Question

ati fundamental test 2024 (nursing process)
28.a home health nurse is caring for a client who has emphysema and has difficulty with mobility. the client spends most of his day in a reclining chair. which of the following physiological responses to prolonged immobility should the nurse expect?
a. increased insulin production
b. decreased rbc production
c. decreased sodium excretion
d. increased calcium excretion
29.a client tells the nurse that he suspects that he grinds his teeth at night. along with giving the client a dental referral, the nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?
a. xerostomia
b. halitosis
c. bruxism
d. sordes
30.a nurse is preparing to document a clients information in the electronic medical record. which of the following nursing statements identifies the purpose of documentation?
a. \documentation provides a communication tool for the health care team.\
b. \documentation facilitates reimbursement from the local government.\
c. \documentation provides information for a client audit.\
d. \documentation enables providers to monitor the nurse.\
31.a nurse is preparing a client for ambulation. which of the following actions should the nurse take to determine the clients level of strength?
a. ask the client how strong she feels today.
b. ask the client if she has been out of bed today.
c. check the clients pedal pulses and feet for edema.
d. ask the client to push her legs and feet against the nurses palms.

Explanation:

• Question 28: Prolonged immobility leads to bone demineralization, which increases calcium excretion. Insulin production is related to pancreatic function, not immobility. RBC production is mainly regulated by erythropoietin (affected by hypoxia, not immobility). Sodium excretion is more related to renal and hormonal (e.g., aldosterone) regulation, not directly to immobility.
• Question 29: Bruxism is the medical term for teeth - grinding. Xerostomia is dry mouth, halitosis is bad breath, and sordes is debris on teeth.
• Question 30: Documentation in healthcare is primarily a communication tool for the inter - professional health care team. While it may have secondary implications for reimbursement or audits, the main purpose is communication. It is not for monitoring the nurse.
• Question 31: Asking the client to push her legs and feet against the nurse's palms is a practical way to assess muscle strength (a form of manual muscle testing). Asking how strong the client feels is subjective. Asking if the client has been out of bed is not a direct measure of strength. Checking pedal pulses and feet for edema assesses circulation and fluid status, not strength.

Answer:

• Question 28: D. Increased calcium excretion
• Question 29: C. Bruxism
• Question 30: A. "Documentation provides a communication tool for the health care team."
• Question 31: D. Ask the client to push her legs and feet against the nurse's palms.