303 Hinkle PrepU Chapter 10: Principles and Practices of Rehabilitation

The nurse preceptor is critiquing a new nurse's plan of care for a client with urinary incontinence. The preceptor suggests a review of nursing interventions for urinary incontinence when which instruction appears on the plan of care?

"Restrict client's fluids" Appropriate nursing interventions for patients with urinary incontinence include encouraging acid-based fluids such as cranberry juice, initiating a toileting schedule, and encouraging Kegel exercises. The client's fluids should not be restricted in order to ensure adequate fluid intake. The preceptor attributes the error on the new nurse's care plan to a lack of knowledge and suggests that the new nurse review nursing interventions for urinary incontinence.

A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?

applying knee splints Applying knee splints prevents leg contractures by holding the joints in a functional position. Elevating the foot of the bed doesn't prevent contractures. Hyperextending a body part for any length of time is inappropriate; doing so can cause contractures. Performing shoulder ROM exercises can prevent contractures in the shoulders but not in the legs.

Students are reviewing information about activities of daily living. They demonstrate understanding of this topic when they identify which of the following as an activity of daily living?

bathing Activities of daily living refer to those activities involving personal care such as bathing, showering, dressing, getting in and out of bed or a chair, using the toilet, and eating. Cleaning, doing laundry, and handling emergencies are examples of independent activities of daily living.

The nurse has developed an evidence-based plan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care?

the patient The evidence-based plan of care that nurses develop must be approved by the patient and family and is an integral part of the rehabilitation process.

The initial sign of skin pressure is erythema, which normally resolves in less than

1 hour The initial sign of pressure is erythema caused by reactive hyperemia, which normally resolves in less than 1 hour. All of the other time frames are incorrect.

A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?

A wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance A wound (regardless of its size) that contains tan, leathery tissue requires evaluation by the wound care nurse. This wound most likely requires debridement before wound healing can take place. Although option A describes a large wound, it's showing signs of healing, so a consult isn't necessary. Option B describes a stage II wound that has a clean wound bed; a wound nurse consult isn't necessary for this type of wound. The wound described in option D is small and shows signs of healing; a wound care consult isn't required at this time.

When is the optimal time for the nurse to begin the rehabilitation process for a patient with a cervical spine injury?

with initial patient contact The principles of rehabilitation are basic to the care of all patients, and rehabilitation efforts should begin during the initial contact with a patient.

The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage?

stage III A stage III ulcer is a full-thickness wound that extends into the subcutaneous tissue with necrosis and infection. A stage I ulcer is characterized by an area of erythema that does not blanch with pressure. A stage II ulcer is a partial-thickness wound characterized by a break in the skin with edema and some drainage. A stage IV ulcer is a full-thickness wound that extends to the underlying muscle and bone with deep pockets of infection and necrosis.

A nurse is caring for a client who is documented to have orthostatic hypotension. The nurse anticipates finding which symptom upon assessment?

dizziness Indicators of orthostatic hypotension include a drop in blood pressure, pallor, diaphoresis, nausea, tachycardia, and dizziness.

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

stage 2 pressure ulcer A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of nonblanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.

During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?

stage III Clinically, in a stage III pressure ulcer, a deep crater with or without undermining of adjacent tissues is noted. A stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone. A stage II ulcer exhibits a break in the skin through the epidermis or dermis. A stage I pressure ulcer is an area of non-blanchable erythema, tissue swelling, and congestion, and the client complains of discomfort.

The nurse assesses initial skin redness in a patient who is at risk for skin breakdown. How should the nurse document this finding?

hyperemia The initial sign of pressure is erythema (redness of the skin) caused by reactive hyperemia, which normally resolves in less than 1 hour. Unrelieved pressure results in tissue ischemia or anoxia. Eschar is a dry scab that forms over a healing ulcer.

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following?

the client does not reach the toilet before experiencing voiding Functional incontinence is incontinence in clients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and cannot reach and use the toilet before soiling themselves. Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Urge incontinence is the involuntary elimination of urine associated with a strong perceived need to void. Stress incontinence is associated with weakened perineal muscles that permit leakage of urine when intraabdominal pressure is increased, such as with coughing or sneezing.

To help prevent the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use

a trochanter roll extending from the crest of the ilium to the midthigh A trochanter roll, properly placed, provides resistance to the external rotation of the hip. Pillows under the legs or a footboard will not prevent the hips from rotating externally. A hip-abductor pillow is used for the patient after total hip replacement surgery.

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply.

edema anemia diaphoresis Risk factors for pressure ulcer development include prolonged pressure on the tissue, sensory deficit or loss, edema, urinary or fecal incontinence, malnutrition, anemia, hypoproteinemia, and excessively moist skin.

A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care?

lubricating the skin with a non-irritating lotion To help reduce the risk of pressure ulcers, the nurse should lubricate the skin with a bland lotion to keep it soft and pliable. Reddened areas should not be massaged because this could damage the capillaries and deep tissues. Clients should shift their weight every 15 to 20 minutes. The semi-reclining position should be avoided because it increases the shearing forces over the sacral area.

