVN take FIRST?

Strategy: As you can see, not all the answers involve positioning. Read the question and answers to identify the topic, and note the level of the spinal cord injury. What complication of spinal cord injury do these symptoms describe? Autonomic dysreflexia is a potential complication when a client has a spinal cord injury of T6 or above. The topic is the FIRST action to take when autonomic dysreflexia is suspected.

Autonomic dysreflexia is an emergency. Immediate action must be taken to prevent severe hypertension and a stroke. Think about which action will decrease blood pressure most quickly.

Category: Implementation/Physiological Integrity/Reduction of Risk Potential
1. Loosening the upper body clothing is an appropriate action when autonomic dysreflexia occurs, but is it the first action? Keep for consideration.
2. Checking for fecal impaction is an appropriate action, as fecal impaction may be a cause of autonomic dysreflexia. The impaction should be removed, but is it the first action? Keep for consideration.
3. Removing the urinary catheter is an appropriate action. Bladder distension may be a cause of autonomic dysreflexia. If the catheter is obstructed, it should be removed. Is this the first action? Keep for consideration.
4. CORRECT: What happens if you sit the client upright? The client’s blood pressure will immediately decrease. Remember that autonomic dysreflexia is an emergency and immediate action must be taken to decrease blood pressure. This action will prevent a further increase in blood pressure. Select this answer.
The Answer is 3
The LPN/LVN assists with the care of a client diagnosed 2 weeks ago with a right-sided stroke. When assisting the client with meals, it is MOST important for the LPN/LVN to take which action?

Strategy: Identify the topic of the question: All answers relate to swallowing and eating. Recall that clients diagnosed with stroke often have difficulty swallowing and are at risk for aspiration. The question asks you to select the priority, or “MOST important” action—preventing aspiration. Consider each answer choice and determine if the action will decrease the risk of aspiration.

Category: Implementation/Physiological Integrity/Physiological Adaptation
1. Swallowing each bite of food more than once will help clear the oropharynx and decreases the risk of aspiration. Is it necessary for the client to swallow each bite of food 4 times? No. Eliminate.
2. Use of a straw and drinking thin liquids both increase the risk of choking and aspiration. Thin liquids are more difficult to swallow. The risk of choking and aspiration is increased. Eliminate.
3. CORRECT: What happens when a client sits in an upright position after a meal? Gravity increases the passage of food into the stomach. Will this help prevent aspiration? Yes. Keep for consideration.
4. Milk and milk products increase production of saliva and make swallowing more difficult. The client is at greater risk for aspiration. Eliminate.
The Answer is 2
The LPN/LVN assists with the care of a client diagnosed with a 4th cervical (C4) complete spinal cord injury. Which observation MOST concerns the LPN/LVN?

Strategy: Read the question and answers to identify the topic: prevention of pressure ulcers. Recall that clients diagnosed with a spinal cord injury are at risk for pressure ulcers due to immobility, inability to detect sensation, and shearing force, which can damage the tissue. Next, consider each answer choice. Remember, you are looking for something that indicates a problem.

Category: Evalution/Physiological Integrity/Physiological Adaptation
1. Does a 30-degree side-lying position indicate a problem? No. This position reduces the risk for pressure ulcer formation.
2. CORRECT: Does this indicate a problem? Yes. If a client sits at a 45-degree angle of elevation, there is shearing force on bony prominences. The risk of pressure ulcer formation is increased.
3. Does bathing with warm water and gentle soap indicate a problem? No. Gentle skin cleansing decreases the tissue irritation and damage that can lead to pressure ulcer formation. These agents are also less irritating to the skin than hot water and strong soap.
4. Does this indicate a problem? No. If light pressure is used when rubbing the skin with a bath towel, there is less risk of tissue irritation and damage.
The Answer is 1
The LPN/LVN assists with the care of a client 48 hours after a right total hip arthroplasty. Which observation requires an intervention by the LPN/LVN?

Strategy: Identify the topic: appropriate positioning after a total hip arthroplasty. Recall the goals for clients after a total hip arthroplasty. One goal is to prevent subluxation (partial dislocation) or total dislocation of the prosthesis.

The question asks which answer requires an intervention. Review the answers and determine if each action is correct or incorrect. Be careful! You are looking for an incorrect action.

Category: Evalution/Physiological Integrity/Physiological Adaptation
1. CORRECT: When a client is in high Fowler’s position, the degree of elevation is 80 to 90 degrees. What is the effect of this position? It increases the risk of prosthesis dislocation. This action is incorrect.
2. What is the effect of slight abduction of the involved hip and leg? It decreases the risk of prosthesis dislocation. This is a desired outcome.
3. Elevating the head 60 degrees or less does not increase the risk of prosthesis dislocation. (By contrast, if the head is elevated more than 60 degrees, the risk of subluxation and dislocation is increased.) This action is correct.
4. Placing a pillow between the legs while turning maintains slight abduction of the involved hip and leg. This action is correct.
The Answer is 2 and 5
The LPN/LVN prepares the female client for a vaginal exam. The client is positioned to best increase the vaginal opening for examination. Which of the following features would this position include? Select all that apply.

