NSG 501 HEALTH ASSESSMENT EXAM 1 VIDEOS EXAM
QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS
VERIFIED LATEST UPDATE
1. To which patient might the nurse apply a physical restraint?
A. An 83-year-old patient with dementia and a history of wandering whose fall risk
assessment indicates a high risk of falling.
B. A 42-year-old critical care patient with a traumatic brain injury who has
repeatedly tried to pull out her shunt.
C. A 74-year-old patient confined to bed who is at risk of pressure ulcers.
D. A 60-year-old patient with dementia who seemed increasingly confused shortly
after having had restraints applied for 1 hour that morning.
B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly
tried to pull out her shunt.
2. Why does the nurse instruct nursing assistive personnel (NAP) to remove the
wrist restraint of a confused patient every 2 hours?
A. To try a less restrictive type of restraint if a more confining restraint has
proved effective
B. To double-check the size by inserting one finger between the wrist and the
restraint
,C. To check the skin integrity and range of motion of the wrist
D. To comply with Joint Commission standards
C. To check the skin integrity and range of motion of the wrist
3. What would the nurse instruct nursing assistive personnel (NAP) to report
when caring for a patient in a wrist restraint?
A. "Tell me if the patient's pulse changes."
B. "Tell me if the skin under the restraint becomes abraded or raw."
C. "Let me know if you think she's ready for them to come off."
D. "Let me know if the patient needs anything for pain."
B. "Tell me if the skin under the restraint becomes abraded or raw."
4. The nurse is discussing the risk of falling with the wife of a patient with
cognitive impairment. What is the nurse's best response when the patient's wife
says, "I don't like him being tied down in the bed?"
A. "I'm sure you don't want him to fall again."
B. "Can you suggest an alternative?"
C. "What did you do to prevent him from falling when he was at home?"
D. "We will try all other alternatives before using physical restraints."
D. "We will try all other alternatives before using physical restraints."
5. When a nursing assistive personnel (NAP) enters the room of a patient in a belt
restraint, he finds the patient's gown bunched around the patient's chest and the
patient asking for help. What would the NAP do?
,A. Check the patient's blood pressure and pulse before smoothing the gown
B. Untie the restraint and smooth the patient's gown
C. Put on the call light for help
D. Ask the patient what specific help she would like
B. Untie the restraint and smooth the patient's gown
1. An otherwise strong, healthy patient with a lower leg cast is learning to
ambulate with axillary crutches. Which gait is most appropriate?
A. Any gait is appropriate
B. Four point gait
C. Three point gait
D. Two point gait
C. Three point gait
2. Where do the patient's feet stop when performing the swing-through crutch
gait?
A. Before reaching the crutch tips
B. Level with the crutch tips
C. Past the crutch tips
D. The patient does not put his feet down
C. Past the crutch tips
, 3. The nurse is teaching a patient who has crutches how to sit down in a chair. In
which hand should the patient hold both crutches?
A. The patient's dominant hand
B. The patient's nondominant hand
C. The hand on the injured side
D. The hand on the uninjured side
C. The hand on the injured side
4. In the United States, forearm crutches are generally used by patients with
which types of conditions?
A. Fractures of the lower extremities
B. Fractures of the upper extremities
C. General weakness or paraplegia
D. Weight-bearing restrictions to the lower extremities
C. General weakness or paraplegia
5. A patient requires only minimal assistance with ambulation. Which assistive
device would be most appropriate?
A. A cane
B. A walker without wheels
C. A wheeled walker
D. crutches
QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS
VERIFIED LATEST UPDATE
1. To which patient might the nurse apply a physical restraint?
A. An 83-year-old patient with dementia and a history of wandering whose fall risk
assessment indicates a high risk of falling.
B. A 42-year-old critical care patient with a traumatic brain injury who has
repeatedly tried to pull out her shunt.
C. A 74-year-old patient confined to bed who is at risk of pressure ulcers.
D. A 60-year-old patient with dementia who seemed increasingly confused shortly
after having had restraints applied for 1 hour that morning.
B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly
tried to pull out her shunt.
2. Why does the nurse instruct nursing assistive personnel (NAP) to remove the
wrist restraint of a confused patient every 2 hours?
A. To try a less restrictive type of restraint if a more confining restraint has
proved effective
B. To double-check the size by inserting one finger between the wrist and the
restraint
,C. To check the skin integrity and range of motion of the wrist
D. To comply with Joint Commission standards
C. To check the skin integrity and range of motion of the wrist
3. What would the nurse instruct nursing assistive personnel (NAP) to report
when caring for a patient in a wrist restraint?
A. "Tell me if the patient's pulse changes."
B. "Tell me if the skin under the restraint becomes abraded or raw."
C. "Let me know if you think she's ready for them to come off."
D. "Let me know if the patient needs anything for pain."
B. "Tell me if the skin under the restraint becomes abraded or raw."
4. The nurse is discussing the risk of falling with the wife of a patient with
cognitive impairment. What is the nurse's best response when the patient's wife
says, "I don't like him being tied down in the bed?"
A. "I'm sure you don't want him to fall again."
B. "Can you suggest an alternative?"
C. "What did you do to prevent him from falling when he was at home?"
D. "We will try all other alternatives before using physical restraints."
D. "We will try all other alternatives before using physical restraints."
5. When a nursing assistive personnel (NAP) enters the room of a patient in a belt
restraint, he finds the patient's gown bunched around the patient's chest and the
patient asking for help. What would the NAP do?
,A. Check the patient's blood pressure and pulse before smoothing the gown
B. Untie the restraint and smooth the patient's gown
C. Put on the call light for help
D. Ask the patient what specific help she would like
B. Untie the restraint and smooth the patient's gown
1. An otherwise strong, healthy patient with a lower leg cast is learning to
ambulate with axillary crutches. Which gait is most appropriate?
A. Any gait is appropriate
B. Four point gait
C. Three point gait
D. Two point gait
C. Three point gait
2. Where do the patient's feet stop when performing the swing-through crutch
gait?
A. Before reaching the crutch tips
B. Level with the crutch tips
C. Past the crutch tips
D. The patient does not put his feet down
C. Past the crutch tips
, 3. The nurse is teaching a patient who has crutches how to sit down in a chair. In
which hand should the patient hold both crutches?
A. The patient's dominant hand
B. The patient's nondominant hand
C. The hand on the injured side
D. The hand on the uninjured side
C. The hand on the injured side
4. In the United States, forearm crutches are generally used by patients with
which types of conditions?
A. Fractures of the lower extremities
B. Fractures of the upper extremities
C. General weakness or paraplegia
D. Weight-bearing restrictions to the lower extremities
C. General weakness or paraplegia
5. A patient requires only minimal assistance with ambulation. Which assistive
device would be most appropriate?
A. A cane
B. A walker without wheels
C. A wheeled walker
D. crutches