The nurse is assisting a patient to sit up on the side of the bed in preparation for standing. The patient has been on strict bedrest for more than a week. While assuming the sitting position, the patient begins to report feeling dizzy and nauseated. The patient is pale and diaphoretic. Which of the following would the nurse do next?

having the patient lie back down The patient is exhibiting signs of orthostatic hypotension and cerebral insufficiency from the change in position. The best action would be have the patient lie back down because he or she is not tolerating the change in position. Taking deep breaths would be ineffective in raising the patient's blood pressure or increasing the blood supply to the brain. Having the patient stand up immediately would worsen the patient's symptoms. Using a transfer board would have no effect on the patient's symptoms, which are from the change in position.

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address?

moisture Although skin color, tissue perfusion, and drainage are important assessment areas to address, the Braden scale uses the following categories to predict pressure ulcer risk: *sensory perception, moisture, activity, mobility, nutrition, and friction and shear.*

The nurse is assisting a patient in assuming a side-lying position. What intervention would be best for the nurse to provide?

place the uppermost hip slightly forward in a position of slight abduction Supporting the patient in a 30-degree side-lying position avoids pressure on the trochanter. In older adult patients, frequent small shifts of body weight may be effective. Placing a small rolled towel or sheepskin under a shoulder or hip allows a return of blood flow to the skin in the area on which the patient is sitting or lying. The towel or sheepskin is moved around the patient's pressure points in a clockwise fashion. A turning schedule can help the family keep track of the patient's turns.

A nurse has taught a client how to perform quadriceps-setting exercises. The nurse determines that the client has understood the instructions when he demonstrates which of the following?

pushes the popliteal area against the mattress while raising the heel The client demonstrates quadriceps-setting exercises by attempting to push the popliteal area against the mattress and at the same time raising the heel. With gluteal setting exercises, the client contracts the buttocks together for a count of five and then relaxes them for a count of five. With push-up exercises, the client raises the body by pushing the hands against the chair seat or mattress while he is in a sitting position. For pull-up exercises, the client lifts the body off the mattress while holding onto a trapeze while in bed or raises the arms above the head then lowers them while holding weights.

A client who has been admitted for weakness and taking fluids poorly is unable to move well in the bed and requires assistance. What are this client's risk factors for developing pressure sores? Select all that apply.

dehydration immobility inactivity Dehydration, immobility, and inactivity are risk factors for pressure ulcers.

While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to:

document the condition of the client's skin The client's warm, red skin is consistent with a stage I pressure ulcer. Documenting the findings will provide a permanent record of the condition. If the nurse fails to take action, the client may experience further skin trauma. Donut rings reduce circulation to the sacral area when the client sits on them; they're contraindicated in this instance. There's no reason for the nurse to contact the client's family at this time; doing so might violate the client's right of privacy.

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown?

practice meticulous hygiene measures Continuous moisture on the skin must be prevented by meticulous hygiene measures. It is important to pay special attention to skin folds, including areas under the breasts, arms, and groin, and between the toes. Perspiration, urine, stool, and drainage must be removed from the skin promptly. The soiled skin should be washed immediately with mild soap and water and blotted dry with a soft towel. The skin may be lubricated with a bland lotion to keep it soft and pliable. Drying agents and powders are avoided. Topical barrier ointments (e.g., petroleum jelly) may be helpful in protecting the skin of patients who are incontinent. Placing an indwelling catheter and administering vitamin B12 would not be effective measures in preventing continuous moisture.

What diet can the nurse recommend to a patient with hypoproteinemia that spares protein?

a diet high in carbohydrates Wounds from which body fluids and protein drain place the patient in a catabolic state and predispose to hypoproteinemia and serious secondary infections. Protein deficiency must be corrected to promote the healing of the pressure ulcer. Carbohydrates are necessary to "spare" the protein and to provide an energy source.

Which nutritional deficiency may delay wound healing?

lack of Vitamin C Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing. Adequate protein intake is necessary for improving skin integrity. Vitamin D and calcium are necessary for bone healing. Vitamin E isn't necessary for wound healing.

Serum albumin is an indicator of which type of deficiency?

protein Serum albumin is a sensitive indicator of protein deficiency. Serum albumin is not an indicator of potassium, calcium, or phosphorous deficiency.

The nurse is working with a physical therapist to create a multidisciplinary plan of care for a client in a rehabilitation unit. The therapist suggests that the client would benefit from the use of light weights during shoulder exercises. The nurse incorporates this into the plan of care as which type of exercise?

resistive The nurse should incorporate exercise that involves the use of light weights, referred to as resistive exercise. In active-assistive exercises the client performs the exercises with assistance from the therapist. In passive exercises, the nurse performs the exercise without assistance from the client. In isometric exercises, the client alternately contracts and relaxes the muscle while keeping the part in a fixed position.

The nurse in collaboration with the rehabilitation team is working with a patient on performing therapeutic exercises. Which of the following would the nurse expect to encourage to increase the patient's muscle power?

resistive exercises Resistive exercises provide resistance to increase muscle power. Passive exercises are used to retain as much joint range of motion as possible and to maintain circulation. Isometric exercises are used to maintain strength when a joint is immobilized. Active exercises are used to increase muscle strength.