Strategy: Visualize the client ready for the examination. Then consider each answer choice in turn.

Category: Planning/Reduction of Risk Potential
1. The pillow will bend the neck upward, causing discomfort.
2. CORRECT: The back remains flat on the exam table.
3. The client’s feet will not fit into the stirrups if knees are straight.
4. Placement of the arms does not play a factor in this position.
5. CORRECT: The thighs are angled away from the trunk of the body (abduction).
6. The legs are not brought close to the trunk of the body (adduction).
The Answer is 2
The LPN/LVN in the long-term care facility assists the client with COPD and varicose veins. Before breakfast is served, the nurse places the client in Fowler’s position. Which of the following BEST describes why Fowler’s position would be used in this client?

Strategy: “BEST” indicates that discrimination is required to answer the question. Remember the ABCs.

Category: Implementation/Physiological Integrity/Basic Care and Comfort
1. A client in Fowler’s position can use a pillow to moderately flex the neck. This would not impede, and might help, the client’s swallowing ability.
2. CORRECT: Gravity pulls the diaphragm downward, increasing space for lung expansion. The client can breathe easier.
3. There is no “natural” back position.
4. Fowler’s position promotes venous return; however, the reason this client is placed in Fowler’s position is to increase chest expansion to help the client breathe.
The Answer is 3 and 5
The LPN/LVN prepares the client with hemorrhoids for a rectal exam. Depending on the physical limitations of the client, the nurse should put the client in which of the following positions? Select all that apply.

Strategy: Visualize the client ready for the examination. Then consider each answer choice.

Category: Planning/Reduction of Risk Potential
1. In the prone position, where the client lies on the abdomen, the rectal area cannot be readily accessed.
2. In the supine position, where the client lies on the back, there is no access to the rectal area.
3. CORRECT: The knee-chest position allows for visualization of the rectal area.
4. The Trendelenburg position has the client lying on the back, which gives no access to the rectal area.
5. CORRECT: In Sims’ position, the client is lying on one side with the upper leg bent. This position allows access to the rectal area.
6. Fowler’s position has the client lying on the back, which gives no access to the rectal area.
The Answer is 1 and 4
The home-care LPN/LVN visits the frail client with type 2 diabetes, osteoporosis, and nighttime drooling. The client sleeps in the prone position. The nurse recognizes which of the following as an advantage of this position for the client? Select all that apply.

Strategy: Remember this client’s characteristics and the benefits of a prone position. Consider each answer choice keeping both facts in mind.

Category: Evaluation/Physiological Integrity/Basic Care and Comfort
1. CORRECT: Allowing full extension of the hip and knee joints is an advantage of the prone position.
2. Producing lordosis (inward curvature of the spine) is a disadvantage, because it puts strain on the client’s back.
3. Causing plantar flexion is a disadvantage, because it overstretches the foot muscles.
4. CORRECT: Allowing saliva drainage to flow from the mouth is an advantage of the prone position.
5. The prone position does not promote better breathing. It inhibits chest expansion, which is a disadvantage.
6. The prone position has no effect on the client’s blood sugar; this is neither an advantage nor a disadvantage.
The Answer is 3, 2, 1, 5, 6, 4
The LPN/LVN in the postsurgical unit cares for the client immediately after an L4-L5 spinal fusion. The physician’s order calls for the client to be turned every hour. Arrange the following steps in the order that the nurse should perform them. All options must be used.

Strategy: Picture the client with a surgical wound in the lumbar region. It must not be distorted when moving the client.

Category: Implementation/Physiological Integrity/Basic Care and Comfort
1. Perform hand hygiene.
2. Remove the pillow from under the client’s head.
3. Place the pillow between the client’s legs.
4. Firmly grasp the client’s draw sheet with both hands.
5. Move the client’s body as a unit.
6. Document the client’s repositioning.
The Answer is 1
The LPN/LVN cares for the obstetrical client who is in active labor. Suddenly the fetus’s umbilical cord can be seen protruding from the vagina. The LPN/LVN will immediately place the client in which of the following positions?

Strategy: Consider the outcome of placing the client in each position.

Category: Planning/Reduction of Risk Potential
1. CORRECT: The Trendelenburg position, with the client’s head down, will shift the weight of her body upward, relieving pressure on the prolapsed cord.
2. Sims’ position does not alter pressure on the prolapsed cord.
3. The prone position puts pressure on the client’s abdominal area.
4. The Semi-Fowler’s position puts pressure on the client’s vaginal area.